Mood stabilizers: Types of mood stabilizers

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Controlling side-effects
Getting the right dose
Lithium
Signs of lithium overdose
Divalproex, valproic acid or valproate
Carbamazepine
Lamotrigine

The oldest and most studied of the mood stabilizers is lithium. Lithium is a simple element in the same family as sodium (table salt).

Many drugs that were first developed as anti-convulsants to treat epilepsy also act as mood stabilizers. These include carbamazepine (Tegretol)*, divalproex (Epival) and lamotrigine (Lamictal). Gabapentin (Neurontin) and topiramate (Topamax) are also anticonvulsants that may act as mood stabilizers, although they are usually only given in addition to other medications.

Some people may be prescribed more than one type of mood stabilizer to take in combination.

Mood stabilizers are available as capsules or tablets, or as liquids for drinking.

Getting the right dose

With lithium, carbamazepine and divalproex, the dose is based on how much of the drug is in your blood and how you respond to treatment. This means that the dose differs for everyone who takes it. Blood samples are taken regularly to make sure that the dose is neither too high nor too low. Taking less may not be effective, and taking more can make you physically sick.

The right dose is within a range, rather than a precise point. It may change over time, depending on whether the medication is being used to treat active symptoms of mania or depression or to help prevent symptoms from returning.

On days that you are scheduled to have your blood level tested, wait until after the test to take your morning dose to avoid inaccurate results.

If you are taking carbamazepine, avoid grape-fruit juice as it can raise the level of this drug in your body.

Lithium

Lithium (Carbolith, Duralith, Lithane, Lithium Carbonate, Lithium Citrate) is found in nature in some mineral waters and is also present in small amounts in the human body.

Lithium is used to treat mania and to prevent further episodes of mania and depression.

Common side-effects of lithium include increased thirst and urination, nausea, weight gain and a fine trembling of the hands. Less common side-effects can include tiredness, vomiting and diarrhea, blurred vision, impaired memory, difficulty concentrating, skin changes (e.g., dry skin, acne) and slight muscle weakness. These effects are generally mild and fade as treatment continues. If, however, any of these effects are severe, they should be reported to your doctor immediately. Thyroid and kidney function can be affected by lithium in some people, and must be monitored regularly by your doctor.

Signs of lithium overdose

Lithium blood levels can increase to dangerous levels when a person becomes severely dehydrated. Remember to drink eight to 12 cups of fluid per day, especially when it’s hot or when you’re exercising. Severe vomiting, diarrhea or a fever can also cause dehydration. If you have these symptoms, stop taking lithium and see your doctor as soon as possible.

Changing the amount of salt you use can also affect lithium levels: avoid low- or no-salt diets.
Signs that the amount of lithium in the body is higher than it should be include severe nausea, vomiting and diarrhea, shaking and twitching, loss of balance, slurred speech, double vision and weakness.

If you experience any of these effects, see your doctor as soon as possible. In the meantime, stop taking lithium and drink plenty of fluids. If you cannot reach your doctor and the symptoms do not clear up, go to the nearest hospital emergency department.

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Divalproex, valproic acid or valproate

The differing names for this anticonvulsant medication reflect the various ways it is formulated. Divalproex (and its various forms) is used when people have frequent mood swings or when they don’t respond to lithium. Brand names include Depakene and Epival.

Common side-effects of divalproex include drowsiness, dizziness, nausea and blurred vision. Less common side-effects are vomiting or mild cramps, muscle tremor, mild hair loss, weight gain, bruising or bleeding, liver problems and, for women, changes in the menstrual cycle.

Carbamazepine

Carbamazepine (Tegretol) is another anticonvulsant. It is used for mania and mixed states that do not respond to lithium or when the person is irritable or aggressive.

Common side-effects of carbamazepine include dizziness, drowsiness, blurred vision, confusion, muscle tremor, nausea, vomiting or mild cramps, increased sensitivity to sun, skin sensitivity and rashes and poor co-ordination.

A rare but dangerous side-effect of carbamazepine is reduced blood cell counts. People who take this drug should have their blood monitored regularly for this effect. Soreness of the mouth, gums or throat, mouth ulcers or sores, and fever or flu-like symptoms can be a sign of this effect and should be reported immediately to your doctor. If carbamazepine is the cause of these symptoms, they will go away when the medication is stopped.

Oxcarbazepine (Trileptal), a closely related drug, may have less side-effects and drug interactions than carbamazepine, but is not as well studied for bipolar disorder.

Lamotrigine

Lamotrigine may be the most effective mood stabilizer for depression in bipolar disorder, but is not as helpful for mania.

The starting dose of lamotrigine should be very low and increased very slowly over four weeks or more. This approach decreases the risk of a severe rash— a potentially dangerous side-effect of this drug.

Common side-effects of lamotrigine include fever, dizziness, drowsiness, blurred vision, nausea, vomiting or mild cramps, headache and skin rash. Although it is rare, a severe skin rash can occur with lamotrigine. Any rashes that begin in the first few weeks of treatment should be reported to your doctor.

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Controlling side-effects

Mood stabilizers can increase your sensitivity to the sun: wear sunscreen when outdoors to prevent burning.

To reduce stomach upset, take your dose with food or milk.

If your medication makes you feel drowsy, check with your doctor to see if you can take it at bedtime.
Taking mood stabilizers can cause weight gain. Getting regular exercise and eating a low-fat, low-sugar, high-fibre diet (e.g., bran, fruits and vegetables) can help prevent weight gain.

If side-effects are troublesome or severe, you may do better on a lower dose. Talk to your doctor.

*Medications are referred to in two ways: by their generic name and by their brand or trade names. Brand names available in Canada appear here in brackets.

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