Mood stabilizers are medications used in the treatment of bipolar disorder, where a person’s mood changes from a depressed feeling to a high “manic” feeling or vice versa. These drugs can help reduce mood swings and prevent manic and depressive episodes.
Mood stabilizers can take up to several weeks to reach their full effect. Because of this, other psychiatric medications such as antipsychotics; are often used in the early stages of treatment to treat acute mania.
Depression in bipolar disorder can be hard to distinguish from other forms of depression. Antidepressant medications can be effective; however, they must never be used alone with bipolar disorder as they can also cause a person who is depressed to switch into mania. Antidepressants may also lead to more frequent mood episodes, known as rapid cycling. This risk is lessened if the person is also taking a mood stabilizer.
The term “bipolar” refers to the two extremes of mood: mania and depression. People with bipolar disorder usually experience these extremes at different times, although the two mood states can occur together (known as a mixed state). With bipolar disorder, people can also have periods where their mood is balanced. Mood stabilizers can help to keep the mood of a person with bipolar disorder within this balanced range.
Treatment with mood stabilizers can reduce symptoms of bipolar disorder and increase people’s ability to pursue their interests and participate more fully in their relationships.
Medication is generally considered to be the cornerstone of treatment for bipolar disorder; however, combining medication with other types of therapy and support can help you to get and stay well. Forms of talk therapy that have been shown to help with bipolar disorder are interpersonal and social rhythm therapy, cognitive-behavioural therapy and family-focused education about bipolar disorder. Other aids can include peer support, school and job counselling, and housing and employment support. Eating a nutritious diet, exercising regularly and getting enough sleep are also important, as are minimizing your use of alcohol and caffeine and avoiding street drugs.
How mood stabilizers work is not fully understood. It is thought that the drugs work in different ways to bring stability and calm to areas of the brain that have become overstimulated and overactive, or to prevent this state from developing.
The side-effects of mood stabilizers vary depending on the type of medication. With some medications, side-effects are kept to a minimum through regular monitoring of the level of the drug in the blood. Some people experience no side-effects. Others may find the side-effects distressing. Side-effects usually lessen as treatment continues.
Check the information given to you by your doctor or pharmacist on the specific effects of any drug you have been prescribed. If side-effects are not mild and tolerable, let your doctor know as soon as possible. Your doctor may:
More information on side-effects is included for each type of mood stabilizer.
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 grapefruit juice as it can raise the level of this drug in your body.
The oldest and most studied of mood stabilizers is lithium. However, many drugs that were first developed as anticonvulsants to treat epilepsy also act as mood stabilizers. These include carbamazepine, divalproex and lamotrigine. Gabapentin and topiramate are also anticonvulsants that may act as mood stabilizers, but they are usually given in addition to other medications.
Lithium (Carbolith, Duralith, Lithane) 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 switching to 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.
The differing names for this anticonvulsant medication reflect the various ways it is formulated. Divalproex (and its various forms) is used for acute manic episodes. 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 (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 (Lamictal) 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.
* 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.
When you start taking mood stabilizers, it may be two weeks or more before you notice their effect and four to six weeks before they reach their full effect. It’s important to give them time to work. Once your symptoms are under control, you will be encouraged to continue to take mood stabilizers for at least six months and probably longer. How much longer varies from person to person.
Mood stabilizers can help prevent further episodes of mania or depression. In other words, staying on these medications for the long term can help to keep you well. Going off mood stabilizers, on the other hand, can greatly increase your chances of having another episode.
Once you have been taking mood stabilizers for a while and you are feeling well, you may do fine on a lower “maintenance” dose. Talk to your doctor if you would like to try this.
Drugs that are addictive produce a feeling of euphoria, a strong desire to continue using the drug, and a need to increase the amount used to achieve the same effect. Mood stabilizers do not have these effects.
While mood stabilizers are not addictive, when you take them (or any drug) over months or years, your body adjusts to the presence of the drug. If you then stop using the drug, especially if you stop suddenly, the absence of the drug may result in withdrawal effects or in return of symptoms. With mood stabilizers, the withdrawal effects are generally mild; the greatest risk with stopping these drugs is the return of symptoms.
Whether you want to cut down your dose or stop taking a medication, the same rule applies: go slowly. Sudden changes in your dose can greatly increase your risk of having another mood episode.
The first step is to ask yourself if this is the right time. Are you feeling well? Is the level of stress in your life manageable? Do you feel supported by your family and friends?
If you think you’re ready, talk to your doctor. If your doctor doesn’t agree, find out why. If you are not satisfied with his or her reasons, you may want to see another doctor for a second opinion.
If your doctor does agree, he or she will advise you not to skip doses but to reduce your dose gradually over a four to six week period. This process of cutting back will take several months.
If you want to stop taking more than one medication, your doctor will usually suggest that you lower the dose of one drug at a time.
As you cut down, if you start to feel unwell, let your doctor know. You may want to go back up with your dose. Find the dose that works best for you.
Some medications can affect the blood levels of mood stabilizers, meaning your dose of mood stabilizer may have to be adjusted while you are taking the other medication. Mood stabilizers, especially carbamazepine, may also reduce the effectiveness of some other drugs. Always make sure your doctor or dentist knows about any drugs you are taking when he or she prescribes another medication. It’s also important to check with your pharmacist before using any over-the-counter medication, including pain medications, herbal remedies, cold or allergy tablets, or cough syrups.
Drinking coffee or other beverages that contain caffeine can lower lithium levels and increase tremor. If you want to dramatically change how much caffeine you have in a day (e.g., cutting back from four cups to one cup of coffee a day), check with your doctor or pharmacist first to see if your mood stabilizer dose should be adjusted.
People with bipolar disorder are generally advised to avoid alcohol. This is recommended because:
While avoiding alcohol is the best choice for many people with bipolar disorder, having a drink or two on occasion should be okay for those who are stable, feeling well and who have not had a substance use problem.
Street drugs can complicate your situation and create problems. Cocaine and amphetamines, for example, can trigger an episode of mania or depression. Marijuana could lift you up or it could bring you down; its effects on mood can be unpredictable, especially when combined with bipolar disorder. Using any street drugs (or alcohol) regularly to modify your mood increases your risk of addiction.
Mood stabilizers, especially early in treatment, may delay your reaction time. This effect could impair your ability to drive a car or operate other machinery. Avoid these activities until you adjust to the medication or if you feel slowed down.
Taking lithium may reduce your interest in sex. This can be a good thing for some people and not so good for others. If you feel your interest in sex is too low, talk to your doctor about it. Sometimes an adjustment in dose can help.
Although not common, some men who take lithium report a decreased ability to maintain an erection or to ejaculate. With bipolar disorder, many complex factors other than medication may contribute to sexual difficulties.
In women, mood stabilizers may cause changes in the menstrual cycle. Carbamazepine and other anticonvulsants may reduce the effectiveness of birth control pills.
Each woman’s situation is unique and should be discussed with her doctor. For any pregnant woman with a history of bipolar disorder, the question of taking mood stabilizers during pregnancy usually comes down to a risk-benefit analysis. All mood stabilizers carry some risk—some more than others; however, episodes of depression or mania can affect prenatal care and a mother’s ability to parent her newborn child. When treatment with a mood stabilizer helps to avoid a relapse or to reduce distress, the benefits may outweigh the risks.
Taking lithium during the first trimester in pregnancy is believed to slightly increase the risk of a heart defect in the baby. This risk has been shown to be .05-.1 per cent (i.e., one in 2,000). Newborns must be monitored for possible toxic effects of lithium; these effects usually resolve within one to two weeks.
Divalproex increases the risk of spinal defects in the developing baby by approximately five to nine per cent. Divalproex is also related to developmental delays and cognitive problems in children. Carbamazepine increases the risk of spinal defects by approximately one per cent. Lamotrigine is associated with a potential increased risk for cleft palate.
Lithium can be passed to the baby through breast milk; however, the amount varies greatly from woman to woman. Some women may be able to breastfeed with close monitoring of lithium levels in the mother’s milk and the baby’s blood.
The amount of anticonvulsant mood stabilizers passed through breast milk is very small and is not considered to be a risk to the baby, especially when weighed against the benefits of breastfeeding.
If you decide to stop taking medications during pregnancy or while breastfeeding, it is a good idea to see your doctor more often to help you monitor for a return of symptoms.
The first signs of bipolar disorder can appear in childhood, usually as depression or behaviour problems. Early substance use problems or petty crime can also be signs. When bipolar disorder in childhood is misdiagnosed as attention-deficit/hyperactivity disorder or unipolar depression, treatment with stimulants or antidepressants can worsen symptoms.
Mood stabilizers were developed and tested on adults. While most of these drugs are not officially approved for use by children and teens, professional guidelines direct their use in this age group. Lithium is approved for treating manic symptoms in children aged 12 and older.
Children and teens may be more prone to the side-effects of these drugs and should be monitored by their doctor regularly for side-effects.
As people age into their 60s and older, their bodies become less able to eliminate medications. This means that older people who take mood stabilizers need to have the drug levels in their blood measured more often than younger people. Those taking lithium also need to have their kidney and thyroid function and heart rate monitored more frequently.
As people get older, they also become more sensitive to medications and may require a lower dose. Mood stabilizers can increase the risk of falls, especially when taken with other drugs.
Copyright © 2009, 2012 Centre for Addiction and Mental Health
Last Giving Tuesday, we raised $100,000 to fund life-saving research at CAMH. Today, we’re aiming twice as high. Donate on or before Tuesday, November 30 to help us beat our goal and drive more progress in mental health.
Keep your finger on our pulse – latest CAMH news, discoveries and ways to get involved delivered to your inbox.
Please select a newsletter
Please complete the following:
We look forward to keeping you informed, inspired and involved in all things CAMH.
Last Giving Tuesday, we raised $100,000. Donate between now and Tuesday, November 30 to help us beat our goal and fuel the life-saving mental health research.