Daniel Carlat, MD. Vice Chair, Community and Public Sector Psychiatry, Tufts University School of Medicine. Publisher, Carlat Publishing.
Dr. Carlat has no financial relationships with companies related to this material.
Mood stabilizers play a critical role in helping patients with bipolar disorder manage symptoms and maintain stability. In this article, we will provide a brief overview of mood stabilizers for bipolar disorder and their implications for psychotherapy.
What are mood stabilizers?
Mood stabilizers are medications that help regulate and stabilize mood in individuals with bipolar disorder (Baldessarini RK et al, Mol Psychiatry 2019;24(2):198-217). They're often used as a long-term treatment to prevent the recurrence of mood episodes and reduce their severity. It's important to note that mood stabilizers are not a one-size-fits-all solution; what works for one client might not work for another. Therefore, it's our responsibility to stay informed about the different types of mood stabilizers, their potential side effects, and the implications for our clients' therapy.
Medications commonly used as mood stabilizers include lithium (Lithobid); divalproex (Depakote); lamotrigine (Lamictal); and atypical antipsychotics—also referred to as “second-generation” antipsychotics.
Lithium is a naturally occurring element that has been used as a mood stabilizer for bipolar disorder since the 1940s (Malhi GS and Outhred T, CNS Drugs 2016;30(10):931-949). It's considered the gold standard in bipolar disorder treatment and is particularly effective in reducing the frequency and severity of manic episodes. It’s generally more effective for classic euphoric manic episodes than for mixed or rapid cycling episodes. It also has antidepressant effects, both in bipolar disorder, and as an add-on agent to antidepressants in patients with unipolar depression.
Common side effects of lithium include hand tremors, increased thirst and urination, weight gain, cognitive difficulties, and hypothyroidism. It can rarely cause kidney impairment in patients who have used it for many years. It is likely underprescribed due to side effect concerns, and in fact most patients tolerate lithium quite well.
2. Anticonvulsant medications
Anticonvulsant medications were initially developed to treat epilepsy but have been found to be effective in managing bipolar disorder symptoms as well. Three of the most commonly prescribed anticonvulsants for bipolar disorder include valproic acid (Depakote), lamotrigine (Lamictal), and carbamazepine (Tegretol) (Yatham et al, Bipolar Disord 2018;20(2):97-170).
Valproic acid is particularly effective for treating acute mania and mixed episodes and can be used as a maintenance treatment to prevent relapses. Potential side effects include weight gain, dizziness, drowsiness, and gastrointestinal issues. Long-term use of valproic acid can lead to liver toxicity and potential birth defects in pregnant clients.
Lamotrigine is especially useful for the maintenance treatment of bipolar disorder and has been found to be more effective in preventing depressive episodes than manic episodes. Common side effects include dizziness, headache, and nausea. A rare but serious side effect of lamotrigine is a potentially life-threatening rash called Stevens-Johnson syndrome.
Carbamazepine is used to treat acute mania and as a maintenance treatment for bipolar disorder. Its side effects can include dizziness, drowsiness, and blurred vision. Long-term use may lead to liver toxicity, low blood sodium levels, and blood disorders.
3. Atypical antipsychotics
Atypical antipsychotics, such as quetiapine (Seroquel), aripiprazole (Abilify), and olanzapine (Zyprexa), can also be used as mood stabilizers in the treatment of bipolar disorder (Goodwin GM et al, J Psychopharmacol, 2017;30(6):495-553.). They are particularly helpful in treating acute manic episodes and can be used as a maintenance treatment to prevent relapses.
It's essential to monitor clients taking atypical antipsychotics for weight gain, high blood sugar, high cholesterol, and high blood pressure, as these factors can contribute to the development of metabolic syndrome and increase the risk of cardiovascular disease. Regular check-ups and lifestyle interventions, such as promoting a healthy diet and exercise routine, can help mitigate these risks.
Quetiapine is effective in treating both manic and depressive episodes in bipolar disorder. Common side effects include sedation, weight gain, and dizziness. It's important to monitor clients for signs of excessive sedation or an increase in suicidal thoughts, particularly during the initial stages of treatment.
Aripiprazole is useful for treating acute mania and as a maintenance treatment. It's generally considered to have a lower risk of weight gain compared to other atypical antipsychotics. Some of the common side effects include headache, anxiety, and insomnia. In some cases, aripiprazole can cause akathisia, a feeling of inner restlessness that can be distressing to clients.
Olanzapine is effective in treating acute mania and mixed episodes. It can also be used for maintenance treatment in combination with fluoxetine (an antidepressant) for clients with a history of severe depressive episodes. However, olanzapine is associated with significant weight gain and an increased risk of metabolic syndrome. Monitoring clients' weight, blood sugar, and lipid levels is crucial during treatment with olanzapine.
How psychotherapists can support patients taking mood stabilizers
As therapists, it's crucial for us to understand how mood stabilizers can interact with psychotherapy. Research has shown that combining mood stabilizers with evidence-based psychotherapy, such as cognitive-behavioral therapy (CBT), family-focused therapy, and interpersonal and social rhythm therapy, can significantly improve treatment outcomes for clients with bipolar disorder (Miklowitz D et al, J Affect Disord 2020;266:710-717).
Here are some practical tips on how you can support your clients who are taking mood stabilizers:
CARLAT TAKE: Prioritize collaboration with prescribing doctors, promote medication adherence, and provide psychoeducation about mood stabilizers to enhance treatment outcomes and overall well-being.
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