Mood stabilizers

Question 1

What are prove mood stabilizing drugs?

Answer 1

Li, carbamazepine (tegretol), valproic acid (Depakote)

Question 2

What are drugs that may be used as mood stabilizers, though they aren’t officially classified as such?

Answer 2

• CCBs, oxcarbazepine (trileptal), lamotrigine (lamictal), zonisamide (zonegram), atypical antipsychotics
• Not all equally good at all mood abherrations- for example, lamictal is better for depression than mania; Li better for mania than depression.

Question 3

What is typical time to response for mood stabilizers? How does that impact practice?

Answer 3

typical time to response 10-14 days for acute mania, so pts may require antipsychotics to break acute mania while more traditional mood stabilizers are being started

Question 4

How is carbamazepine dosed?

Answer 4

• Dosages were determined for seizures- rough guide only for psych
• titrate up to desired therapeutic effect/ side effect intolerability
• May have to increase dose at 2 wks- carbamazepine may induce induce its own metabolism

Question 5

Valproic acid- what are special uses?

Answer 5

Like carbamazepine, may help control behavior in pts w/ intellectual disability

• Good for rapid cyclers (> or = to 4 mood episodes/yr)
• Good for pts with comorbid substance abuse
• Good for pts with mixed/dysphoric mania
• Helps with agitation in dementia

Question 6

Valproic acid- what are special uses?

Answer 6

Like carbamazepine, may help control behavior in pts w/ intellectual disability

• Good for rapid cyclers (> or = to 4 mood episodes/yr)
• Good for pts with comorbid substance abuse
• Good for pts with mixed/dysphoric mania
• Helps with agitation in dementia

Question 7

How is valproic acid doses?

Answer 7

• May begin with loading dose
• use levels to determine therapeutic dose- generally 50-100 is therapeutic, though may need as high as 125 mcg/mL for mania

Question 8

What are the uses of lamotrigine?

Answer 8

• mania maintenance (helps prevent recurrent mania, though less effective in preventing mania than in preventing depressive episodes)
• bipolar

Question 9

What are side effects of lamotrigine?

Answer 9

TEN/Stevens Johnson, ESP. with valproic acid, or if you exceed recommended dose or recommended dose escalation

Question 10

What kinds of side effects are seen with carbamazepine?

Answer 10

neuro effects (sedation, ataxia, dysarthria), benign blood dyscrasias, conduction system disturbances in the heart, hepatitis

Question 11

What kinds of medications can effect Li levels?

Answer 11

diuretics (esp. thiazides), NSAIDS, CCBs, ACE-Is

Question 12

What are the blood goals for Li levels?

Answer 12

typically 0.6-1.2 mEq/L. typically >1 for mania; 0.6-0.8 for prophylaxis, and ~0.6 for augmentation in unipolar depression

Question 13

What are the side effects of lithium?

Answer 13

MNOP:
M: motor tremor (also irritability, dysarthria, ataxia, seizures if at toxic levels). Tremor may be treated with a beta blocker.
O: hypothyroidism/goiter
N: nephrogenic diabetes insipitus (may be treated with thiazide), possible proteinuria and/or renal toxicities
Pregnancy concerns
May cause sinus arrhythmias

Question 14

What monitoring should be done in pts on lithium?

Answer 14

screening, then annual/biannual urinalysis
serum creatinine leves
TSH levels

Question 15

What monitoring should be done in pts on lithium?

Answer 15

screening, then annual/biannual urinalysis
serum creatinine leves
TSH levels

Question 16

What makes lorazepam unique? What are other intermediate-active benzos?

Answer 16

• available in PO and IM forms
• only benzo that is consistently well absorbed in IM format
• one of the few that is metabolized by directu conjugation without requiring hepatic oxidation, and without active metabolites
• other intermediate-acting benzos: clonazepam (klonopin), alprazolam (Xanax)

Question 17

What is the tx for benzodiazepam overdose?

Answer 17

Flumazenil