Mood Stabilizers

Question 1

Lithium, overview

Answer 1

Naturally-occurring element
*Prescriptions Li= 1000X concentration

Typical dose in bipolar patients is 200 mg/day

Therapeutic usage of lithium first discovered by John Cade, in 1949
o But therapeutic effects have been noted prior

Healing springs – contain elevated levels of lithium
• Lithium-infused drinks, i.e. 7-Up

Question 2

Lithium: Side effects

Answer 2

Blurred vision

Hair loss

Nausea

Weight gain

Tremors

Seizures

Slurred speech

Kidney failure

Lithium can produce hyper- or hypothyroidism.

*Initially, may cause GI complaints, but these decrease over time

Question 3

Lithium: Predictors of positive response

Answer 3

Prior long-term positive response

Family members who have responded positively to the drug

Classic, pure, mania

Mania that is typically followed by depression

Question 4

Lithium: Suicide Prevention

Answer 4

Lithium significantly reduces suicide rate

• 25-50% of all those diagnosed with bipolar disorder attempt suicide (highest rates of any mental disorder)
• 15% complete suicide

Question 5

Lithium: Mechanism of Action

Answer 5

Theories:

Stabilize Na+ ion channels

Alters neural responding

Stimulates neural growth

Question 6

Lithium: Contraindications / Interactions

Answer 6

Non-steroid, anti-inflammatory drugs increase lithium levels in the body

Lithium toxicity:
• Coma, kidney failure, delirium, death

Contraindication - pregnant women
*Can cause fetal abnormalities

Question 7

Lithium: Response rates

Answer 7

50% success

• Lithium is not as effective in treating depressive episodes of bipolar disorder
• 70% of bipolar patients who are using lithium no longer experience switching

Question 8

Lithium: Why not more commonly prescribed?`

Answer 8

Stigma: Associated with severe mental illness (SMI)

Low cost = low profits

Lack of proper monitoring can cause serious side effects

Physicians in the mid-90s used to prescribe lithium instead of NaCl for hypotension
• Excessive use leads to death

Question 9

Depakote vs. Lithium

Answer 9

Similar effectiveness for treating mania as lithium

Also effectively treats BP depression (unlike lithium)
*but not unipolar depression

Better tolerated than lithium

Question 10

Depakote: Mechanism of Action

Answer 10

Increases GABA activation and decreases Na+ ions

Modulates 5-HT and NE

Question 11

Depakote: Side Effects

Answer 11

Weight gain

Nausea

Sedation

Hair Loss

Tremor

Transaminitis, or a liver enzyme dysfunction

Polycycstic ovaries
*Harmful to fetus and fertility–neural tube defect 2ndary to reduction in folic acid

Question 12

“Depakote Loading”

Answer 12

Depakote is metabolized by the liver within 18 hours

Able to quickly increase levels within TWO DAYS in order to achieve therapeutic levels

Question 13

Lamictal, general

Answer 13

Anticonvulsant

Effective tx of bipolar depressive episodes

*Also be used to treat chronic pain

Question 14

Lamictal: Mechanism of Action

Answer 14

Theories:

Inhibition of Na+ channels

5-HT antagonism to increase DA and stabilize mood

Question 15

Lamictal: SJ Syndrome

Answer 15

Lamictal increases risk of Stevens-Johnson syndrome, a lethal rash

Requires strict monitoring and slow titration
*especially when paired with Depakote

Lamictal can also cause non-lethal rashes

Discontinue immediately if any rash develops
*readminister after medical testing to rule out SJ

Question 16

Lamictal: Side Effects

Answer 16

Biggest risk: SJ Syndrome

Nausea/vomiting

Sedation

Dizziness

Confusion

Ataxia

Question 17

AP: Seroquel, general

Answer 17

Atypical AP commonly used to treat bipolar disorder

Popularly prescribed to those with schizoaffective disorder

Reduces suicidal ideation and suicide attempts by 50%

Question 18

Anticonvulsants: Tegretol

Answer 18

Second line agent in bipolar disorder
*also used as adjunctive med for SZ

Indications:

• Acute Mania
• Mania prophylaxis
• Cyclothymia
• Mixed episodes

High side effects, drug-drug interactions, not very effective

Question 19

Mood Stabilizers: Tests prior to treatment

Answer 19

Baseline liver function

CBC

EKG

Pregnancy

Question 20

Depakote: Factors predicting a positive response

Answer 20

Rapid cycling patients (females>males)

Bipolar with mixed features

Comorbid substance issues

Comorbid anxiety disorders

Question 21

Mood stabilizers: Classes

Answer 21

Lithium and Anticonvulsants

Selection is based on symptoms and sfx profile

Question 22

Lithium: Potential Benefits

Answer 22

Increases density of gray matter
*Decreased risk of Alzheimer’s and dementia

Neurogenesis, promotes resilience of neurons, and protecting from stress effects

Question 23

Mood stabilizers: Indications

Answer 23

Bipolar Disorder

Cyclothymia

Schizoaffective Disorder

Impulse control and intermittent explosive disorders

Question 24

AP: Seroquel: Rapid Onset

Answer 24

Within 1 week Seroquel can:

• decrease core ax and dep sx
• improve QoL
• increase compliance rate of other medications

Question 25

The “1 - 2 Punch” tx of Bipolar Disorder

Answer 25

Lithium combined with Lamictal
*No interaction effects

Lithim for mania

Lamictal for bipolar depression

Question 26

Depakote: other indications

Answer 26

Anger

Social anxiety