Mood Stabilizers

Question 1

Indications of mood stabilisers

Answer 1

Bipolar, cyclothymia, schizoaffective,

Question 2

Classes of mood stabilisers

Answer 2

Lithium, anticonvulsants, antipsychotics

Question 3

What is the only medication to reduce suicide rate

Answer 3

Lithium

Question 4

Lithium is effective in

Answer 4

Long-term prophylaxis of both mania and depressive episodes in 70% of bipolar affective disorder

Question 5

Factors predicted + response to lithium

Answer 5

Prior long-term response or family member with good response
Classic pure mania
Mania is followed by depression

Question 6

How should lithium be used (before starting)

Answer 6

Get baseline U+E and TSH.

In women check a pregnancy test- during the first trimester is associated with Ebstein’s anomaly 1/1000

Question 7

Monitoring of lithium treatment

Answer 7

Steady state achieved after 5 days- check 12 hours after last dose. Once stable check level 3 months and TSH and creatinine 6 months.

Question 8

Blood level goal of lithium

Answer 8

0.6-1.0

Question 9

Side effects of lithium

Answer 9

Most common are GI distress including reduced appetite, nausea/vomiting, diarrhea
Thyroid abnormalities
Nonsignificant leukocytosis
Polyuria/polydypsia secondary to ADH antagonism. In a small number of patients can cause interstitial renal fibrosis.
Hair loss, acne
Reduces seizure threshold, cognitive slowing, intention tremor

Question 10

Mild lithium toxicity

Answer 10

1-5-2 presents with vomiting, diarrhea, ataxia, dizziness, slurred speech, nystagmus

Question 11

Moderate lithium toxicity

Answer 11

2-2.5 nausea, vomiting, anorexia, blurred vision, clonic limb movements, convulsions, delirium, syncope

Question 12

Severe lithium toxicity

Answer 12

> 2.5 generalised convulsions, oliguria and renal failure

Question 13

Valproic acid

Answer 13

Is as effective as lithium in mania prophylaxis but is not as effective in depression prophylaxis

Question 14

Factors predicting a positive response in valproic acid

Answer 14

rapid cycling patients (females>males)
comorbid substance issues
mixed patients
Patients with comorbid anxiety disorders

Question 15

Before Valproic acid is started

Answer 15

baseline liver function tests (lfts), pregnancy test and FBC

Question 16

Avoid Valproic acid in

Answer 16

Women of child bearing age

Question 17

Monitoring of Valproic acid

Answer 17

Steady state achieved after 4-5 days -check 12 hours after last dose and repeat CBC and lfts
target level is between 50-125

Question 18

Side effects of valproic acid

Answer 18

Thrombocytopenia and platelet dysfunction
Nausea, vomiting, weight gain
Sedation, tremor
Increased risk of neural tube defect 1-2% vs 0.14-0.2% in general population secondary to reduction in folic acid
Hair loss

Question 19

Carbamazepine

Answer 19

First line agent for acute mania and mania prophylaxis. Indicated for rapid cyclers ad mixed patients.

Question 20

Before carbamazepine started

Answer 20

baseline liver function tests, FBC and an ECG

Question 21

Monitoring of carbamazepine

Answer 21

Steady state achieved after 5 days -check 12 hours after last dose and repeat CBC and lfts
Goal: Target levels 4-12mcg/ml

Question 22

Side effects of carbamazepine

Answer 22

Rash- most common SE seen
Nausea, vomiting, diarrhea
Sedation, dizziness, ataxia, confusion
AV conduction delays
Aplastic anemia and agranulocytosis (<0.002%)
Water retention due to vasopressin-like effect which can result in hyponatremia
Drug-drug interactions!

Question 23

Lamotrigine (lamictal) indications

Answer 23

Similar to other anti-convulsants and neuropathic/chronic pain

Question 24

Before lamotrigine started

Answer 24

baseline liver function tests

Question 25

Initiation/titration of lamotrigine

Answer 25

start with 25 mg daily X 2 weeks then increase to 50mg X 2 weeks then increase to 100mg- faster titration has a higher incidence of serious rash

Question 26

Side effects of lamotrigine

Answer 26

Nausea/vomiting
Sedation, dizziness, ataxia and confusion
The most severe are toxic epidermal necrolysis and Stevens Johnson’s Syndrome. The character/severity of the rash is not a good predictor of severity of reaction. Therefore, if ANY rash develops, discontinue use immediately.
Blood dyscrasias have been seen in rare cases.
Drugs that increase lamotrigine levels: VPA (doubles concentration, so use slower dose titration), sertraline.