Psychopharmacology - mood stabilisers

Question 1

Indications of mood stabilisers

Answer 1

• Bipolar depression
• Cyclomania
• Schizoaffective disorder

Question 2

Classes of mood stabilisers

Answer 2

• Lithium
• Anticonvulsants
• Antipsychotics

Question 3

Lithium

Answer 3

• Only psychotropic that reduces suicide rate
• Effective for long-term prophylaxis → mania and depressive episodes of BAD
• Factors indicating positive response → prior positive response, family members with response, classic pure mania, mania followed by depression

Question 4

Mechanism to use lithium

Answer 4

• Before
  
  • Baseline U’s and E’s and ash
  • Pregnancy test → teratogenic in first trimester
• Monitoring
  
  • Steady state after 5 days
  • Check 12 hours after last dose
  • 3 monthly check
  • 6 monthly check for TSH and creatinine clearance
• Goal → blood levels 0.6 -1.2

Question 5

Side effects of lithium

Answer 5

• Gi distress → reduced appetite, nausea/ vomiting, diarrhoea
• Thyroid abnormality
• Leuokocytosis
• Polyuria/ polydypsia → secondary to ADH antagonism
• Hair loss, acne
• Reduced seizure threshold, cognitive slowing, intentional tremor

Question 6

Lithium toxicity

Answer 6

• Mild → vomiting, diarrhoea, ataxia, dizziness, slurred speech, nystagmus
• Moderate → nausea, vomitting, anorexia, blurred vision, clonic limb movements, convulsions, delirium, syncope
• Severe → generalised convulsion, oliguria and renal failure

Question 7

Valproic acid (depakote)

Answer 7

• Ass effects as lithium in mania prophylaxis
• Not as effective in depression prophylaxis
• Factors predicting good response → rapid cycling patient, comorbid substance misuse, mixed patients, comorbid anxiety disorders
• Better tolerated than lithium

Question 8

Mechanisms of using valproic acid

Answer 8

• Before
  
  • Baseline LFT
  • Pregnancy test → highly teratogeniC, avoid in woman of childbearing age
• Monitoring
  
  • Steady state after 4-5 days
  • Check 12 hours after last dose
  • Repeat CBC and LFT
• Target → 50-125 serum level

Question 9

Side effects of valproic acid

Answer 9

• Thrombocytopenia and platelet dysfunction
• Nausea, vomiting, weight gain
• Sedation, tremor
• Risk of neural tube defect
• Hair loss

Question 10

Carbamazepine

Answer 10

• First line in acute mania and mania prophylaxis
• rapid cycling and mixed patients

Question 11

Mechanisms of using carbamazepine

Answer 11

• Before
  
  • baseline LFT
  • FBC
  • ECG
• Monitoring
  
  • Steady state after 5 days
• Goal → 4-12 mcg/ml

Question 12

Carbamazepine side effects

Answer 12

• Rashes
• Nausea, vomiting, diarrhoea
• Sedation, dizziness, ataxia, confusion
• AV conduction play
• Aplastic anaemia, agranulocytosis
• Water retention → vasopressin-like effects (hyponatremia)
• Many drug interactions

Question 13

Lamotrigine (lamictal)

Answer 13

• Similar indication to other anticonvulsants
• Also for neuropathic/ chronic pain
• Before → baseline LFT
• Slow titration to prevent rash
• Must titrate consistently or have restart from 25mg again

Question 14

Side effects of lamotrigine

Answer 14

• Nausea/ vomiting
• Sedation, dizziness, ataxia and confusion
• Stevens-johnsons syndrome and epidermal necrolysis
• Blood dyscrasia → rare cases
• Drugs that increases serum lamotrigine level

Question 15

Antipsychotics as mood stabilisers