Mood-stabilizing medicines for bipolar disorder

Examples

The above medicines are taken as tablets or capsules (orally).

These medicines are available in syrup, tablet, capsule, and chewable tablet forms.

How It Works

Each of these medicines works similarly to treat bipolar disorder. Mood stabilizers balance certain brain chemicals (neurotransmitters) that control emotional states and behavior.

Valproate and divalproex have been approved as treatments for acute manic episodes in bipolar disorder.¹ Lamotrigine was recently approved for the long-term maintenance treatment of bipolar I disorder. These medicines, which are also called anticonvulsants, have been used for some time to treat seizures.

Why It Is Used

Lithium is usually one of the first medicines prescribed for bipolar disorder to treat mania and to prevent the return of both manic and depressive episodes.

Valproate, divalproex sodium, lamotrigine, and carbamazepine may be used during a manic episode or to prevent mood cycling between depression and mania.

Valproate may be taken along with lithium carbonate or antidepressants to avoid a depressive episode. Valproate is also used during manic episodes for people who do not respond well to lithium carbonate alone.

Carbamazepine is used to treat mania and may be used in people who cannot take or don't respond to lithium or valproate.

How Well It Works

Lithium carbonate may provide relief from acute episodes of mania or depression and can help prevent them from recurring.

Lithium is often helpful in treating manic episodes that are not mixed with any depressive mood.² Long-term use of lithium has been shown to reduce the risk of suicide related to bipolar disorder.¹

Divalproex has been shown to help reduce rapid cycling between moods and is effective in those with bipolar disorder who also have substance abuse or anxiety problems.²

Initial research shows that lamotrigine is effective in treating both depression and mania associated with bipolar disorder.² Lamotrigine improves mood, alertness, and the way you relate to others. It has also been shown to be an effective treatment for rapid cycling.³ Lamotrigine is usually taken alone, without other medicines normally used to treat bipolar disorder.

Side Effects

Side effects of lithium may include:

• Nausea, vomiting, and diarrhea.
• Trembling.
• Increased thirst and increased need to urinate.
• Weight gain in the first few months of use.
• Drowsiness.
• A metallic taste in the mouth.
• Abnormalities in kidney function.
• Abnormalities in thyroid function.

More serious side effects of lithium can include blacking out, slurred speech, changes in heart rhythm or a heart block, and an increase in the number of white blood cells (not usually because of an infection).

Side effects of valproate may include weight gain, drowsiness, low energy, stomach upset, changes in liver function, and problems with platelet functioning (thrombocytopenia). Uncommon side effects can include temporary hair loss, headaches, and confusion.

A warning label has been added to valproate injections and divalproex tablets and capsules that warns of a potential increase in pancreatitis associated with the use of these products. A recent study connected long-term use of valproate to the development of polycystic ovary syndrome in women.⁴ Using valproate during pregnancy significantly increases the risk of birth defects, including spina bifida. So women of childbearing age should use birth control or avoid becoming pregnant while on valproate and should talk to their doctor if they become pregnant.

Lithium carbonate also increases the risk of birth defects during pregnancy.⁵

Lamotrigine was well tolerated by people in initial studies. Some side effects occurred, including headaches, sleepiness, weight gain, and, most seriously, Stevens-Johnson syndrome, which causes dangerous sores on the mucous membranes of the mouth, nose, genitals, and eyelids. Serious negative side effects were uncommon. Rare side effects can include dizziness, blurred vision, nausea and vomiting, liver function problems, hypersensitivity reaction, and Stevens-Johnson syndrome. Although rare, a dangerous rash from lamotrigine may require hospitalization and may be life-threatening. If you develop a rash, fever, or swollen glands, stop taking lamotrigine and call your doctor right away.

Lamotrigine may increase the chance of birth defects. If you are pregnant or thinking about becoming pregnant, talk to your doctor before taking this medicine.

Side effects of carbamazepine may include nausea, vomiting, diarrhea, Stevens-Johnson syndrome, dizziness, blurred vision, drowsiness, and headache. Carbamazepine should not be taken during pregnancy.

The U.S. Food and Drug Administration (FDA) has issued a warning on anticonvulsants and the risk of suicide and suicidal thoughts. The FDA does not recommend that people stop using these medicines. Instead, people who take anticonvulsant medicine should be watched closely for warning signs of suicide. People who take anticonvulsant medicine and who are worried about this side effect should talk to a doctor.

See Drug Reference for a full list of side effects. (Drug Reference is not available in all systems.)

What To Think About

Do not stop taking these medicines suddenly. You should taper off of these drugs slowly with the help of your doctor to avoid negative and serious side effects.

High blood levels of lithium carbonate can be life-threatening. People who take lithium carbonate need to have their blood checked regularly to measure the amount of the drug in their blood.

Your doctor will need to periodically test the function of your kidneys and thyroid gland if you are taking lithium.

Sometimes other medicines cause higher- or lower-than-expected amounts of lithium carbonate in a person's blood. People who take lithium carbonate need to tell their doctors if they take other medicines.

Some mood stabilizers may interact negatively with other medicines. Be sure to talk with your doctor about any medicines you are taking.

Your doctor may want you to have regular blood tests while on valproate, divalproex, lamotrigine, or carbamazepine to check your medicine levels, liver function, and blood counts.

If you have been taking antidepressants but have not been able to control your episodes of depression or mania, you may want to ask your doctor about taking lamotrigine to treat bipolar disorder.

Making the decision about which medicines to use can be a very complicated issue in the treatment of bipolar disorder. Be sure to discuss all the options and side effects with your doctor. You may have to try several medicines or combinations of medicines before you find out what works best for you.

Taking medicines for bipolar disorder during pregnancy may increase the risk of birth defects. If you are pregnant, or thinking of becoming pregnant, talk to your doctor. Medicines may need to be continued if your bipolar disorder is severe. Your doctor can help weigh the risks of treatment against the risk of harm to your pregnancy.

If you must take medicines during pregnancy to treat bipolar disorder, the mood stabilizer lithium has been shown to have a lower risk of neural tube birth defects than carbamazepine. But lithium may raise the risk of other birth defects, such as heart defects.

The FDA has recommended that women of childbearing age not take divalproex sodium unless it is essential for treatment.

Complete the new medication information form (PDF) (What is a PDF document?) to help you understand this medication.

References

Citations

1. Müller-Oerlinghausen B, et al. (2002). Bipolar disorder. Lancet, 359(9302): 241-247.

2. Sachs GS, et al. (2000). Expert Consensus Guidelines Series: Medication Treatment of Bipolar Disorder. Available online: http://www.psychguides.com/gl-treatment_of_bp2000.html.

3. Calabrese JR, et al. (2001). Bipolar rapid cycling: Focus on depression as its hallmark. Journal of Clinical Psychiatry, 62(Suppl 14): 34-55.

4. American Psychiatric Association (2002). Practice guideline for the treatment of patients with bipolar disorder (revision). American Journal of Psychiatry, 159(4, Suppl):1-50.

5. Altshuler LL, et al. (1996). Pharmacologic management of psychiatric illness during pregnancy: Dilemmas and guidelines. American Journal of Psychiatry, 153(5): 592-606.

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