MOOD

STABILIZERS
 WHAT IS MOOD STABILIZER

• “Any medication that was able to decrease vulnerability to subsequent episodes of mania
or depression and not exacerbate the current episode or maintenance phase of treatment“.
• Ideally any agent that possesses triple threat" properties (antimanic, antidepressant,
prophylactic) in the management of bipolar disorder.
• “Class A" mood stabilizers - Stabilize mood from above baseline and possess marked
antimanic properties without causing a worsening of depression.
• “Class B” mood stabilizers - Stabilize mood from below baseline and possess marked
antidepressant properties without destabilizing the course of illness by inducing switches
into mania or episode acceleration.
 CLASSIFICATION

• LITHIUM • ATYPICAL ANTIPSYCHOTICS

• ANTICONVULSANTS 1. ARIPIPRAZOLE
1. CARBAMAZEPINE 2. LURASIDONE
2. DIVALPROEX 3. OLANZAPINE
3. LAMOTRIGINE 4. OLANZAPINE+FLUOXETINE
5. QUETIAPINE
• TYPICAL ANTIPSYCHOTICS 6. RISPERIDONE
1, CHLORPROMAZINE 7. ZIPRASIDONE
8. ASENAPINE
2. HALOPERIDOL
COMMONLY USED MOOD STABILIZERS

1. LITHIUM
2. DIVALPROEX
3. LAMOTRIGINE
4. OLANZAPINE
5. ARIPIPRAZOLE
6. QUETIAPINE
7. ZIPRASIDONE
8. RISPERIDONE
LITHIUM

• It reduces motor activity, decrease euphoria, relieves insomnia and stabilizes the mood in bipolar disorder.

• Has slow onset of action (5-7 days are required for clinical effect) hence antipsychotic drugs (chlorpromazine or
haloperidol) with or without potent benzodiazepines (lorazepam or clonazepam) is preferred for initial therapy.
Also Sodium valproate can provide rapid antimanic effects.
• Can be used for prevention of recurrent manic and depressive episodes

• Li+ is the only mood stabilizer suicide reduction in bipolar patients.

• Prescribed as Lithium Carbonate/Citrate.

• MOA – It reduces the formation of inositol triphosphate (IP3) by inhibiting inositol monophosphatase, hence
decrease phosphatidyIinositol-4,5 -bisphosphate (PIP2) which are markedly increased during manic episode. It
mimic the role of Na+ , It also decrease NA and DA in brain.
• Approximately 30% patients of mania and bipolar disorder (especially rapidly cycling cases) show incomplete
or poor response to lithium
LITHIUM

• Therapeutic uses –

• 1- Prophylaxis and treatment of mania

• 2- Prophylaxis of and maintenance treatment of bipolar disorders (in combination with antidepressants)

• 3-Lithium augmentation (prophylaxis of recurrent depression) in unipolar depression and schizophrenic patients who don’t
respond to treatment (i.e. Used in patients who don’t have mania)

• Lithium has narrow therapeutic index , hence TDM is essential for optimal therapy.

• Dose – 1800mg/day in acute attack , 900-1200 mg/day in maintenance.

• Not recommended for use in patient with severe renal or cardiovascular disease, dehydration, or sodium depletion.

• It also induces weight gain in women than in men.

SODIUM VALPROATE

• Advantages of Sodium Valproate over Lithium: Rapid action, Wider therapeutic index, Better tolerability.

• A reduction in manic relapses when valproate is used in bipolar disorder.

• Now First line treatment of acute mania in which high dose valproate acts faster than lithium.

• Useful in those not responding to lithium or not tolerating it and patient with rapid cycling pattern.

• A combination of lithium and valproate may succeed in cases resistant to monotherapy with either drug.

• its use as prophylactic in bipolar disorder has better than that of lithium.

• Combination of valproate with an atypical antipsychotic has high efficacy in acute mania.

• Divalproex, a compound of valproate, is more commonly used due to better gastric tolerance

• Dose – 1200 – 1500 mg/day for mania

CARBAMAZEPINE

• It was found to prolong remission in bipolar disorder.

• It is less effective than lithium or valproate in acute mania, bcz acute mania requires rapidly acting
drug, while effective doses of carbamazepine have to be gradually built up.
• In high dose it has neurotoxicity property and are poorly tolerated.

• Compared to lithium and valproate, It is not preferred for long-term prophylaxis of bipolar disorder

• Nevertheless, it is a valuable alternative/adjunct to lithium.

• Dose – 400-1200 mg/day

• An extended-release formulation has better evidence in bipolar disorder than immediate-

release carbamazepine.
• It may be effective for depressed phase of bipolar disorder and for maintenance.
LAMOTRIGINE

• For prophylaxis of depression in bipolar disorder.

• It is not effective for treatment as well as prevention of mania.
• It is now extensively used in the maintenance therapy of type II bipolar disorder, because in this
condition risk of inducing mania is minimal.
• Lamotrigine can be combined with lithium to improve its efficacy.
• The tolerability profile of lamotrigine is favourable.
• Dose – Monotherapy (100-200 mg/day started as 25 mg/day for 2 weeks) Adjunctive (100 mg/day
with valproate) and (400mg/day with antiepileptic drug)
ARIPIPRAZOLE

• It is a dopamine partial agonist ,

• Favoured drug for treatment of mania in bipolar I disorder. Used both as monotherapy as well as
adjuvant to lithium or valproate.
• Maintenance therapy with aripiprazole prevents mania, but not depressive episodes.
• Lack of metabolic effects, favours its long-term use.
• Used in Acute agitation associated with bipolar disorder (IM)
• Dose – 15-30 mg/day for mania and 2-10 mg/day for augmenting SSRIs/SNRIs in depression.
OLANZAPINE

• It is serotonin- dopamine antagonist.

• Approved for maintenance therapy of bipolar disorder, Though both manic and depressive phases
are suppressed, it is not considered suitable for long-term therapy due to higher risk of weight gain,
hyperglycaemia.

• It can be used in Acute agitation associated with bipolar I mania (IM) , Bipolar depression
(in combination with fluoxetine) and also Treatment-resistance depression (in
combination with fluoxetine)
• Dose – 10-20 mg/day oral/IM , 6-12 mg /25-50 mg fluoxetine , 210-300 mg/2 weeks
(depot).
• Its disadvantages is weight gain.
QUETIAPINE

• More effective in bipolar depression.

• Combination of an atypical antipsychotic with valproate or lithium has demonstrated high efficacy
in acute phases as well as for maintenance therapy of bipolar disorder.
• Not for stabilizing patient in long term maintenance, and it has more sedation than other
antipsychotic.
• Dose – 400-800 mg/day in 1 dose quetiapine XR or 2 dose in quetiapine and 300 mg OD for biporal
mania.
• Can be used for Bipolar maintenance, Acute mania in adult , Depression.
RISPERIDONE

• It is a Serotonin-dopamine antagonist.
• Used in Acute mania/Mixed mania as Monotherapy and adjunct with lithium or valproate.
• Can be use as Bipolar maintenance (long-acting microsphere intramuscularly
Monotherapy or as adjunct)
• Dose – 2-8 mg/day orally for acute psychosis and bipolar disorder.
ZIPRASIDONE

• It is a serotonin-dopamine antagonist
• Used in Acute mania/Mixed mania and in bipolar maintenance and bipolar depression.
• Dose – 80-160 mg/day orally or 10-20 mg IM
SUMMARY

Manic phase Recurrence Depressive Phase

• Lithium carbonate • Lithium carbonate • Olanzapine plus fluoxetine

• Valproic add • Valproic add • Quetiapine

• Carbamazepine • Carbamazepine
• Chlorpromazine
• lamotrigine
• Aripiprazole

• Olanzapine

• Quetiapine

• Risperidone

• Ziprasidone
THANK YOU