Mood Stabilizers edit
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General Overview edit
What is a mood stabilizer? edit
Historically, mood stabilizer has referred to pharmacotherapies that prevent mood episodes (i.e., manic episodes, hypomanic episodes, depressive episodes). However, as knowledge of psychopharmacology has grown, mood stabilizer now includes medications that decrease the frequency and/or severity of mood episodes and medications that target mood disorder symptoms (Malhi et al., 2018). Mood stabilizers are most commonly used to treat bipolar disorder but efficacy has been shown for borderline personality disorder and mood stabilizers are commonly used in conjunction with other antipsychotics to treat schizophrenia (Bauer et al., 2019; Orsolini et al., 2020).
The Three Classes of Mood Stabilizers edit
Lithium, antiseizure medications, and second-generation antipsychotics can be used as mood stabilizers (Kishi et al., 2021). Due to the broad range of medications that make up this type of medication, guidelines on first-line treatment (Kessing et al., 2018). As of 2020, the U.S. Food and Drug Administration and the E.U. European Medical Agency (EMA) has only approved valproate, carbamazepine, lamotrigine, and lithium for the treatment of mood disorders (Orsolini et al., 2020).
Efficacy edit
Although there is variability in the specific medication prescribed, pharmacological treatments are often the primary treatment for preventing relapse and reducing symptoms of bipolar disorder (Kishi et al., 2021). In response to the dearth of medication with mood stabilizing properties and the lack of agreed upon treatment guidelines, recent research has focused on determining which mood stabilizer and/or antipsychotic is better. Efficacy varies across medications, with Lithium having the most well-documented efficacy for the treatment of acute mania, prevention of depressive episode recurrence, as well as suicide and seld-harm prevention (Orsolini et al., 2020).
Defining ‘mood stabilizer’ edit
Despite the pervasive use of the term when discussing treatment for bipolar disorder, the term ‘mood stabilizer’ lacks a clear definition. The ambiguity of what constitutes a mood stabilizer has led to debate over the continued use of the term (Malhi et al., 2018). Proponents of replacing the term argue that there are too many consequences of its use. The most notable concern is that the lack of consensus on what constitutes a mood stabilizer has led to medications being used beyond their initial purpose and reputed usefulness. For example, medications that have only been shown to have short-term efficacy for manic or depressive symptoms are being used for chronic treatment without evidence of its long-term effectiveness (Malhi & Chengappa, 2017, as cited in Malhi et al., 2018). Despite these concerns, clients and practitioners also argue for the term's continued use. This is not only due to the frequency of use in our lexicon, but, according to Mahli and colleagues (2018), it also provides comfort and hope for patients, which are associated with positive treatment outcomes and improved effectiveness.
Controversial Issues edit
Lithium edit
Lithium is the first-line treatment in bipolar disorder as it remains the drug that has produced the most convincing evidence of prophylactic action and has undergone the longest periods of observation (Solmi et al., 2020). However, lithium has received negative attention for its possible serious side effects. Lithium has been shown to produce side effects related to renal, thyroid, and parathyroid function (Yatham et al., 2018). More importantly, lithium has a narrow therapeutic window meaning that small differences in dose or blood concentration may lead to serious therapeutic failures and/or adverse drug reactions that are life-threatening or result in persistent or significant disability or incapacity (Food and Drug Administration). Lithium toxicity, and the consequential serious side effects, can occur if too high of levels are prescribed, or if a patient intentionally takes more than intended.
Physical and Health Risks edit
The adverse physical and health risks of mood stabilizers has been contended over time. Research by Wu and colleagues (2018) found that all mood stabilizers except lithium and lamotrigine were associated with an increased risk of stroke. Specifically, carbamazepine and valproic acid carried a significantly increased risk of stroke. The combined use of antipsychotics, antidepressants, and mood stabilizers carried the highest stroke risk and should be taken into consideration when assessing a client's medications and lifestyle factors. Furthermore, although Tournier and colleagues’ study (2022) found that there was not an increased risk of dementia for those taking mood stabilizers, this conclusion was not found for antipsychotics.
Developmental concerns edit
There has been much debate about medication management during pregnancy. Pregnancy and pre-pregnancy exposure to mood stabilizers may harm fetal development as results suggest mood stabilizers valproic acid and lamotrigine significantly increased the risk of offspring developing ADHD, while pre-pregnancy lithium exposure showed a strong association with higher Autism Spectrum Disorder risk (Yeh et al., 2021). For adolescents, medication should be closely monitored as it is a time of crucial development. The main adverse events for mood stabilizers were sedation and weight gain. Moreso, adolescents may experience negative side effects as compliance for this age group is especially low (less than 40% according to a study on bipolar disorder) (Munch & Godart, 2017).
Considerations for Use of Mood Stabilizers with Diverse Populations edit
Incarcerated individuals edit
A study done in 2016 found that incarcerated individuals tend to be given liquid mood stabilizers so that the jails can avoid the chances of "checking", where individuals push their medication to the side where a nurse or the person administering the medication, cannot see, in order to spit out the medication after the check. However, these mood stabilizers specifically, valproic acid (Depakene) is more irritating to the stomach than divalproex sodium (Depakote) (Simpson, 2016). They also found that mood stabilizers like valproic acid/divalproex sodium, or oxcarbazepine (Trileptal) are often prescribed to individuals who do not have any classic symptoms of bipolar disorder, but who are agitated and aggressive (Simpson, 2016).
The Journal of American Academy of Psychiatry and the Law (2018) reported that the use of divalproex sodium was being used for impulsivity and mood lability in those without bipolar disorder. Along with similar results for those with impulsive aggression and violence, not linked to bipolar disorder, were receiving lithium.
Psychiatric patients edit
In a study conducted by Lähteenvuo and colleagues (2018), they had found that the prescription of mood stabilizers were the only medication to be associated with a decreased risk of relapse of the participants readmitting to a psychiatric hospital.
McIntyre and Calabrese (2019) found that an estimated 40-50% of patients in their study were nonadeherent or partially adherent in their treatment with medications. They tied this to the fear of medication dependence, perceiving that the medication is ineffective, and the stigma of being on medication (p. 2000). They further state that if a patient is on lithium, divalproex, or carbamazepine, they would need to have the serum medication levels monitored to ensure that they are within a therapeutic range (McIntyre & Calabrese, 2019).
In a study conducted by Lin and colleagues on the time it takes for patients with bipolar mania, who are taking a long-acting injectable (LAI) or oral antipsychotics, to be rehospitalized, they found that LAIs were better than oral antipsychotics in reducing the chances of a patient's risk of being rehospitalized. They found that it took participants longer to be rehospitalized if they were using mood stabilizers, if they experienced mania at a later age of onset, fewer previous hospitalizations, and shorter hospital stay during their hospitalization. They also found that if a patient uses LAIs, it did not guarantee they were more likely to adhere to their medicine regime as compared to oral antipsychotics (Lin et al., 2021).
Pregnant women edit
Women who are diagnosed with bipolar disorder and then choose to stop taking medication during pregnancy may relapse in their symptoms. Therefore, cessation of mood stabilizers while pregnant may not be advised. (Haskey & Galbally, 2017). Some people are getting antiepileptic drugs (AEDs) prescribed because these are shown to be more effective than lithium (Haskey & Galbally, 2017).
Across the literature, results showed that higher doses of valproate given to pregnant women resulted in lower IQ scores of their children. Some neurodevelopmental issues have been found in babies when their mothers are taking valproate, especially if the dosage is high (Haskey & Galbally, 2017). Additionally, one study found that higher doses of valproate given to pregnant women was a “significant predictor of increased rates of autistic traits” (Haskey & Galbally, 2017). Researchers found that AEDs had the most to offer pregnant women who have been diagnosed with bipolar disorder without causing too many risks (Haskey & Galbally, 2017).
In a systematic review, Poels and colleagues (2018) discuss how the literature regarding pregnancy and usage of mood stabilizers is inconsistent. Some studies show that women who are pregnant and using mood stabilizers experience adverse pregnancy outcomes while others do not show this (Poels et al., 2018). This review concluded that pregnant women who are diagnosed with bipolar disorder should discuss their treatment options with clinicians. Additionally, they should be given enough information about the risks of lithium usage to make the independent choice to take it or not (Poels et al., 2018).
Persons who are homeless edit
In a 2019 study conducted in France, researchers explored how a cohort of the homeless population diagnosed with either schizophrenia or bipolar disorder was inappropriately prescribed medication (Fond et al., 2019). This study measured Potentially Inappropriate Psychotropic drugs (PIP) by examining whether a person who was both homeless and diagnosed with schizophrenia or bipolar disorder was given the right kind of medication or any medication at all (Fond et al., 2019). PIP was specifically defined by one of the following: an absence of background regimen (i.e., mood stabilizers for bipolar disorder), an absence of an antidepressant for major depressive disorder, and daily long-term anxiolytic or hypnotic prescription (Fond et al., 2019, p. 84). Based on this study, it appears that many of these homeless individuals were only prescribed medications that would alleviate symptoms momentarily rather than for the long-term (Fond et al., 2019).
Results from this study showed that 88% of participants had at least one PIP which indicates that prescribing the wrong medication or failing to prescribe appropriate medication may impact the homeless population (Fond et al., 2019). This means that mood stabilizers are not being prescribed to individuals who have severe bipolar disorder and are homeless and therefore they are not going to recover from their symptoms (Fond et al., 2019). One reason for this could be due to assuming that homeless individuals will misuse their prescriptions rather than take them seriously (Fond et al., 2019).
Recommendations & Considerations for Practice edit
Adherence edit
Clients’ medication adherence has been an ongoing concern for treatment using mood stabilizers. Partial or intermittent adherence is most common, and clients’ adherence changes over time (Jawad et al., 2018, as cited in Bauer et al., 2019). Nonadherence is associated with negative outcomes such as increased suicide and suicide attempts, relapse, voluntary and involuntary hospitalizations, emergency room visits, and involvement in the criminal justice system. Bauer and colleagues’ (2019) analysis of medication adherence among clients with bipolar I or II indicated that roughly one-quarter of participants were found to be “less adherent” (p. 1). However, it has recently been acknowledged that treatment adherence is affected by a number of individual and environmental factors such as patient attitudes towards medication, health literacy, clinical symptoms, and medication cost (Bauer et al., 2019). Thus, practitioners need to work with clients collaboratively to develop a treatment plan that minimizes adverse effects and optimizes client adherence.
Adverse events monitoring edit
Due to the known side effects of mood stabilizers and the influence of the safety and tolerability of medication on “ treatment adherence, patient’s compliance, and discontinuation rate”, Orsolini and colleagues (2020) argue that it is essential for practitioners to monitor for and identify treatment-emergent adverse effects and suicide risk in clients prescribed mood stabilizers.
Most importantly: Stay informed edit
Mood stabilizers are a complex class of medication with considerable amounts of controversy and considerations for diverse populations. Thus, practitioners need to do their due diligence and educate themselves on the current research when working with clients prescribed mood stabilizers.
References edit
Bauer, M., Glenn, T., Alda, M., Bauer, R., Grof, P., Marsh, W., Monteith, S., Munoz, R., Rasgon, N., Sagduyu, K., & Whybrow, P. C. (2019). Trajectories of adherence to mood stabilizers in patients with bipolar disorder. International Journal of Bipolar Disorders, 7(19), 1-9. https://doi.org/10.1186/s40345-019-0154-z
Fond, G., Tinland, A., Boucekine, M., Girard, V., Loubière, S., Auquier, P., & Boyer, L. (2019). Prescription of potentially inappropriate psychotropic drugs in homeless people with schizophrenia and bipolar disorders. Results from the French Housing First (FHF) program. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 89, 84-89. https://doi.org/10.1016/j.pnpbp.2018.08.024
Haskey, C. & Galbally, M. (2017). Mood stabilizers in pregnancy and child developmental outcomes: A systematic review. Australian & New Zealand Journal of Psychiatry, 51(11), 1087-1097. https://doi.org/10.1177/0004867417726175
Journal of the American Academy of Psychiatry and the Law. (2018, June 1). AAPLE practice resource for prescribing in corrections. http://jaapl.org/content/46/2_Supplement/S2
Kessing, L. V., Bauer, M., Nolen, W. A., Severus, E., Goodwin, G. M., & Geddes, J. (2018). Effectiveness of maintenance therapy of lithium vs other mood stabilizers in monotherapy and in combinations: A systematic review of evidence from observational studies. Bipolar Disorders, 20(5), 419-431. https://doi.org/10.1111/bdi.12623
Kishi, T., Sakuma, K., Okuya, M., Matsuda, Y., Esumi, S., Hashimoto, Y., Hatano, M., Miyake, N., Miura, I., Mishima, K., & Iwata, N. (2021). Effects of a conventional mood stabilizer alone or in combination with second-generation antipsychotics on recurrence rate and discontinuation rate in bipolar 1 disorder in the maintenance phase: A systematic review and meta-analysis of randomized, placebo-controlled trials. Bipolar Disorders, 23(8), 789-800. https://doi.org/10.1111/bdi.13053
Lähteenvuo, M., Tanskanen, A., & Taipale, H. (2018). Real-world effectiveness of pharmacologic treatments in bipolar disorder. JAMA Psychiatry, 75(4), 347-355. https://doi.org/10.1001/jamapsychiatry.2017.4711
Lin, C.-H., Chan, H.-Y., Hsu, C.-C., & Chen, F.-C. (2021). Time to rehospitalization in patients with bipolar mania discharged on long-acting injectable or oral antipsychotics. Journal of Affective Disorders, 279, 292-298. https://doi.org/10.1016/j.jad.2020.10.023
Mahli, G. S., Porter, R., Irwin, L., Hamilton, A., Morris, G., Bassett, D., Baune, B. T., Boyce, P., Hopwood, M. J., Mulder, R., Parker, G., Mannie, Z., Outhred, T., Das, P., & Singh, A. B. (2018). Defining a mood stabiliser: Novel framework for research and clinical practice. BJPsych Open, 4(4), 278-281. https://doi.org/10.1192/bjo.2018.36
McIntyre, R. S. & Calabrese, J. R. (2019). Bipolar depression: The clinical characteristics and unmet needs of a complex disorder. Current Medical Opinion and Research, 35(11), 1993-2005. https://doi.org/10.1080/03007995.2019.1636017
Munch, G. & Godart, N. (2017). Guidelines for the prescription of mood stabilizers for adolescents: A literature review. L’Encephale, 43(5), 464-470. https://doi.org/10.1016/j.encep.2016.09.005
Orsolini, L., Pompili, S., & Volpe, U. (2020). The ‘collateral side’ of mood stabilizers: Safety and evidence-based strategies for managing side effects. Expert Opinion on Drug Safety, 19(11), 1461-1495. https://doi.org/10.1080/14740338.2020.1820984
Poels, E. M. P., Bijma, H. H., Galbally, M., & Bergink, V. (2018). Lithium during pregnancy and after delivery: A review. International Journal of Bipolar Disorders, 6(26). https://doi.org/10.1186/s40345-018-0135-7
Simpson, J. (2016). Psychopharmacology in jails: An introduction. Carlat Psychiatry Report 14(5). https://www.thecarlatreport.com/the-carlat-psychiatry-report/psychopharmacology-in-jails-an-introduction/
Solmi, M., Fornaro, M., Ostinelli, E. G., Zangani, C., Croatto, G., Monaco, F., Krinitski, D., Fusar-Poli, P., & Correll, C. U. (2020). Safety of 80 antidepressants, antipsychotics, anti-attention-deficit/hyperactivity medications and mood stabilizers in children and adolescents with psychiatric disorders: A large scale systematic meta-review of 78 adverse effects. World Psychiatry, 19(2), 214-232. https://doi.org/10.1002/wps.20765
Tournier, M., Pambrun, E., Maumas-Robert, S., Pariente, A., & Verdoux, H. (2022). The risk of dementia in patients using psychotropic drugs: Antidepressants, mood stabilizers or antipsychotics. Acta Psychiatrica Scandinavica, 145(1), 56-66. https://doi.org/10.1111/acps.13380
Wu, C.-S., Wu, K.-Y., Lo, Y.-R., Huang, Y.-W., Tsai, Y.-T., Li, Y., & Tsai, H.-J. (2018). Psychotropic use and risk of stroke among patients with bipolar disorders: 10-year nationwide population based study. Journal of Affective Disorders, 226, 77–84. https://doi.org/10.1016/j.jad.2017.09.020
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