This document outlines mood stabilizers, including lithium, valproate, carbamazepine, and antipsychotic agents. It discusses their pharmacologic actions, therapeutic indications, dosages, guidelines, and precautions. Mood stabilizers are used to treat bipolar disorder and other conditions by decreasing the frequency and severity of manic and depressive episodes. Key precautions include risks during pregnancy, adverse effects like weight gain and liver toxicity, and the need for monitoring. Mood stabilizers are an important treatment option for bipolar disorder but require awareness of safety considerations.

1. MOOD
STABILIZERS
BY: Nur Liyana binti ABD Malek
Supervisor: Prof Ramli

2. Outlines
Pharmacologic actions
Dosage and clinical guidelines
Precautions and adverse
reactions
Therapeutic indications
The examples

3. MOOD STABILISERS
Lithium Valproate LamotrigineCarbamazepine
Anti psychotic
agent
Others

4. Lithium
◦ Used for short-term and prophylactic treatment of bipolar I disorder.
◦ Absorbed by GIT
◦ Does not bind to plasma proteins, not metabolized in liver
◦ ½ life: 20 hours, equilibrium: 5-7 d of regular intake
◦ Excretion:
◦ through kidney (decreased clearance in renal insufficiency & after delivery,
◦ increased in pregnancy
BBB permits only slow passage of lithium (a single overdose of Li
does not necessarily toxicity)
Pharmacologic actions

5. Therapeutic indications
◦Bipolar 1 disorder
◦Major depressive disorder
◦Schizoaffective disorder and
schizophrenia
 Manic episodes : control acute
mania and prevent relapse, slow
onset of action and exerts its
antimanic effect over 1 to 3
weeks
 Bipolar depression: effective in
the treatment of depression
associated with bipolar type 1
 Maintenence : decreases the
frequency, the severity and the
duration of manic and
depressive episodes.
 Effective against in the long
treatment of major depressive
disorder
 Not more effective than
antidepressant drug
 Person with predominant mood
symptom in schizoaffective are
more likely react to Lithium
rather than those with
predominant psychotic
symptom.
 As augmentation agent.
 As the treatment of choice for
schizoaffective are dopamine
receptor antagonist, serotonin-
dopamine antagonist
 For schizophrenia patient that
do not tolerate with anti-
psychotic drug

6. Precaution and adverse effect
• Start with low dose firstElderly person
• Don’t start Lithium in 1st trismester (Ebstein anomaly (20
x HR)
Pregnant lady
• Need to evaluate potential risk and benefit as lithium is
excreted into breast milk
Breastfeed mother

7. • Nausea, decreased appetite, vomiting and diarrheaGIT
• Lithium induce hypothyroidism, lithium induced edemaWeight gain
• Tremor, cognitive effect (dysphoria, lack of spontaneousity, slowed reaction times and impaired
memory)
Neurological
• Polyuria and polydipsia, Nonspecific interstitial fibrosis (10 years), renal failure, nephrotic
syndrome
Renal
• Benign reversible exophthalmos, hyperthyroidism, hypothyroidismThyroid
• ECG: resemble of hypokalemia, T- wave flattening or inversion
• Sinus dysrhythmias, heart block and syncope.
Cardiac
• Dose dependent: acneiform, follicular and muculopapular eruption, pretibial ulceration,
worsening psoriasis
Dermatological

9. Dosage and clinical guideline
Baseline
investigations
• Renal profile
• Thyroid function
• Full blood count
• ECG
• Pregnancy test
Serum & plasma
concentrations of
lithium
• Every 2 to 6
months
• Except :
• Non-
compliant
• Toxicity
• Dosage
adjustment
*1 to 1.5mEq/L in acute mania
0.4 to 0.8 mEq/L in maintenance
Acute mania: 600 – 1800
mg/day in divided doses
Maintenance dose: 300 –
1200 mg/day in divided
doses
(Desired serum level : 0.6 -
1.2 mEq/L not exceeding
1.5 mEq/L) To be used
with caution and correlate
clinically
#CPG Bipolar disorder

10. Valproate
◦ More preferable than lithium
◦ Epilim
◦ Also being used in treatment of seizure and migraine prophylaxis
◦ Absorbed 1 to 2 hours after oral administration,
◦ Plasma half life: 10 to 16 hours
◦ Highly protein bound
◦ Metabolized in liver
Pharmacologic actions

11. Therapeutic indications
Bipolar 1 disorder
Acute mania, mixed episodes, acute bipolar depression, prophylaxis
Schizophrenia and schizoaffective (accelerate response to AP’s drug)
Other mental disorder
(alcohol withdrawal and relapse prevention, panic disorder, PTSD,
impulse control disorder, behavioural agitation and dementia)

12. Precautions and adverse reaction
• Please avoid use it. May cause spina bifida (1st trimester)Pregnant lady
• Not contraindicationBreastfeeding mother
• Please avoid use itHepatic disease patient

13. • Hepatotoxicity (rare cause of death in patient older than 10 years old)Liver
• Pancreatitis (rare)Pancreas
• Thrombocytopenia, platelet dysfunctionHaematological
• Nausea, vomiting, dyspepsia, diarrheaGIT
• Tremor, sedation, ataxia, dysarthriaNervous
• In long term treatmentWeight gain
Hair loss

15. Dosage and clinical guideline
◦ Acute Mania: 600 - 2500
mg/day in divided doses
◦ Maintenance dose: 400 -
2000 mg/day in divided
doses
◦ (Desired serum level 50-
100 µg/mL @ 347-693
µmol/L)
◦ #CPG Bipolar disorder
Baseline
investigations
• Liver function
test
• Serum amylase
After 1 month of
therapy
• Full blood count
• Liver function
test
• Pregnancy test

16. Carbamezapine
◦ Tegral
◦ Also used in partial and generalized onset epilepsy and trigeminal
neuralgia.
◦ Absorption is slow and unpredictable
◦ Protein bound
◦ Metabolised in liver
Pharmacologic actions

17. Therapeutic indications
Bipolar disorder
(acute mania, prophylaxis, acute depression)
Other disorders
(alcohol withdrawal)

18. • Nausea, vomiting, constipation, diarrhea, anorexiaGIT
• sedation, ataxiaNervous
Not cause weight gain
• Blood dyscriasis (aplastic anemia, agranulocytosis)haematological
• hepatitisLiver
• Benign maculopapular rash, exfoliative dermatitis, erythema multiforme, steven Johnson
syndrome, toxic epidermal necrolysis
Dermatological
Renal
Cardiac effect
• Hyponatremia, water intoxication
• Exacerbate cardiac disease

20. Dosage and clinical guideline
◦ Mania/mixed episodes
◦ 200 to 1600 mg/day in
divided doses (Desired
serum level 4-12 mg/L @
1750 µmol/L)
◦ #CPG Bipolar disorder
Laboratory
monitoring
 Full blood count
 Liver function test
 Renal profile
 ECG

21. Antipsychotic: act as mood stabilizers
◦Olanzapine (can be used in maintenance phase)
◦Respiridone
◦Aripripazole
◦Quatiapine
◦Paliperidone
◦Asenapine

22. Other mood stabilizing agent
◦ Symbax (olanzapine and fluoxetine)
◦ Levitiracetam (keppra)
◦ Oxcarbazepine (trileptal)

23. Take home messages
1. Mood stabilizers is one of the treatment of bipolar
disorder
2. Lithium and valproate are contraindication in
pregnancy
3. Carbamezapine can cause steven Johnson syndrome
4. It is important to remember the side effect of the
medication as it will alter the management.

24. References
◦ Kaplan & Saddock’ s pocket handbook of clinical psychiatrist
◦ CPG Management of Bipolar Disorder in Adults

25. THANK YOU 