Mood stabilizing agents

1. Mood stabilizing
agent
MS SHARIKA RATISH
ASSISTANT PROFESSOR
MENTAL HEALTH NURSING

2. Introduction
 Any medication that is able to decrease vulnerability to
subsequent episodes of mania or depression and not
exacerbate the current episode or maintenance phase off
treatment. - Sachs 1996
 Mood stabilizers are used for the treatment of bipolar affective
disorders.

3. Brief history
 1817 – Lithium was discovered as a
chemical element.
 1871 – First recorded use as a treatment of mania.
 1876 – Li2CO3 used in the prevention of
depression.
 By the beginning of 20th century - use of
Lithium largely abandoned due to its toxicity.
 1949 – Use of Lithium for mania rediscovered
by John Cade.
 1970- FDA approved use of Lithium for mania.
 1995- Sodium valproate approved for acute mania.

4. Drugs used as mood stabilizers
 Lithium
 Anticonvulsants- Carbamazepine, Sodium Valproate,
Lamotrigine, Gabapentin & Pregabalin, Topiramate etc.
 Atypical antipsychotics - Olanzapine, Quetiapine,
Risperidone, Aripiprazole .

5. Indications
 acute mania
 Prophylactic for bipolar and unipolar mood disorder.
 Schizo affective disorder
 Cyclothymia.
 impulsivity and aggression.
 other disorders
 premenstrual dysphoric disorder
 bulimia nervosa
 borderline personality disorder

6. Pharmacokinetics
 lithium is readily absorbed with peak plasma level occurring two to
four hours after a single oral dose of lithium carbonate.
 Lithium is distributed rapidly in liver and kidney and more slowly in
muscle, brain and bone .
 Elimination is through kidney. It is reabsorbed in the proximal tubules
and is influenced by sodium balance. Depletion of sodium can
precipitate lithium toxicity.

7. Mechanism of action
 it accelerate presynaptic reuptake and destruction
of catecholamines, like norepinephrine.
 It inhibits the release of catecholamines at the synapse.
 It decreases post synaptic serotonin receptor sensitivity.
 all these action result in decreased catecholamines
activity.

8. Blood lithium level
 therapeutic level is equal to 0.8 -1.2 milliequivalent/L ( for
treatment of acute mania).
 Prophylactic levels equal to 0.6- 1.2 mEq/L ( for prevention of
relapse in bipolar disorder)
 toxic lithium levels more than 2.0 mEq/L

9. Side effects
 Neurological- tremors, motor hyperactivity,
muscular weakness, seizures, neurotoxicity.
 Renal - polydipsia, polyurea, tubular
enlargement, nephrotic syndrome.
 cardiovascular- T wave depression
 Gastrointestinal- nausea, vomiting,
diarrhea, abdominal pain and metallic taste.
 Endocrine- abnormal thyroid function,
goiter and weight again.
 Teratogenic effect during pregnancy and
lactation

10. Sign in symptom of lithium toxicity
 Ataxia
 coarse tremor
 Nausea and vomiting
 impaired memory
 impaired concentration
 nephro toxicity
 muscle weakness
 Convulsions
 muscle twitching's
 Dysarthria (slowed or slurred speech)
 Lethargy
 Confusion
 Coma
 hyperreflexia
 Nystagmus (involuntary eye movement)

11. Management of lithium toxicity
 discontinue the drug immediately.
 Gastric content should be removed gastric lavage and adsorption
by activated charcoal.
 If possible instruct the patient to ingest fluids
 maintain fluid and electrolyte balance.
 assess serum lithium levels, serum electrolytes, renal functions, ECG
as soon as possible.
 In a patient with serious manifestations of lithium toxicity,
hemodialysis should be initiated.

12. Contraindications
 cardiac, renal, thyroid or neurological dysfunctions.
 presence of blood dyscrasis.
 during 1st trimester of pregnancy and lactation.
 severe dehydration.
 Hypothyroidism
 history of seizures

13. Lithium pretreatment test
 a complete physical history, ECG, blood test, renal function
test, thyroid function test and urine examination must be
carried out

14. Nurses responsibility
 Baseline evaluation of the patient including ECG, liver function test, renal function
test.
 Serum lithium levels should be tested every 3–4 days during initial phase of
therapy, every 1–2 mos thereafter, and weekly if there is no improvement of
disorder or adverse effects occur.
 Lithium serum testing should be performed as close as possible to 12th hour after
last dose.
 mental status examination including assessment of behavior, appearance,
emotional status, response to environment, speech pattern, thought content are
done frequently to monitor therapeutic effect.
 Monitor for signs of lithium toxicity. Supervise suicidal risk pt closely during early
therapy (as depression lessens, energy level improves, and suicide potential
increases).
 If severe vomiting or diarrhea or high fever develops, it should be reported to the
physician

15. Patient / family education
 ask the patient to take the medication as directed preferably at the same time
daily; do not discontinue except on physician’s advice.
 Do not engage in activities requiring alert response until effects of drug are
known.
 Avoid activities causing excessive sweating.
 Thirst, frequent urination may occur.
 A fluid intake of 2–3 L liquid per day and maintenance of a normal salt intake are
necessary during initial phase of treatment to avoid dehydration.

16. Carbamazepine
 Indications in mood disorders
 Treatment of acute mania
 Prophylaxis of bipolar disorder
 Effectiveness in prophylaxis of
unipolar/ bipolar depression is not well
established.
 Overall efficacy is less than that of
Lithium.

17. Indications
 complex and partial seizures, seizures due to alcohol
withdrawal.
 psychiatric disorders like rapid cycling bipolar disorder, acute
depression, impulse control disorders, aggression, psychosis
with epilepsy, schizoaffective disorders, borderline
personality disorder cocaine withdrawal syndrome.
 Pain syndromes

18. Dosage
 The average daily dose is 600-1800 mg orally in divided doses.
 Therapeutic blood level = 6-12 µg/ml
 Toxic level more than 15 µg/ml

19. Side effects
 drowsiness, confusion headache, ataixia , hypertension, skin
rashes, nausea, vomiting, diarrhea, dry mouth, abdominal
pain, jaundice, hepatitis, oliguria,
leukopenia,thrombocytopenia ,bone marrow depression
leading to aplastic anemia

20. nurses responsibility
advise the patient to avoid driving and
other activities requireing alertness.
1
Advise patient not to consume
alcohol when he is on the drug.
2
Emphasize the importance of regular
follow up visits and periodic examinations
of blood count and monitoring of cardiac,
renal, hepatic and bone marrow functions.
3

21. Sodium valproate
 Indications
 acute mania, treatment of bipolar I
disorder, rapid cycling bipolar disorder
 seizures
 other disorders like bulimia nervosa,
obsessive compulsive disorder, agitation
and PTSD.

22. Mechanism of action
 the drug acts on gamma aminobutyric acid which
reduce the neuronal excitability.
 The usual dose is 15 milligram/kg/day with a
maximum of 60 milligram/ kg/ day orally.

23. Side effects
 nausea, meeting, vomiting, diarrhea, ataxia, sedation, weight gain, loss of
hair, thrombo cytopenia and platelet dysfunctions.
Nurses responsibility
 explain to the patient to take the drug immediately after food to reduce gastrointestinal
irritation.
 advice to come for regular follow up and periodic examination of blood count, hepatic
function and thyroid function.
 therapeutic serum level of valproic acid is 50- 100 ug/ml.

24. THANK YOU