Mood Stabilizers - Hyperexcision

Last updated: March 9, 2025

Table Of Contents

Overview
Lithium
Valproic acid
Carbamazepine
Lamotrigine

Overview

Mood stabilizers are drugs that are used to stabilise manic, mixed, and depressive episodes. They do not induce alternate mood symptoms AND prevent future relapse into manic, mixed, or depressive episodes.

Selected mood stabilizers

Mood stabilizer	Nota bene
Lithium	Oldest and best mood stabilizer (1949). First-line treatment for Bipolar I, Bipolar II, and Schizoaffective disorder (alongside antipsychotics)
Valproic acid (Divalproex)	Preferred for acute mania, rapid-cycline bipolar disorder, or if lithium is innefective
Carbamazepine (Tegretol)	Second-line mood stabilizer due to its side effect.
Lamotrigine (Lamicta)	Preferred for pregnant patients (due to teratogenic effects of lithium and valproate). Effective against depressive phases
Gabapentin	Has only mild mood-stabilizing effects

4 phase process in the treatment of Bipolar Disorder
1. Evaluation and diagnosis
2. Acute care and crisis stabilization
3. Full recovery from depression/mania
4. Maintenance of euthymia

Lithium

Lithium is the treatment of choice for Bipolar Disorder and Schizoaffective Disorder (alongside antipsychotic). The mechanism is not fully understood but is theorized to interfere with the formation of inositol triphosphate and cAMP. Lithium is not metabolized by the liver and is excreted unchanged by the kidney. Serum lithium levels should be monitored and kept below 1.5 mEq/L (therapeutic window is 0.8-1.2 mEq/L). Ensure the patient is hydrated and consider dialysis if the patient has very high lithium levels. Despite its narrow therapuetic range, lithium is actually the safest mood stabilizer in case of overdose (provided renal function is preserved). Lithium is HIGHLY TERATOGENIC and should be avoided in pregnancy since it causes Ebstein’s anomaly.

Lithium toxicity

Serum levels	Clinical features
1.5 mEq/L	coarse tremor, arrhythmia, dysarthria, ataxia, nausea, diarrhoea, nystagmus
2.5 mEq/L	+ seizures, + coma
> 3 mEq/L	+ death

Investigations before prescribing Lithium
- Electrocardiogram
- Thyroid function tests
- Complete blood count
- Pregnancy test
- Fasting blood glucose
- Lipid profile
- Renal function test
Investigations after prescribing lithium
- Lithium blood levels: every 3 months after a stable dose is reached. Blood should be drawn 12 hours post-dose
- Thyroid and renal function test: every 6 months
EKG changes seen in lithium toxicity (similar to hypokalemia)
- ST depression
- T wave flattening or inversion
- QT prolongation
Adverse effects of Lithium (LITHIUMS)
- Leukocystosis
- Increased irritation
- Thirsty (polydypsia ,polyuria) and Tremors
- Hair thinning (alopecia) and Hypothyrodism (and thyroid enlargment)
- Interactions with other drugs
- stomach Upset (and weight gain)
- Muscle weakness
- Skin lesions and psoriasis
  - Idiopathic intracranial hypertension
Contraindications of lithium
- Pregnancy
What is the best way to keep lithium levels low (but therapeutic)?
- Adequate hydration
Treatment of Lithium toxicity
- Dialysis
- Diuresis

Valproic acid

Valproic acid is the treatment of choice for acute mania, rapid cycling, mixed state OR if Lithium is ineffective. Valproate is ineffective in the depressive phase.

Valproate is ALSO TERATOGENIC (Causes neural tube defects e.g. spina bifida)

Adverse effects
- Cognitive dulling
- CNS symptoms: sedation, tremor, dizziness, ataxia, headache
- GI symptoms: abdominal pain, nausea, vomiting, diarrhea, constipation, weight gain

Carbamazepine

Carbamazepine is a second-line treatment for mood disorders due to its complications – severe agranulocytosis and hepatotoxicity. Therefore, draw blood for CBC and LFTs when prescribing. Most effective for mixed state and rapid cycling (> 4 mood episodes per year). Caution when prescribed with OCPs (lower efficacy of contraceptives)

Which group of patients with mood disorders do we avoid using Carbamazepine?
- Patients with pre-existing liver disease
Adverse effects
- Significant sedation
- Hepatotoxicity
- Agranulocytosis

Lamotrigine

Lamotrigine is best used for the depressive phase and in women of childbearing age.

Adverse effects
- Sedation
- Dizziness
- Nausea or emesis
- Diplopia

Reference Intervals ›

Biochemistry

ACTH	P: <80 ng/L
ALT	P: 5–35 U/L
Albumin	P: 35–50 g/L
Aldosterone	P: 100–500 pmol/L
Alk. phosphatase	P: 30–130 U/L
α-Amylase	P: 0–180 IU/dL
α-Fetoprotein	S: <10 kU/L
Angiotensin II	P: 5–35 pmol/L
ADH	P: 0.9–4.6 pmol/L
AST	P: 5–35 U/L
Bicarbonate	P: 24–30 mmol/L
Bilirubin	P: 3–17 μmol/L
BNP	P: <50 ng/L
CRP	P: <10 mg/L
Calcitonin	P: <0.1 mcg/L
Calcium (ionized)	P: 1.0–1.25 mmol/L
Calcium (total)	P: 2.12–2.60 mmol/L
Chloride	P: 95–105 mmol/L
Cholesterol	P: <5.0 mmol/L
VLDL	P: 0.128–0.645 mmol/L
LDL	P: <2.0 mmol/L
HDL	P: 0.9–1.93 mmol/L
Cortisol AM	P: 450–700 nmol/L
Cortisol Midnight	P: 80–280 nmol/L
CK ♂	P: 25–195 U/L
CK ♀	P: 25–170 U/L
Creatinine	P: 70–100 μmol/L
Ferritin	P: 12–200 mcg/L
Folate	S: 2.1 mcg/L
FSH	P: 2–8 U/L ♂; >25 menopause
GGT ♂	P: 11–51 U/L
GGT ♀	P: 7–33 U/L
Glucose (fasting)	P: 3.5–5.5 mmol/L
Growth hormone	P: <20 mu/L
HbA1C (DCCT)	B: 4–6%
HbA1C (IFCC)	B: 20–42 mmol/mol
Iron ♂	S: 14–31 μmol/L
Iron ♀	S: 11–30 μmol/L
Lactate (venous)	P: 0.6–2.4 mmol/L
Lactate (arterial)	P: 0.6–1.8 mmol/L
LDH	P: 70–250 U/L
LH	P: 3–16 U/L
Magnesium	P: 0.75–1.05 mmol/L
Osmolality	P: 278–305 mosmol/kg
PTH	P: 0.8–8.5 pmol/L
Potassium	P: 3.5–5.3 mmol/L
Prolactin ♂	P: <450 U/L
Prolactin ♀	P: <600 U/L
PSA	P: 0–4 mcg/mL
Protein (total)	P: 60–80 g/L
Red cell folate	B: 0.36–1.44 μmol/L
Renin (erect)	P: 2.8–4.5 pmol/mL/h
Renin (recumbent)	P: 1.1–2.7 pmol/mL/h
Sodium	P: 135–145 mmol/L
TBG	P: 7–17 mg/L
TSH	P: 0.5–4.2 mU/L
T4	P: 70–140 nmol/L
Free T4	P: 9–22 pmol/L
TIBC	S: 54–75 μmol/L
Triglycerides	P: 0.50–2.3 mmol/L
T3	P: 1.2–3.0 nmol/L
Troponin T	P: <0.1 mcg/L
Urate ♂	P: 210–480 μmol/L
Urate ♀	P: 150–390 μmol/L
Urea	P: 2.5–6.7 mmol/L
Vitamin B12	S: 0.13–0.68 nmol/L
Vitamin D	S: 50 nmol/L

Arterial Blood Gases

pH	7.35–7.45
PaCO₂	4.7–6.0 kPa
PaO₂	>10.6 kPa
Base excess	±2 mmol/L

Urine

Cortisol (free)	<280 nmol/24h
Hydroxyindole acetic acid	16–73 μmol/24h
Hydroxymethylmandelic acid	16–48 μmol/24h
Metanephrines	0.03–0.69 μmol/mmol cr.
Osmolality	350–1000 mosmol/kg
17-Oxogenic steroids ♂	28–30 μmol/24h
17-Oxogenic steroids ♀	21–66 μmol/24h
17-Oxosteroids ♂	17–76 μmol/24h
17-Oxosteroids ♀	14–59 μmol/24h
Phosphate (inorganic)	15–50 mmol/24h
Potassium	14–120 mmol/24h
Protein	<150 mg/24h
Protein/creatinine ratio	<3 mg/mmol
Sodium	100–250 mmol/24h

Haematology

WCC	4.0–11.0 ×10⁹/L
RBC ♂	4.5–6.5 ×10¹²/L
RBC ♀	3.9–5.6 ×10¹²/L
Hb ♂	130–180 g/L
Hb ♀	115–160 g/L
PCV ♂	0.4–0.54 L/L
PCV ♀	0.37–0.47 L/L
MCV	76–96 fL
MCH	27–32 pg
MCHC	300–360 g/L
RDW	11.6–14.6%
Neutrophils	2.0–7.5 ×10⁹/L (40–75%)
Lymphocytes	1.0–4.5 ×10⁹/L (20–45%)
Eosinophils	0.04–0.44 ×10⁹/L (1–6%)
Basophils	0–0.10 ×10⁹/L (0–1%)
Monocytes	0.2–0.8 ×10⁹/L (2–10%)
Platelets	150–400 ×10⁹/L
Reticulocytes	0.8–2.0% / 25–100 ×10⁹/L
Prothrombin time	10–14 s
APTT	35–45 s

Paediatric

Pulse Rate (bpm)
Neonate	140–160
Infant <1yr	120–140
1–5 years	110–130
5–12 years	80–120
>12 years	70–100
Respiratory Rate (tachypnoea)
0–2 months	≥60/min
2–12 months	≥50/min
1–5 years	≥40/min
>5 years	≥30/min
Blood Pressure (mmHg)
Term	65/45
1 year	75/50
4 years	85/60
8 years	95/65
10 years	100/70
Weight Formulas
3–12 months	(a + 9)/2 kg
1–6 years	2a + 8 kg
>6 years	(7a − 5)/2 kg
Haemoglobin (g/dL)
Term newborn	13–20
1 month	11–18
2 months	10–15
1–2 years	10–13
>2 years	11–14
MUAC (6 months–5 years)
Obese	>17.5 cm
Normal	13.5–17.4 cm
At risk	12.5–13.4 cm
Moderate malnutrition	11.5–12.4 cm
Severe malnutrition	<11.5 cm
Developmental Milestones
Social smile	1.5 months
Head control	4 months
Sits unsupported	7 months
Crawls	10 months
Stands unsupported	10–12 months
Walks	12–13 months
Talks	18 months
CSF WBC (/mm³)
Term newborn	0–25
>2 weeks	0–5

Calculator ›

Overview

Lithium

Valproic acid

Carbamazepine

Lamotrigine

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