Psych · Psychopharmacology — mood stabilisers
Mood stabilisers
Also known as Lithium · Valproate · Sodium valproate · Divalproex · Lamotrigine · Carbamazepine · Mood stabilizers · Anticonvulsant mood stabilisers
Exam-exhaustive fellowship psychopharmacology of mood stabilisers — lithium, valproate, lamotrigine, carbamazepine: mechanisms, levels, monitoring, toxicity and EXTRIP, teratogenicity hierarchy, BALANCE and maintenance evidence, enzyme-induction interactions, HLA-B*1502, pregnancy and contraception, when not to use valproate. FRANZCP-primary, globally tagged.
Practise this topic
On this page
Study tools
Your progress
Saved on this device.
Target exams
FRANZCPMRCPsychABPNMD-DNBNEET-SS
Red flags
- Lithium toxicity: coarse tremor, ataxia, dysarthria, vomiting, confusion — stop lithium, urgent level and renal panel, hydrate, escalate
- Valproate in a person who can become pregnant without documented pregnancy-prevention counselling — major teratogen; avoid as routine bipolar care
- Any concerning rash on lamotrigine or carbamazepine — stop the drug; SJS/TEN pathway until proven otherwise
- Starting carbamazepine in East/South-East Asian ancestry without HLA-B*1502 consideration where local guidance requires testing
- New confusion on valproate — consider hyperammonaemic encephalopathy even if LFT relatively preserved
- Oral contraceptive failure risk on carbamazepine (enzyme induction) — counsel backup contraception
Meet the patient
A 29-year-old woman is admitted in her second manic episode — three nights without sleep, spending thousands she does not have, grandiose, irritable. She is on the oral contraceptive pill but admits she forgets it most days. Her mother took lithium for years and "swore by it".[1][16]
Three questions land on the ward round at once, and the wrong answer to any of them fails the station: which pole are you treating, can she become pregnant, and can this service actually deliver the monitoring? Everything below exists to answer those three questions at consultant depth.[1][16][21]
References22ShowHide
- [1]Geddes JR, Goodwin GM, Rendell J, et al. Lithium plus valproate combination therapy versus monotherapy for relapse prevention in bipolar I disorder (BALANCE): a randomised open-label trial Lancet, 2010.PMID 20092882
- [2]Cipriani A, Hawton K, Stockton S, et al. Lithium in the prevention of suicide in mood disorders: updated systematic review and meta-analysis BMJ, 2013.PMID 23814104
- [3]Cipriani A, Barbui C, Salanti G, et al. Comparative efficacy and acceptability of antimanic drugs in acute mania: a multiple-treatments meta-analysis Lancet, 2011.PMID 21851976
- [4]Miura T, Noma H, Furukawa TA, et al. Comparative efficacy and tolerability of pharmacological treatments in the maintenance treatment of bipolar disorder: a systematic review and network meta-analysis Lancet Psychiatry, 2014.PMID 26360999
- [5]Geddes JR, Burgess S, Hawton K, et al. Long-term lithium therapy for bipolar disorder: systematic review and meta-analysis of randomized controlled trials Am J Psychiatry, 2004.PMID 14754766
- [6]Bowden CL, Brugger AM, Swann AC, et al. Efficacy of divalproex vs lithium and placebo in the treatment of mania. The Depakote Mania Study Group JAMA, 1994.PMID 8120960
- [7]Goodwin GM, Bowden CL, Calabrese JR, et al. A pooled analysis of 2 placebo-controlled 18-month trials of lamotrigine and lithium maintenance in bipolar I disorder J Clin Psychiatry, 2004.PMID 15096085
- [8]Calabrese JR, Bowden CL, Sachs GS, et al. A double-blind placebo-controlled study of lamotrigine monotherapy in outpatients with bipolar I depression. Lamictal 602 Study Group J Clin Psychiatry, 1999.PMID 10084633
- [9]Chung WH, Hung SI, Hong HS, et al. Medical genetics: a marker for Stevens-Johnson syndrome Nature, 2004.PMID 15057820
- [10]McCormack M, Alfirevic A, Bourgeois S, et al. HLA-A*3101 and carbamazepine-induced hypersensitivity reactions in Europeans N Engl J Med, 2011.PMID 21428769
- [11]Tomson T, Battino D, Bonizzoni E, et al. Dose-dependent risk of malformations with antiepileptic drugs: an analysis of data from the EURAP epilepsy and pregnancy registry Lancet Neurol, 2011.PMID 21652013
- [12]Meador KJ, Baker GA, Browning N, et al. Cognitive function at 3 years of age after fetal exposure to antiepileptic drugs N Engl J Med, 2009.PMID 19369666
- [13]Decker BS, Goldfarb DS, Dargan PI, et al. Extracorporeal Treatment for Lithium Poisoning: Systematic Review and Recommendations from the EXTRIP Workgroup Clin J Am Soc Nephrol, 2015.PMID 25583292
- [14]Nolen WA, Licht RW, Young AH, et al. What is the optimal serum level for lithium in the maintenance treatment of bipolar disorder? A systematic review and recommendations from the ISBD/IGSLI Task Force on treatment with lithium Bipolar Disord, 2019.PMID 31112628
- [15]Gitlin M Lithium side effects and toxicity: prevalence and management strategies Int J Bipolar Disord, 2016.PMID 27900734
- [16]Yatham LN, Kennedy SH, Parikh SV, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder Bipolar Disord, 2018.PMID 29536616
- [17]Sachs GS, Nierenberg AA, Calabrese JR, et al. Effectiveness of adjunctive antidepressant treatment for bipolar depression N Engl J Med, 2007.PMID 17392295
- [18]Okusa MD, Crystal LJ Clinical manifestations and management of acute lithium intoxication Am J Med, 1994.PMID 7942943
- [19]Tomson T, Battino D, Bonizzoni E, et al. Comparative risk of major congenital malformations with eight different antiepileptic drugs: a prospective cohort study of the EURAP registry Lancet Neurol, 2018.PMID 29680205
- [20]Gitlin M, Bauer M Lithium: current state of the art and future directions Int J Bipolar Disord, 2024.PMID 39609318
- [21]Malhi GS, Gessler D, Outhred T The use of lithium for the treatment of bipolar disorder: Recommendations from clinical practice guidelines J Affect Disord, 2017.PMID 28437764
- [22]Calabrese JR, Bowden CL, McElroy SL, et al. Spectrum of activity of lamotrigine in treatment-refractory bipolar disorder Am J Psychiatry, 1999.PMID 10401445