Four mood stabilizers in common use: lithium, valproic acid, carbamazepine/oxcarbazepine, and lamotrigine (Table 200-4). Lithium is the gold standard and the best studied, and along with carbamazepine and valproic acid, is used for treatment of acute manic episodes; 1–2 weeks to reach full effect. As prophylaxis, the mood stabilizers reduce frequency and severity of both manic and depressed episodes in cyclical mood disorders. In refractory bipolar disorder, combinations of mood stabilizers may be beneficial.

TABLE 200-4: Clinical Pharmacology of Mood Stabilizers
LithiumCommon Side Effects

Starting dose: 300 mg bid or tid

Therapeutic blood level: 0.8–1.2 meq/L

Nausea/anorexia/diarrhea, fine tremor, thirst, polyuria, fatigue, weight gain, acne, folliculitis, neutrophilia, hypothyroidism

Blood level is increased by thiazides, tetracyclines, and NSAIDs

Blood level is decreased by bronchodilators, verapamil, and carbonic anhydrase inhibitors

Rare side effects: Neurotoxicity, renal toxicity, hypercalcemia, ECG changes

Valproic AcidCommon Side Effects

Starting dose: 250 mg tid

Therapeutic blood level: 50–125 µg/mL

Nausea/anorexia, weight gain, sedation, tremor, rash, alopecia

Inhibits hepatic metabolism of other medications

Rare side effects: Pancreatitis, hepatotoxicity, Stevens-Johnson syndrome

Carbamazepine/OxcarbazepineCommon Side Effects

Starting dose: 200 mg bid for carbamazepine, 150 mg bid for oxcarbazepine

Therapeutic blood level: 4–12 µg/mL for carbamazepine

Nausea/anorexia, sedation, rash, dizziness/ataxia

Carbamazepine, but not oxcarbazepine, induces hepatic metabolism of other medications

Rare side effects: Hyponatremia, agranulocytosis, Stevens-Johnson syndrome

LamotrigineCommon Side Effects
Starting dose: 25 mg/d

Rash, dizziness, headache, tremor, sedation, nausea

Rare side effect: Stevens-Johnson syndrome

Abbreviations: ECG, electrocardiogram; NSAIDs, nonsteroidal anti-inflammatory drugs.

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