Mood Stabilizers (Anti-manic Medications)

Anti-manic medications treat a mental illness called bipolar disorder. Bipolar disorder, or manic-depressive illness, is characterized by cycling mood changes: severe highs (mania) and lows (depression). Cycles may be mostly manic or depressive with normal mood between cycles. Episodes usually last several days to several weeks, if untreated. Some people switch back and forth between depression and mania, and some will have mostly repeated manic episodes. Mood swings sometimes follow each other very closely, or they may be separated by months or years. These "highs" and "lows" can vary in intensity and severity.

When someone is in a manic "high," that person may be overactive, extremely talkative and have a tremendous amount of energy. People with bipolar switch quickly from one topic to another as if their thoughts cannot get out fast enough. Attention span is often short, and these people can easily be distracted. Sometimes, someone who is "high" becomes irritable or angry and has false or inflated ideas about their importance in the world, or feels elated and full of grand schemes ranging from business deals to romantic sprees. Often, poor judgment shows in these ventures. Mania, if untreated, may worsen to a psychotic state.

People with bipolar with dramatic manic episodes and relatively mild depression have bipolar disorder type 1. Those who have more severe depressions and more mild manic episodes are considered to have type 2.

Almost always, mania is followed by depression - a "low" mood, lack of energy, changes in eating and sleeping, feelings of hopelessness, helplessness, sadness, worthlessness and guilt, and sometimes thoughts of suicide. Some people have a hard time functioning in day-to-day life during both manic and depressive episodes. While many people with the condition do well between episodes, some are always ill. For most people, medication is the only way to control symptoms, allowing them to enjoy and participate in a full and normal life. Lithium, anticonvulsants and antipsychotics are the main types of drugs used for bipolar. Some benzodiazepines also may be prescribed for short-term manic and occasionally on an ongoing basis.

Lithium

Lithium is the medication used most often to control a manic "high." Mania is usually paired with subsequent or preceding depression. Lithium evens out mood swings in both directions. Someone may have one episode of bipolar and never have another, or be free of symptoms for several years. However, for those who have more than one episode, staying on lithium is usually recommended.

Lithium reduces severe manic symptoms in about five to 14 days, but it may take anywhere from days to several months until the condition is fully controlled. Antipsychotics are sometimes used in the first several days of treatment to control manic symptoms until the lithium starts working. Then, antidepressants may be needed along with lithium during the depressive phase. Response to treatment with lithium varies for each person, and the doctor cannot tell beforehand who will do well on it.

Side effects

Lithium levels must be checked every so often to be sure how much medication is in the body. This may be checked often when the medication is started but eventually may be checked every few months if there are no signs of there being too much in the body. If too little lithium is taken, lithium won't work. If too much is taken, side effects may occur. The range between an effective dose and a toxic one is small. How much lithium someone needs may change over time, depending on the severity of the illness, body chemistry and the person's physical condition.

Considerations with lithium

Lithium either may not be recommended or may be given with caution when a person has existing thyroid, kidney, or heart disorders, epilepsy, or brain damage. Keeping tabs on your thyroid is part of treatment with lithium because of a possibility of the thyroid gland becoming underactive or enlarged. You may need a thyroid hormone pill along with lithium.

Women of childbearing age should be aware that lithium increases the risk of birth defects. Special caution should be taken during the first three months of pregnancy.

Many factors, including dangerous interactions with other medications, affect lithium levels. An unusual amount of exercise, fever, vomiting, diarrhea or a switch to a low-salt diet can cause body changes that interfere with lithium levels. Also, some diuretics, or anything that removes water from the body, can increase the level of lithium to dangerous levels. Other diuretics, like coffee and tea, can lower the level of lithium.

A serious lithium overdose can be life-threatening. But, with regular monitoring by your doctor, lithium is a safe drug that helps many people lead normal lives.

Anticonvulsants

Not everyone with mania symptoms gets relief through lithium. Some do best with anticonvulsants - drugs that are usually used to treat epilepsy. Carbamazepine (Tegretol®, Equetro®) is an anticonvulsant prescribed for people with bipolar disorder who rapidly change from mania to depression and back again over hours or days, rather than months.

Valproic acid (Depakene®) can be as effective as lithium in controlling mania. Because valproic acid can cause liver problems, blood tests to check the liver should be done before starting medication and then regularly, particularly during the first six months.

Lamotrigine (Lamictal®) was approved as a maintenance therapy along with standard medications. It has been effective in delaying disordered mood episodes (depression and mania). A rare but serious side effect is a rash called Steven-Johnson syndrome that may need hospitalization. For this reason, people taking lamotrigine should call the doctor immediately. The dose is increased very slowly to reduce the risk of this type of rash.

Antidepressants

Occasionally, people with bipolar are given antidepressants during depressive episodes. However, antidepressants are less likely to be used for extended periods in bipolar disorder patients because these drugs can increase the risk of a switch to a manic episode.

Children, teens and adults being treated with antidepressants, particularly people being treated for depression, should be watched closely for worsening of depression and for increased suicidal thinking or behavior. Close watching may be especially important early in treatment or when the dose is changed - either increased or decreased. Bring up your concerns immediately with your doctor.

Paxil may increase the risk for birth defects, particularly heart defects, when women take it during the first three months of pregnancy, according to a 2005 advisory from the Food and Drug Administration (FDA). The FDA is waiting for the results of recent studies to better understand the higher risk. Discuss with your doctor about the health risks of Paxil if you plan to become pregnant or are in the first three months of pregnancy. You may want to consider taking a different antidepressant. Do not stop taking the drug without first talking to your doctor.

Antipsychotics

Antipsychotics commonly have been used to treat acutely manic patients and sometimes on a long-term basis.

Related Articles Mental Health: Questions for Your Doctor Medication Index for Mental Health Conditions Antidepressant Medications Antianxiety Medications Antipsychotic Medications Mental Health Glossary What Is Psychotherapy?

External Sources National Institute of Mental Health Depression and Bipolar Support Alliance Physicians' Desk Reference The Food and Drug Administration

This article was reviewed and updated June 2007.

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