Mood Stabilisers

Mood stabilisers are used in day to day management of the condition.  They are used to maintain a person's mood at a stable level and help prevent future episodes of low or high mood. Some are also used to help control episodes of high mood (mania).

There are two types of mood stabiliser. The oldest and most widely used is lithium, but anticonvulsant medicines that are traditionally used to treat epilepsy have also proved to be effective mood stabilisers and are used either as an alternative to, or in combination with lithium.

How do they work?

It is still unclear how mood stabilisers work. Lithium is thought to modify the production and turnover of certain chemical compounds called neurotransmitters that are found in the brain. Neurotransmitters are involved in transmitting messages between the nerve cells in the brain. Serotonin and Dopamine are neurotransmitters that are involved in regulating mood, and it is thought that lithium may affect the activity of these compounds in the brain.

Anticonvulsants are also thought to work by affecting natural chemicals in the brain. It is thought that they increase the amount of a natural ‘nerve calming’ chemical called GABA, and reduce the amount of a natural ‘nerve exciting’ chemical called glutamate. This stabilises the electrical activity in the brain and is thought to explain how these medicines calm episodes of mania.

How long do they take to work?

Mood stabilisers may not begin to work immediately, and is important to keep taking them even if there seems to be no effect at first. Lithium may take a week or more to begin working. Anticonvulsants such as valproate may work more rapidly to control a manic episode. Other medicines such as antipsychotics or sedatives are usually used initially with the mood stabiliser to help control an episode of high mood while the mood stabiliser takes effect.

In general, people with bipolar disorder continue treatment with mood stabilisers for extended periods of time (sometimes years) to help prevent episodes of ill health. Other medicines may be added when necessary, typically for shorter periods, to treat episodes of mania or depression that break through despite the mood stabiliser.

Lithium

Lithium is a naturally occurring element that is consumed in small amounts in the diet. It is used in therapeutic doses as a medicine to treat episodes of high mood (mania), and is also effective in preventing the episodes of high and low moods once somebody is well. It is very clearly an effective drug, on average halving the risk of becoming unwell. Like all drugs in this class, it does not guarantee that an episode of ill health will never occur, but it does reduce the frequency and intensity of manic episodes. However, it is not as good in people with ‘rapid cycling’ bipolar disorder compared to those with a more classical form of the illness.

Lithium is available as two salts: lithium citrate (Li-liquid, Priadel liquid) and lithium carbonate (Camcolit, Liskonum, Priadel tablets). These are not equivalent to one another and the same brand of lithium should always be used. There are various other issues to be aware of when taking lithium, including the need for regular blood tests to monitor the level of lithium in the blood, the importance of maintaining an adequate fluid intake, and the potential problems of using certain other medicines at the same time. You can read about these in the lithium factsheets listed in the table at the end of this article.

Anticonvulsants

The first anticonvulsant to be discovered as an effective mood stabiliser as well as a treatment for epilepsy was carbamazepine (Tegretol). It is probably not quite as effective as lithium but may be better for rapid cycling bipolar illness. However, many people find that it causes unwanted side effects, and it can also interact with various other medicines.

The most commonly used anticonvulsant is valproate semi-sodium (Depakote) or sodium valproate (Epilim). This tends to cause fewer side effects than carbamazepine, works probably as well as lithium, but is better in rapid cycling disorder. While both medicines are very effective, the Depakote brand is the only form of valproate that is actually licensed for bipolar disorder, which is why any patient information leaflets you may be given with Epilim do not mention this use. 

A number of other anticonvulsants are now also being used as mood stabilisers in bipolar disorder. These medicines are also currently unlicensed for this use.

Lamotrigine (Lamictal) has been shown to be effective in treating episodes of low mood in bipolar disorder and probably also in reducing the risk of low mood. It's down side is that the dose needs to be increased slowly over a number of weeks to prevent a serious skin problem occurring, though this is usually not a problem.

Gabapentin (Neurontin) is widely used in the USA, but much less so in the UK. Recent research suggests it is ineffective in bipolar disorder and so it is no longer recommended. However, it may help to reduce the anxiety symptoms.

Other currently used anticonvulsants such as topiramate (Topamax), tiagabine (Gabitril) and vigabatrin (Sabril) are also being investigated in bipolar disorder. In addition new drugs are under development.

Some people with bipolar disorder do better with a combination of mood stabilisers to help prevent episodes of high and low mood. For example, an anticonvulsant may be used together with lithium or with another anticonvulsant.

For more detailed information about specific mood stabilisers click on the links below.

Mood Stabilisers

Camcolit*		Sodium valproate
Carbamazepine*	Li-Liquid*	Tegretol*
Convulex	Liskonum*	Tegretol Retard*
Depakote*		Teril Retard*
Epilim		Trileptal
Epilim chrono	Orlept
Epimaz*
Epival CR	Priadel liquid*	.
Lamictal	Priadel tablets*	.
Those that are licensed as mood stabilisers are marked with *