Mood stabilizers are psychotropic drugs which are used in controlling mood disorders.
Indications of Mood Stabilizers
The major indications are the following:
- Bipolar affective disorder with frequent fluctuation of mood at short intervals.
- Can also be used as maintenance drug in mood disorder.
However, patients with acute-phases of mania or depression should be treated first with anti-psychotics or anti-depressants respectively.
MODE OF ACTION
Mood stabilizers are a class of psychiatric medications that are primarily used to treat bipolar disorder, but can also be used for other conditions that involve mood swings or instability. The exact mode of action of mood stabilizers is not fully understood, but there are several theories that attempt to explain how they work.
One theory is that mood stabilizers work by regulating the levels of neurotransmitters in the brain, particularly serotonin, dopamine, and norepinephrine. These neurotransmitters are involved in the regulation of mood, and imbalances in their levels can lead to mood swings and instability. Mood stabilizers may help to normalize these imbalances, which can reduce symptoms of bipolar disorder and other mood disorders.
Second theory is that mood stabilizers work by modulating the activity of certain ion channels in the brain, particularly those that regulate the flow of sodium and calcium ions. These ion channels are involved in the regulation of neuronal excitability, and abnormalities in their activity can lead to mood swings and other symptoms of bipolar disorder. Mood stabilizers may help to normalize the activity of these ion channels, which can reduce symptoms of bipolar disorder and other mood disorders.
Third theory is that mood stabilizers work by affecting the structure and function of certain brain regions that are involved in the regulation of mood, such as the prefrontal cortex and the amygdala. These brain regions are thought to play a key role in the regulation of emotional processing and response, and abnormalities in their structure or function can lead to mood instability and other symptoms of bipolar disorder. Mood stabilizers may help to normalize the structure and function of these brain regions, which can reduce symptoms of bipolar disorder and other mood disorders.
Pharmacodynamics of Mood Stabilizers
Changes in heart rate and blood pressure: Some mood stabilizers, such as lithium, can affect the cardiovascular system and cause changes in heart rate and blood pressure. This is why people taking these medications may need to have regular check-ups to monitor their heart health.
Changes in electrolyte balance: Some mood stabilizers, such as lithium, can affect the balance of electrolytes in the body, particularly sodium and potassium. This can lead to side effects such as nausea, vomiting, diarrhea, and muscle weakness. When cerebral sodium concentration is reduced, there is control of mania which reduces excitements.
Changes in kidney function: Lithium is primarily excreted by the kidneys, and long-term use of this medication can sometimes lead to kidney damage or impairment. Regular kidney function tests may be required for people taking lithium.
Changes in thyroid function: Some mood stabilizers, such as lithium and valproic acid, can affect thyroid function and lead to hypothyroidism (an underactive thyroid). This can cause symptoms such as fatigue, weight gain, and cold intolerance.
Changes in liver function: Some mood stabilizers, such as valproic acid, can affect liver function and lead to elevated liver enzymes. Regular liver function tests may be required for people taking valproic acid.
Changes in metabolism: Some mood stabilizers, such as valproic acid, can affect metabolism and lead to weight gain.
LITHIUM CARBONATE (ESKALITH)
Lithium carbonate is a medication that is commonly used as a mood stabilizer to treat bipolar disorder. It is a naturally occurring element that is found in small amounts in the body, and it works by affecting the levels of certain neurotransmitters in the brain, particularly serotonin and norepinephrine.
Indications of Lithium Carbonate
- In bipolar affective where there are mood swings.
- Prophylaxis therapy (preventive measure which prolongs the re-occurrence).
- In aggressive disorders i.e. in personality disorders.
- Schizoaffective disorder.
Contra indications of Lithium Carbonate.
Allergies: People who are allergic to lithium carbonate or any of its ingredients should not take this medication.
Kidney disease: Lithium is primarily excreted by the kidneys, and people with kidney disease may be at risk of toxicity if they take lithium. Lithium is contraindicated in people with severe kidney disease or end-stage renal disease.
Dehydration: Lithium can affect the body’s electrolyte balance, particularly sodium, and dehydration can increase the risk of toxicity. People who are dehydrated or at risk of dehydration should not take lithium.
Cardiovascular disease: Lithium can affect the cardiovascular system, and people with a history of heart disease or other cardiovascular conditions may be at increased risk of complications if they take lithium.
Pregnancy and breastfeeding: Lithium can cross the placenta and pass into breast milk, and it may be harmful to a developing fetus or nursing infant. Lithium is contraindicated during pregnancy and breastfeeding, unless the benefits outweigh the risks.
Low sodium levels: Lithium can cause or worsen hyponatremia (low sodium levels in the blood), which can be life-threatening. Lithium is contraindicated in people with severe or uncontrolled hyponatremia.
Seizures: Lithium can lower the seizure threshold, and it is contraindicated in people with a history of seizures or epilepsy.
Thyroid disease: Lithium can affect thyroid function and may exacerbate hypothyroidism (an underactive thyroid). Lithium is contraindicated in people with severe hypothyroidism.
- The typical starting dose of lithium carbonate for the treatment of bipolar disorder is 300-600 mg per day, divided into two or three doses.
- The dosage is then gradually increased, usually by 300-600 mg per week, until a therapeutic blood level is achieved.
- Maintenance doses of lithium carbonate can range from 600-2400 mg per day, depending on the individual’s needs and the therapeutic blood level.
- Lithium carbonate is not typically prescribed for children under the age of 12, as there is limited research on its safety and efficacy in this population.
- For adolescents aged 12-18, the starting dose of lithium carbonate is 300 mg per day, divided into two or three doses.
- The dosage is then gradually increased as needed, usually by 150-300 mg per week, until a therapeutic blood level is achieved.
Note: When one is on the lithium carbonate, the following base line investigation should be done:
- Blood serum lithium level. The normal range 0.6-1.2 mEq/l (for prevention of relapse in BAD)
- Therapeutic levels 0.8-1.2mEq/l (for treatment of acute mania)
- Toxic lithium levels greater than 2.0 mEq/l
Other Investigations include;
Blood tests: A complete blood count (CBC) and blood chemistry panel should be done to assess the person’s overall health and to check for any underlying medical conditions that could affect their response to lithium. The blood chemistry panel should include tests for electrolyte levels (including sodium and potassium), kidney function, liver function, and thyroid function.
Urinalysis: A urinalysis should be done to assess kidney function and to check for any signs of kidney damage.
ECG: An electrocardiogram (ECG) should be done to assess the person’s heart function and to check for any underlying cardiac conditions that could affect their response to lithium.
Pregnancy test: Women of childbearing age should have a pregnancy test before starting lithium, as this medication can be harmful to a developing fetus.
Medical history: A thorough medical history should be taken to assess the person’s overall health, including any past or current medical conditions, medications, or allergies.
Psychiatric evaluation: A comprehensive psychiatric evaluation should be done to assess the person’s symptoms and to establish a diagnosis of bipolar disorder.
Baseline mood assessment: A baseline assessment of the person’s mood and behavior should be done to establish a baseline for monitoring the effects of the medication.
N.B: A patient on lithium carbonate should also be given thyroxin tablet (also known as levothyroxine), a medication that is used to treat an underactive thyroid gland (hypothyroidism). This is because lithium can affect the functioning of the thyroid gland
Lithium carbonate is generally well-tolerated when used as a mood stabilizer for the treatment of bipolar disorder. However, like any medication, it can cause side effects, both in the short term and the long term.
Short-term side effects of lithium can include:
- Nausea, vomiting, and diarrhea
- Dry mouth and thirst
- Increased urination
- Muscle weakness and tremors
- Fatigue and drowsiness
- Increased appetite and weight gain
- Mild cognitive impairment (difficulty with attention, memory, or problem-solving)
- Skin rash or acne
- Dysarthria (impaired articulation of speech).
- Cardiac arrhythmias.
- In some patients they may have oedema.
Many of these side effects are usually mild and may resolve on their own as the body adjusts to the medication. Some people may be able to manage these side effects by adjusting the dosage or timing of their medication, or by taking it with food or milk.
Long-term use of lithium can cause more serious side effects, including:
- Kidney damage or kidney failure
- Hypothyroidism (underactive thyroid gland)
- Increased risk of diabetes mellitus
- Cardiovascular disease (heart disease)
- Neurological effects (such as hand tremors, slurred speech, and impaired coordination)
- Teratogenicity (birth defects in fetuses exposed to lithium during pregnancy)
- Hypothyroidism i.e. reduced thyroxin in the body as lithium carbonate interferes with metabolism
- Nephrogenic diabetes insipidus
- Depletion of calcium in bones
- Memory impairment affects memory centers of the brain.
NB: Big doses of neuroleptics e.g. haloperidol when used together with lithium for a long time may cause irreversible toxic encephalopathy.
Management of lithium toxicity
The following are some general principles for managing lithium toxicity:
Stop taking lithium: The person should stop taking lithium immediately to prevent further toxicity.
Fluid and electrolyte replacement: Intravenous fluids may be given to help flush out the excess lithium from the body and to restore electrolyte balance.
Supportive care: The person may need to be hospitalized for close monitoring of their vital signs and mental status. In severe cases, mechanical ventilation and dialysis may be necessary.
Pharmacological treatment: Depending on the severity of the symptoms, the person may be given medications to help control nausea, vomiting, seizures, or other symptoms.
- Assess serum lithium levels, serum electrolytes, renal functions, ECG as soon as possible.
- Maintenance of fluid and electrolyte balance
- In a patient with serious manifestations of lithium toxicity, hemodialysis should be initiated.
- For significant short time ingestions, residual gastric content should be removed by induction of emesis, gastric lavage and adsorption with activated charcoal
- If possible instruct the patient to ingest fluids
NURSE’S RESPONSIBILITIES FOR PATIENT RECEIVING LITHIUM
Assessment: Nurses should perform a thorough assessment of the patient before starting lithium treatment, including a physical examination, medical history, and laboratory tests to establish baseline values. Nurses should also monitor the patient regularly for potential side effects or adverse reactions.
Education: Nurses should educate the patient and their family members about the proper use of lithium, including the dosage, timing, and potential side effects. They should also instruct the patient to avoid dehydration and to maintain a consistent level of sodium intake.
Medication administration: Nurses should administer lithium carbonate according to the prescribed dosage and timing. They should also monitor the patient’s compliance with the medication regimen and report any missed doses or concerns to the healthcare provider.
Monitoring: Nurses should monitor the patient regularly for potential side effects or adverse reactions, such as tremors, confusion, or kidney dysfunction. They should also monitor the patient’s blood levels of lithium, electrolytes, and kidney function regularly and report any abnormalities to the healthcare provider.
Collaboration: Nurses should collaborate with the healthcare provider and other members of the healthcare team to ensure the safe and effective use of lithium carbonate. They should also communicate any concerns or changes in the patient’s condition to the healthcare provider in a timely manner.
The pre-lithium work up: A complete physical history, ECG, blood studies (FBS, creatinine, electrolytes) urine examination (routine and microscopic) must be carried out. It is important to assess renal function as renal side effects are common and the drug can be dangerous in an individual with compromised kidney function. Thyroid functions should also be assessed, as the drug is known to depress the thyroid gland.
To achieve therapeutic effect and prevent lithium toxicity, the following precautions should be taken:
- Lithium must be taken on regular basis, preferably at the same time daily. For example, a client taking lithium on TID schedule, who forgets a dose, should wait until the next scheduled time to take lithium and not take twice the amount at one time, because lithium toxicity can occur.
- When lithium therapy is initiated, mild side effects such as fine tremors, increased thirst and urination, nausea, anorexia etc may develop.
- Serious side effects of lithium that necessitate its discontinuance include vomiting, extreme hand tremors, sedation, muscle weakness and vertigo. The psychiatrist should be notified immediately if any of these effects occur.
- Since polyurea can lead to dehydration with risk of lithium intoxication, patients should advised to drink water to compensate for the fluid loss
- Various situations can require an adjustment in the amount of lithium administered to a client, such as the addition of a new medicine to the client’s drug regimen, a new diet or an illness with fever or excessive sweating. People involved in heavy outdoor labor are prone to excessive sweating sodium loss through sweating. Must be advised to consume large quantities of water with water with salt, to prevent lithium toxicity due to decreased sodium levels.
- Frequent serum lithium level evaluation is important. Blood for determination of lithium levels should be drawn in the morning approximately 12-14 hours after the last dose was taken.
- The patient should be told about the importance of regular follow up. In every six months, blood sample should be taken for estimation of electrolytes, urea, creatinine, a full blood count, and thyroid function test.
SODIUM VALPROATE (EPILIM)
Sodium valproate is a medication used to treat a variety of neurological and psychiatric conditions. It belongs to a class of drugs called anticonvulsants, which are typically used to treat epilepsy, but sodium valproate has also been found to be effective in treating bipolar disorder, migraine headaches, and certain types of seizures.
Mode of action
Sodium valproate works by increasing the levels of a neurotransmitter called gamma-aminobutyric acid (GABA) in the brain, which helps to calm overactive neurons and prevent seizures. It also has mood-stabilizing properties that make it effective in treating bipolar disorder.
- Adults: The usual starting dose is 600-1000 mg per day, divided into two or three doses. The maintenance dose may be increased gradually up to 2500-3000 mg per day, as needed.
- Children: The starting dose is usually 10-15 mg/kg/day, divided into two or three doses. The maintenance dose may be increased gradually up to 30-60 mg/kg/day, as needed.
- Elderly: The starting dose may be lower, usually around 250-500 mg per day, divided into two or three doses. The maintenance dose may be increased gradually up to 2000 mg per day, as needed.
For Bipolar Disorder:
- Adults: The starting dose is usually 500-750 mg per day, divided into two or three doses. The maintenance dose may be increased gradually up to 2000-2500 mg per day, as needed.
- Children: The starting dose is usually 10-15 mg/kg/day, divided into two or three doses. The maintenance dose may be increased gradually up to 60 mg/kg/day, as needed.
- Elderly: The starting dose may be lower, usually around 250-500 mg per day, divided into two or three doses. The maintenance dose may be increased gradually up to 2000 mg per day, as needed.
Indications of Sodium Valproate
Epilepsy: Sodium valproate is used to prevent and control seizures in patients with epilepsy, including generalized and partial seizures, absence seizures, and myoclonic seizures.
Bipolar disorder: Sodium valproate is used as a mood stabilizer in the treatment of bipolar disorder, which is characterized by episodes of mania and depression.
Migraine prophylaxis: Sodium valproate is sometimes used to prevent migraines, particularly in patients who do not respond to other treatments or who have frequent, severe, or long-lasting migraines.
Neuropathic pain: Sodium valproate may be used to treat certain types of neuropathic pain, such as trigeminal neuralgia and diabetic neuropathy.
Agitation and aggression: Sodium valproate may be used to treat agitation and aggression in patients with dementia, autism, or other psychiatric conditions.
Alcohol withdrawal: Sodium valproate may be used to treat alcohol withdrawal symptoms, such as seizures and delirium tremens.
- Gastrointestinal effects: Nausea, vomiting, diarrhea, and abdominal pain are common side effects of sodium valproate.
- Weight gain: Sodium valproate can cause weight gain and changes in appetite.
- Sedation and drowsiness: Sodium valproate can cause sedation and drowsiness, which can affect the ability to operate machinery or drive.
- Tremor: Sodium valproate can cause tremors, which are involuntary movements of the hands, arms, or other body parts.
- Hair loss: Sodium valproate can cause hair loss, although this side effect is usually reversible.
- Liver toxicity: Sodium valproate can cause liver toxicity in some patients, especially those who are taking other medications that affect the liver or who have pre-existing liver disease.
- Blood disorders: Sodium valproate can affect blood cells, leading to anemia, low platelet counts, and increased risk of bleeding.
- Pancreatitis: In rare cases, sodium valproate can cause inflammation of the pancreas, which can be a serious and potentially life-threatening condition.
- Hypersensitivity: Sodium valproate should not be used in patients who have had an allergic reaction to it in the past.
- Liver disease: Sodium valproate can cause liver toxicity, so it should be used with caution or avoided altogether in patients with pre-existing liver disease or abnormal liver function tests.
- Pancreatitis: Sodium valproate can cause inflammation of the pancreas, so it should not be used in patients with a history of pancreatitis.
- Pregnancy: Sodium valproate can cause birth defects and other developmental problems in fetuses, so it should be avoided in pregnant women or used only if the benefits outweigh the risks.
- Breastfeeding: Sodium valproate can pass into breast milk and harm a nursing baby, so it should not be used in breastfeeding women or used only if the benefits outweigh the risks.
- Urea cycle disorders: Sodium valproate can cause hyperammonemia, which is an increase in ammonia levels in the blood, in patients with urea cycle disorders, a group of rare genetic conditions that affect the body’s ability to eliminate ammonia.
Carbamazepine is a medication used primarily to treat seizures and nerve pain, such as trigeminal neuralgia. It works by reducing the excessive electrical activity in the brain that can cause seizures and by reducing the sensitivity of nerve fibers, which can help to relieve pain. Carbamazepine belongs to a class of medications called anticonvulsants, which are also used to treat bipolar disorder and mood disorders.
- In epilepsy especially in complex partial seizure (drug of choice)
- Rapid cycling
- Acute mania.
- Trigeminal neuralgia i.e. inflammation of the trigeminal nerve.
- Herpes zoster
- Schizoid affective disorder
Children: The starting dose for children with epilepsy is usually 10-20 mg/kg/day, divided into two or three doses. The maximum dose should not exceed 1000 mg/day. For children with trigeminal neuralgia, the starting dose is usually 100 mg/day, divided into two doses, and can be increased gradually over time as needed.
Adults: The starting dose for adults with epilepsy is usually 200-400 mg/day, divided into two or three doses. The maximum dose should not exceed 1200 mg/day. For adults with trigeminal neuralgia, the starting dose is usually 100-200 mg/day, divided into two doses, and can be increased gradually over time as needed.
Elderly: The starting dose for elderly patients may be lower than that for younger adults, due to age-related changes in metabolism and potential for side effects. The dosage should be carefully monitored and adjusted as needed.
- Hypersensitivity or allergy to carbamazepine: Individuals who have had an allergic reaction to carbamazepine in the past should not take this medication.
- Bone marrow suppression: Carbamazepine can cause bone marrow suppression, which can lead to a decrease in blood cell production. Therefore, it should not be used in individuals with bone marrow suppression or blood disorders.
- History of agranulocytosis: Agranulocytosis is a rare but serious blood disorder that can cause a severe decrease in white blood cells. Individuals who have had this condition in the past should not take carbamazepine.
- Use of MAO inhibitors: Carbamazepine should not be used in combination with monoamine oxidase (MAO) inhibitors, as this can cause a potentially life-threatening drug interaction.
- Pregnancy: Carbamazepine can cause harm to a developing fetus, and therefore should be used with caution or avoided during pregnancy.
- Breastfeeding: Carbamazepine can be present in breast milk and may cause harm to a nursing infant. Women who are breastfeeding should consult with their healthcare provider before taking this medication.
- Dizziness or drowsiness
- Nausea or vomiting
- Blurred vision or double vision
- Skin rash or itching
- Dry mouth
- Constipation or diarrhea
- Swelling or fluid retention
- Unsteadiness or loss of coordination
- Fatigue or weakness
More serious adverse effects may occur with carbamazepine, and may require medical attention. These can include:
- Severe skin reactions, such as Stevens-Johnson syndrome or toxic epidermal necrolysis
- Blood disorders, such as agranulocytosis or aplastic anemia
- Liver damage or hepatitis
- Allergic reactions, including anaphylaxis
- Increased risk of suicidal thoughts or behaviors, particularly in young adults
- Interactions with other medications, such as causing birth control pills to be less effective