Chapter 13
Mood Stabilisers
74
, Chapter 13: Mood Stabilisers
1. Lithium.
2. Valproate.
3. Carbamazepine.
4. Lamotrigine.
1. Lithium
Indications
Treatment of mild to moderate mania (the use of lithium for mania is limited by the fact that it usually takes
at least one week to achieve a response and that the co-administration of antipsychotics may increase the risk
of neurological side effects).
Prophylaxis of bipolar affective disorder (lithium is more effective at preventing manic than depressive
relapses).
Prophylaxis of recurrent depression (in people who have not responded to standard
antidepressants, lithium can be added for antidepressant augmentation).
Treatment of aggressive behaviour.
Treatment of self-mutilating behaviour.
Prevention and treatment of steroid-induced psychosis.
Lithium and suicide
Lithium decreases suicidal behaviour in people with unipolar or bipolar disorder.
Duration of treatment
Because of the risk of relapse following discontinuation, the need for prolonged treatment (at least three years)
should be discussed with patients.
Monitoring
Prior to starting lithium
o Bloods (RFTs, TFTs, calcium level), ECG, weight, exclude pregnancy.
After starting or changing the dose of lithium
o Serum lithium should be measured after 5-7 days. The lithium dose should then be adjusted to achieve a
serum lithium concentration of between 0.5-0.8mmol/l.
Note: lithium has a narrow therapeutic index/window.
o Blood should ideally be taken 12 hours after the last dose was administered.
Note: lithium is usually taken at night time.
During treatment
o Check serum lithium level every three months.
o Check RFTs, TFTs and calcium level every six months.
o Monitor weight.
o Advise patients to seek attention if symptoms of hypothyroidism develop (e.g. lethargy and feeling cold).
o If lithium is to be discontinued, the dose should be reduced gradually over a period of a few weeks. Patients
should be warned of possible relapse if lithium is discontinued abruptly.
Lithium formulations
Lithium carbonate (lithium in the form of tablets).
Lithium citrate (lithium in the form of liquid).
Note: both lithium carbonate and citrate have the same indications as listed above.
Use in women of childbearing age
Any female of childbearing potential should receive appropriate advice about contraception.
Lithium is a human teratogen. Women should be advised to use a reliable form of contraception.
Risks to consider when lithium is prescribed during pregnancy:
o Fetal heart defects (risk raised from 8 in 1,000 to around 60 in 1,000).
o Ebstein’s anomaly (risk raised from 1 in 20,000 to 10 in 20,000).
o Floppy baby syndrome.
o Potential thyroid abnormalities (e.g. goiter) and nephrogenic diabetes insipidus.
o Increased associated miscarriage risk with lithium treatment during pregnancy.
Note: Ebstein’s anomaly is a congenital condition which occurs due to a defect in the tricuspid valve in which the septal
and posterior leaflets are downwardly displaced into the right ventricle. The anterior leaflet is malformed and
abnormally attached to the right ventricle free wall. Blood leaks backward from the right ventricle to the right
atrium resulting in an enlargement of the right atrium and the ‘atrialisation’ of the right ventricle, leading to
congestive heart failure (a back-up of blood flow that results in a fluid build-up in the lungs) and insufficient blood
flow to the body (‘blue baby’ syndrome).
Note: the period of highest risk for organ malformation is the first trimester of pregnancy.
75
Mood Stabilisers
74
, Chapter 13: Mood Stabilisers
1. Lithium.
2. Valproate.
3. Carbamazepine.
4. Lamotrigine.
1. Lithium
Indications
Treatment of mild to moderate mania (the use of lithium for mania is limited by the fact that it usually takes
at least one week to achieve a response and that the co-administration of antipsychotics may increase the risk
of neurological side effects).
Prophylaxis of bipolar affective disorder (lithium is more effective at preventing manic than depressive
relapses).
Prophylaxis of recurrent depression (in people who have not responded to standard
antidepressants, lithium can be added for antidepressant augmentation).
Treatment of aggressive behaviour.
Treatment of self-mutilating behaviour.
Prevention and treatment of steroid-induced psychosis.
Lithium and suicide
Lithium decreases suicidal behaviour in people with unipolar or bipolar disorder.
Duration of treatment
Because of the risk of relapse following discontinuation, the need for prolonged treatment (at least three years)
should be discussed with patients.
Monitoring
Prior to starting lithium
o Bloods (RFTs, TFTs, calcium level), ECG, weight, exclude pregnancy.
After starting or changing the dose of lithium
o Serum lithium should be measured after 5-7 days. The lithium dose should then be adjusted to achieve a
serum lithium concentration of between 0.5-0.8mmol/l.
Note: lithium has a narrow therapeutic index/window.
o Blood should ideally be taken 12 hours after the last dose was administered.
Note: lithium is usually taken at night time.
During treatment
o Check serum lithium level every three months.
o Check RFTs, TFTs and calcium level every six months.
o Monitor weight.
o Advise patients to seek attention if symptoms of hypothyroidism develop (e.g. lethargy and feeling cold).
o If lithium is to be discontinued, the dose should be reduced gradually over a period of a few weeks. Patients
should be warned of possible relapse if lithium is discontinued abruptly.
Lithium formulations
Lithium carbonate (lithium in the form of tablets).
Lithium citrate (lithium in the form of liquid).
Note: both lithium carbonate and citrate have the same indications as listed above.
Use in women of childbearing age
Any female of childbearing potential should receive appropriate advice about contraception.
Lithium is a human teratogen. Women should be advised to use a reliable form of contraception.
Risks to consider when lithium is prescribed during pregnancy:
o Fetal heart defects (risk raised from 8 in 1,000 to around 60 in 1,000).
o Ebstein’s anomaly (risk raised from 1 in 20,000 to 10 in 20,000).
o Floppy baby syndrome.
o Potential thyroid abnormalities (e.g. goiter) and nephrogenic diabetes insipidus.
o Increased associated miscarriage risk with lithium treatment during pregnancy.
Note: Ebstein’s anomaly is a congenital condition which occurs due to a defect in the tricuspid valve in which the septal
and posterior leaflets are downwardly displaced into the right ventricle. The anterior leaflet is malformed and
abnormally attached to the right ventricle free wall. Blood leaks backward from the right ventricle to the right
atrium resulting in an enlargement of the right atrium and the ‘atrialisation’ of the right ventricle, leading to
congestive heart failure (a back-up of blood flow that results in a fluid build-up in the lungs) and insufficient blood
flow to the body (‘blue baby’ syndrome).
Note: the period of highest risk for organ malformation is the first trimester of pregnancy.
75
