Learning Objectives

1. Identify the common mood stabilizers used in the treatment of bipolar disorder and their specific therapeutic effects.
2. Recognize the potential side effects associated with different mood stabilizers and their implications for patient management.
3. Understand the role of psychotherapists in supporting patients being treated with mood stabilizers and promoting treatment adherence.

Mood stabilizers play a critical role in helping patients with bipolar disorder manage symptoms and maintain stability. In this article, we will provide a brief overview of mood stabilizers for bipolar disorder and their implications for psychotherapy.

What are mood stabilizers?

Mood stabilizers are medications that help regulate and stabilize mood in individuals with bipolar disorder (Baldessarini RK et al, Mol Psychiatry 2019;24(2):198-217). They're often used as a long-term treatment to prevent the recurrence of mood episodes and reduce their severity. It's important to note that mood stabilizers are not a one-size-fits-all solution; what works for one client might not work for another. Therefore, it's our responsibility to stay informed about the different types of mood stabilizers, their potential side effects, and the implications for our clients' therapy.

Medications commonly used as mood stabilizers include lithium (Lithobid); divalproex (Depakote); lamotrigine (Lamictal); and atypical antipsychotics—also referred to as “second-generation” antipsychotics.

1. Lithium

Lithium is a naturally occurring element that has been used as a mood stabilizer for bipolar disorder since the 1940s (Malhi GS and Outhred T, CNS Drugs 2016;30(10):931-949). It's considered the gold standard in bipolar disorder treatment and is particularly effective in reducing the frequency and severity of manic episodes. It’s generally more effective for classic euphoric manic episodes than for mixed or rapid cycling episodes. It also has antidepressant effects, both in bipolar disorder, and as an add-on agent to antidepressants in patients with unipolar depression. 

Common side effects of lithium include hand tremors, increased thirst and urination, weight gain, cognitive difficulties, and hypothyroidism. It can rarely cause kidney impairment in patients who have used it for many years. It is likely underprescribed due to side effect concerns, and in fact most patients tolerate lithium quite well. 

2. Anticonvulsant medications

Anticonvulsant medications were initially developed to treat epilepsy but have been found to be effective in managing bipolar disorder symptoms as well. Three of the most commonly prescribed anticonvulsants for bipolar disorder include valproic acid (Depakote), lamotrigine (Lamictal), and carbamazepine (Tegretol) (Yatham et al, Bipolar Disord 2018;20(2):97-170).

Valproic acid is particularly effective for treating acute mania and mixed episodes and can be used as a maintenance treatment to prevent relapses. Potential side effects include weight gain, dizziness, drowsiness, and gastrointestinal issues. Long-term use of valproic acid can lead to liver toxicity and potential birth defects in pregnant clients.

 Lamotrigine is especially useful for the maintenance treatment of bipolar disorder and has been found to be more effective in preventing depressive episodes than manic episodes. Common side effects include dizziness, headache, and nausea. A rare but serious side effect of lamotrigine is a potentially life-threatening rash called Stevens-Johnson syndrome.

Carbamazepine is used to treat acute mania and as a maintenance treatment for bipolar disorder. Its side effects can include dizziness, drowsiness, and blurred vision. Long-term use may lead to liver toxicity, low blood sodium levels, and blood disorders.

3. Atypical antipsychotics

Atypical antipsychotics, such as quetiapine (Seroquel), aripiprazole (Abilify), and olanzapine (Zyprexa), can also be used as mood stabilizers in the treatment of bipolar disorder (Goodwin GM et al, J Psychopharmacol, 2017;30(6):495-553.). They are particularly helpful in treating acute manic episodes and can be used as a maintenance treatment to prevent relapses.

It's essential to monitor clients taking atypical antipsychotics for weight gain, high blood sugar, high cholesterol, and high blood pressure, as these factors can contribute to the development of metabolic syndrome and increase the risk of cardiovascular disease. Regular check-ups and lifestyle interventions, such as promoting a healthy diet and exercise routine, can help mitigate these risks.

Quetiapine is effective in treating both manic and depressive episodes in bipolar disorder. Common side effects include sedation, weight gain, and dizziness. It's important to monitor clients for signs of excessive sedation or an increase in suicidal thoughts, particularly during the initial stages of treatment.

Aripiprazole is useful for treating acute mania and as a maintenance treatment. It's generally considered to have a lower risk of weight gain compared to other atypical antipsychotics. Some of the common side effects include headache, anxiety, and insomnia. In some cases, aripiprazole can cause akathisia, a feeling of inner restlessness that can be distressing to clients.

Olanzapine is effective in treating acute mania and mixed episodes. It can also be used for maintenance treatment in combination with fluoxetine (an antidepressant) for clients with a history of severe depressive episodes. However, olanzapine is associated with significant weight gain and an increased risk of metabolic syndrome. Monitoring clients' weight, blood sugar, and lipid levels is crucial during treatment with olanzapine.

 How psychotherapists can support patients taking mood stabilizers

As therapists, it's crucial for us to understand how mood stabilizers can interact with psychotherapy. Research has shown that combining mood stabilizers with evidence-based psychotherapy, such as cognitive-behavioral therapy (CBT), family-focused therapy, and interpersonal and social rhythm therapy, can significantly improve treatment outcomes for clients with bipolar disorder (Miklowitz D et al, J Affect Disord 2020;266:710-717).

 Here are some practical tips on how you can support your clients who are taking mood stabilizers:

1. Inquire about side effects: Encourage your clients to communicate openly about any side effects they're experiencing and collaborate with their prescribing doctor to address these concerns. Regular check-ins can help identify potential issues early on and make necessary adjustments to their medication regimen. Don't hesitate to call or email the prescriber to alert them to side effects (Haddad PM and Sharma SG, CNS Drugs 2007;21(11):911-936.). Remember that the prescriber may see patients as infrequently as every 3 to 6 months, and they will be grateful for your timely input.
2. Medication adherence: Encourage clients to take their medications as prescribed and explore any barriers they may face in adhering to their treatment plan. Discussing the importance of consistency and addressing common misconceptions about mood stabilizers, such as the idea that they "flatten" emotions or are only needed during acute episodes, can help improve adherence. Offer strategies for managing medication schedules, such as using pill organizers or setting reminders on their phone (Velligan DT et al, J Clin Psychiatry 2009;70(Suppl 4):1-46).
3. Psychoeducation: Educate your clients about bipolar disorder and the role of mood stabilizers in managing their symptoms. Providing them with accurate information, such as the benefits of mood stabilizers in reducing the frequency and severity of mood episodes (Yatham et al, 2018), can empower them to make informed decisions about their treatment. Direct clients to reputable sources, like the National Institute of Mental Health (NIMH) or the International Bipolar Foundation, for additional information and support (NIMH. Bipolar disorder. https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml. 2021.)
4. Encourage self-monitoring: Teach your clients to track their mood, sleep patterns, and other symptoms using mood charts or smartphone apps like MoodPanda or eMoods (Faurholt-Jepsen M et al, Psychol Med 2015;45(13):1691-704). Self-monitoring can help identify early warning signs of an impending mood episode and allow for timely intervention. This information can also be valuable for their treatment team in making adjustments to their medications or therapy.
5. Collaborate with other healthcare professionals: Maintain open lines of communication with your clients' psychiatrists and other medical providers to ensure coordinated care. Sharing information about your clients' progress, side effects, and concerns can help create a more effective treatment plan. Additionally, consider participating in interdisciplinary team meetings, if available, to further enhance collaboration and understanding of your clients' needs.

CARLAT TAKE: Prioritize collaboration with prescribing doctors, promote medication adherence, and provide psychoeducation about mood stabilizers to enhance treatment outcomes and overall well-being.