What are mood stabilizers?
Mood stabilizers are medicines used in the treatment of bipolar disorder, where a person’s
mood changes from a depressed feeling to a high “manic” feeling, or
vice versa. These drugs can help reduce mood swings and prevent manic
and depressive episodes.
Mood stabilizers can take up to several weeks to reach their full
effect. Because of this, other psychiatric medications such as
antipsychotics are often used in the early stages of treatment.
Antipsychotics and antidepressants may also be used in combination with
mood stabilizers as longer-term treatments for bipolar disorder.
Medication is generally considered to be the cornerstone of treatment
for bipolar disorder; however, combining medication with other therapy
and support can help you to get and stay well. Forms of talk therapy
that have been shown to help with bipolar disorder are interpersonal and
social rhythm therapy, cognitive-behavioural therapy and family-focused
education about bipolar disorder. Other aids can include peer support,
school and job counselling and housing and employment support. Eating a
nutritious diet, exercising regularly and getting enough sleep are also
important, as are minimizing your use of alcohol and caffeine, and
avoiding street drugs.
Do I need treatment?
The term “bipolar” refers to the two extremes of mood: mania and
depression. People with bipolar disorder usually experience these
extremes at different times, although the two mood states can occur
together (known as a mixed state). With bipolar disorder, people can
also have periods where their mood is balanced. Mood stabilizers can
help to keep the mood of a person with bipolar disorder within this
Bipolar disorder can make it impossible for people to keep their
minds on work or school or to have a two-way relationship with their
friends and family. It can also make them impulsive and affect their
judgment, leading them to say or do things that are dangerous or that
they might later regret. Untreated bipolar disorder is associated with a
high risk of suicide.
When people are in a manic state, they sleep little, talk a lot and
are active and energetic. They may be happy and feel great or they may
be cranky and irritable. In the early stages, they may seem quite
productive, but as symptoms worsen, they tend to get more impulsive and
start things they do not finish. Their thoughts jump around so fast, it
can be hard to follow what they’re saying. They may have delusions, or
beliefs that are not based in reality, and hallucinations, such as
hearing voices when no one is speaking. They may not be able to see that
their judgment and behaviour are unsound or dangerous. Often they use
alcohol or other drugs to try to control their mood, which can worsen
Depression in bipolar disorder can be hard to distinguish from other forms of depression. Antidepressant medications
can be effective; however, they must be used with caution with bipolar
disorder as they can also cause a person who is depressed to switch into
mania. Antidepressants may also lead to more frequent mood episodes,
known as rapid cycling. This risk is lessened if the person is also
taking a mood stabilizer.
Treatment with mood stabilizers can reduce symptoms of bipolar
disorder and increase people’s ability to pursue their interests and
participate more fully in their relationships.
What do mood stabilizers do?
How mood stabilizers work is not fully understood; however, it is
thought that the drugs work in different ways to bring stability and
calm to areas of the brain that have become overstimulated and
overactive, or to prevent this state from developing.
Do mood stabilizers have side-effects?
The side-effects of mood stabilizers vary depending on the type of
medication. With some medications, side-effects are kept to a minimum
through regular monitoring of the level of the drug in the blood. Some
people experience no side-effects. Others may find the side-effects
distressing. Side-effects usually lessen as treatment continues.
Check the information given to you by your doctor or pharmacist on
the specific effects of any drug you have been prescribed. If
side-effects are not mild and tolerable, let your doctor know as soon as
possible. Your doctor may:
- adjust your dose
- suggest you take the medication at a different time of day
- suggest you take your medication with food
- prescribe other medications to help control side-effects
- change your medication.
More information on side-effects is included for each type of mood stabilizer.
What are the different types of mood stabilizers?
Divalproex, valproic acid or valproate
The oldest and most studied of the mood stabilizers is lithium.
Lithium is a simple element in the same family as sodium (table salt).
Many drugs that were first developed as anticonvulsants to treat
epilepsy also act as mood stabilizers. These include carbamazepine
(Epival) and lamotrigine (Lamictal). Gabapentin (Neurontin) and
topiramate (Topamax) are also anticonvulsants that act as mood
stabilizers, although they are usually only given in addition to other
Some people may be prescribed more than one type of mood stabilizer to take in combination.
Mood stabilizers are available as capsules or tablets, or as liquids for drinking.
Getting the right dose
With lithium, carbamazepine and
divalproex, the dose is based on how much of the drug is in your blood
and how you respond to treatment. This means that the dose differs for
everyone who takes it. Blood samples are taken regularly to make sure
that the dose is neither too high nor too low. Taking less may not be
effective, and taking more can make you physically sick.
The right dose is within a range,
rather than a precise point. It may change over time, depending on
whether the medication is being used to treat active symptoms of mania
or depression or to help prevent symptoms from returning. On days that
you are scheduled to have your blood level tested, wait until after the
test to take your morning dose to avoid inaccurate results.
If you are taking carbamazepine, avoid grapefruit juice as it can raise the level of this drug in your body.
Lithium (Carbolith, Duralith, Lithane, Lithium Carbonate, Lithium
Citrate) is found in nature in some mineral waters and is also present
in small amounts in the human body.
Lithium is used to treat mania and to prevent further episodes of mania and depression.
side-effects of lithium include increased thirst and urination, nausea,
weight gain and a fine trembling of the hands. Less common side-effects
can include tiredness, vomiting and diarrhea, blurred vision, impaired
memory, difficulty concentrating, skin changes (e.g., dry skin, acne)
and slight muscle weakness. These effects are generally mild and fade as
treatment continues. If, however, any of these effects are severe, they
should be reported to your doctor immediately. Thyroid and kidney
function can be affected by lithium in some people, and must be
monitored regularly by your doctor.
What are the signs of lithium overdose?
blood levels can increase to dangerous levels when a person becomes
severely dehydrated. Remember to drink eight to 12 cups of fluid per
day, especially when it’s hot or when you’re exercising. Severe
vomiting, diarrhea or a fever can also cause dehydration. If you have
these symptoms, stop taking lithium and see your doctor as soon as
Changing the amount of salt you use can also affect lithium levels: avoid low- or no-salt diets.
that the amount of lithium in the body is higher than it should be
include severe nausea, vomiting and diarrhea, shaking and twitching,
loss of balance, slurred speech, double vision and weakness.
experience any of these effects, see your doctor as soon as possible.
In the meantime, stop taking lithium and drink plenty of fluids. If you
cannot reach your doctor and the symptoms do not clear up, go to the
nearest hospital emergency department.
Divalproex, valproic acid or valproate
The differing names for this
anticonvulsant medication reflect the various ways it is formulated.
Divalproex (and its various forms) is used when people have frequent
mood swings or when they don’t respond to lithium. Brand names include
Depakene and Epival.
side-effects of divalproex include drowsiness, dizziness, nausea and
blurred vision. Less common side-effects are vomiting or mild cramps,
muscle tremor, mild hair loss, weight gain, bruising or bleeding, liver
problems and, for women, changes in the menstrual cycle.
(Tegretol) is another anticonvulsant. It is used for mania and mixed
states that do not respond to lithium or when the person is irritable or
side-effects of carbamazepine include dizziness, drowsiness, blurred
vision, confusion, muscle tremor, nausea, vomiting or mild cramps,
increased sensitivity to sun, skin sensitivity and rashes and poor
rare but dangerous side-effect of carbamazepine is reduced blood cell
counts. People who take this drug should have their blood monitored
regularly for this effect. Soreness of the mouth, gums or throat, mouth
ulcers or sores, and fever or flu-like symptoms can be a sign of this
effect and should be reported immediately to your doctor. If
carbamazepine is the cause of these symptoms, they will go away when the
medication is stopped.
(Trileptal), a closely related drug, may have less side-effects and
drug interactions than carbamazepine, but is not as well studied for
Lamotrigine may be the most effective mood stabilizer for depression in bipolar disorder, but is not as helpful for mania.
starting dose of lamotrigine should be very low and increased very
slowly over four weeks or more. This approach decreases the risk of a
severe rash—a potentially dangerous side-effect of this drug.
side-effects of lamotrigine include fever, dizziness, drowsiness,
blurred vision, nausea, vomiting or mild cramps, headache and skin rash. Although
it is rare, a severe skin rash can occur with lamotrigine. Any rashes
that begin in the first few weeks of treatment should be reported to
Mood stabilizers can increase your sensitivity to the sun: wear sunscreen when outdoors to prevent burning.
To reduce stomach upset, take your dose with food or milk.
If your medication makes you feel drowsy, check with your doctor to see if you can take it at bedtime.
Taking mood stabilizers can cause weight
gain. Getting regular exercise and eating a low-fat, low-sugar,
high-fibre diet (e.g., bran, fruits and vegetables) can help prevent
If side-effects are troublesome or severe, you may do better on a lower dose. Talk to your doctor.ergency department.
* Medications are referred to in two ways: by their generic
name and by their brand or trade names. Brand names available in Canada
appear here in brackets.
How long should I take mood stabilizers?
you start taking mood stabilizers, it may be two weeks or more before
you notice their effect, and four to six weeks before they reach their
full effect. It’s important to give them time to work. Once your
symptoms are under control, you will be encouraged to continue to take
mood stabilizers for at least six months, and probably longer. How much
longer varies from person to person.
stabilizers can help prevent further episodes of mania or depression.
In other words, staying on these medications for the long term can help
to keep you well. Going off mood stabilizers, on the other hand, can
greatly increase your chances of having another episode.
you have been taking mood stabilizers for a while and you are feeling
well, you may do fine on a lower “maintenance” dose. Talk to your doctor
if you would like to try this.
Are mood stabilizers addictive?
that are addictive produce a feeling of euphoria, a strong desire to
continue using the drug, and a need to increase the amount used to
achieve the same effect. Mood stabilizers do not have these effects.
mood stabilizers are not addictive, when you take them (or any drug)
over months or years, your body adjusts to the presence of the drug. If
you then stop using the drug, especially if you stop suddenly, the
absence of the drug may result in withdrawal effects or in return of
symptoms. With mood stabilizers, the withdrawal effects are generally
mild; the greatest risk with stopping these drugs is the return of
How do I cut down or stop taking mood stabilizers?
you want to cut down your dose or stop taking a medication, the same
rule applies: go slowly. Sudden changes in your dose can greatly
increase your risk of having another mood episode.
first step is to ask yourself if this is the right time. Are you
feeling well? Is the level of stress in your life manageable? Do you
feel supported by your family and friends?
you think you’re ready, talk to your doctor. If your doctor doesn’t
agree, find out why. If you are not satisfied with his or her reasons,
you may want to see another doctor for a second opinion.
your doctor does agree, he or she will advise you not to skip doses but
to reduce your dose gradually—usually by about 10 per cent at a
time—with at least two to three weeks between each reduction. This
process of cutting back will take several months. Using a pill cutter or
a liquid form of your medication can help you to cut your dose down in
you want to stop taking more than one medication, your doctor will
usually suggest that you lower the dose of one drug at a time.
you cut down, if you start to feel unwell, let your doctor know. You
may want to go back up with your dose. Find the dose that works best for
Will mood stabilizers interact with other medications?
medications can affect the blood levels of mood stabilizers, meaning
your dose of mood stabilizer may have to be adjusted while you are
taking the other medication. Mood stabilizers, especially carbamazepine,
may also reduce the effectiveness of some other drugs. Always make sure
your doctor or dentist knows about any drugs you are taking when he or
she prescribes another medication. It’s also important to check with
your pharmacist before using any over-the-counter medication, including
pain or herbal remedies, cold or allergy tablets, or cough syrups.
What if I drink coffee or alcohol while taking mood stabilizers?
coffee or other beverages that contain caffeine can lower lithium
levels and increase tremor. If you want to dramatically change how much
caffeine you have in a day (e.g., cutting back from four cups to one cup
of coffee a day), check with your doctor or pharmacist first to see if
your mood stabilizer dose should be adjusted.
People with bipolar disorder are generally advised to avoid alcohol. This is recommended because:
- Drinking alcohol can worsen depression and further impair judgment in mania.
- Many people
with bipolar disorder develop addiction problems with alcohol and other
drugs, especially when they use these substances to “take the edge off”
symptoms or to offset the effects of medication.
- Combining mood
stabilizers with alcohol tends to enhance the negative effects of both
drugs, such as drowsiness, nausea and poor co-ordination.
While avoiding alcohol is the best choice for
many people with bipolar disorder, having a drink or two on occasion
should be okay for those who are stable, feeling well and who have not
had a substance use problem.
What if I use street drugs while taking mood stabilizers?
Street drugs can complicate your situation
and create problems. Cocaine and amphetamines, for example, can trigger
an episode of mania or depression. Marijuana could lift you up or it
could bring you down: its effects on mood can be unpredictable,
especially when combined with bipolar disorder. Using any street drugs
(or alcohol) regularly to modify your mood increases your risk of
Will mood stabilizers affect my ability to drive safely?
stabilizers, especially early in treatment, may delay your reaction
time. This effect could impair your ability to drive a car or operate
other machinery. Avoid these activities until you adjust to the
medication or if you feel slowed down.
Will mood stabilizers affect my sex drive and function?
Taking mood stabilizers may reduce your
interest in sex. This can be a good thing for some people and not so
good for others. If you feel your interest in sex is too low, talk to
your doctor about it. Sometimes an adjustment in dose can help.
not common, some men who take lithium report a decreased ability to
maintain an erection or to ejaculate. With bipolar disorder, many
complex factors other than medication may contribute to sexual
In women, mood stabilizers may cause changes
in the menstrual cycle. Carbamazepine and other anticonvulsants may
reduce the effectiveness of birth control pills.
Is it safe to take mood stabilizers while pregnant or breastfeeding?
Each woman’s situation is unique and should
be discussed with her doctor. For any pregnant woman with a history of
bipolar disorder, the question of taking mood stabilizers during
pregnancy usually comes down to a risk-benefit analysis. All mood
stabilizers carry some risk—some more than others; however, episodes of
depression or mania can affect prenatal care and a mother’s ability to
parent her newborn child. When treatment with a mood stabilizer helps to
avoid a relapse or to reduce distress, the benefits may outweigh the
Taking lithium during the first trimester in
pregnancy is believed to slightly increase the risk of a heart defect in
the baby. This risk has been shown to be .05 per cent (i.e., one in
2,000). Newborns must be monitored for possible toxic effects of
lithium; these effects usually resolve within one to two weeks.
Divalproex increases the risk of spinal
defects in the developing baby by approximately five to nine per cent.
Divalproex is also related to developmental delays and cognitive
problems in children. Carbamazepine increases the risk of spinal defects
by approximately one per cent. Lamotrigine is associated with a
potential increased risk for cleft palate.
Lithium can be passed to the baby through
breast milk; however, the amount varies greatly from woman to woman.
Some women may be able to breastfeed with close monitoring of lithium
levels in the mother’s milk and the baby’s blood.
The amount of anticonvulsant mood stabilizers
passed through breast milk is very small and is not considered to be a
risk to the baby, especially when weighed against the benefits of
If you decide to stop taking medications
during pregnancy or while breastfeeding, it is a good idea to see your
doctor more often to help you monitor for a return of symptoms.
Can children and teens use mood stabilizers?
first signs of bipolar disorder can appear in childhood, usually as
depression or behaviour problems. Early substance use problems or petty
crime can also be signs. When bipolar disorder in childhood is
misdiagnosed as attention-deficit/hyperactivity disorder or unipolar
depression, treatment with stimulants or antidepressants can worsen symptoms.
stabilizers were developed and tested on adults. While most of these
drugs are not officially approved for use by children and teens,
professional guidelines direct their use in this age group. Lithium is
approved for treating manic symptoms in children aged 12 and older.
and teens may be more prone to the side-effects of these drugs and
should be monitored by their doctor regularly for side-effects.
Can older adults use mood stabilizers?
people age into their 60s and older, their bodies become less able to
eliminate medications. This means that older people who take mood
stabilizers need to have the drug levels in their blood measured more
often than younger people. Those taking lithium also need to have their
kidney and thyroid function and heart rate monitored more frequently.
As people get older, they also become more
sensitive to medications and may require a lower dose. Mood stabilizers
can increase the risk of falls, especially when taken with other drugs.
Copyright © 2009, 2012 Centre for Addiction and Mental Health
Where can I find treatment and support for using mood stabilizers?
Treatment from CAMH
Help for Families from CAMH
Ontario Mental Health Helpline (open 24/7 for treatment anywhere in Ontario)
Support groups in your area: call 211 or check online at www.211Ontario.ca
To find out more information on medications, contact your doctor, nurse or pharmacist.
For information on using medications while pregnant or breastfeeding, contact MotherRisk at 416 813-6780 or visit www.motherisk.org.