Determining the Best Mood Stabilizers

Click here to see how Dr. Jones determines “Best Meds”
In my clinical experience mood disorders are the most challenging and in many ways the most difficult to treat. Frequently mood problems lead to substance abuse, which makes them worse. Lifetime suicide risk for Bipolar Disorder is 15%. Only 1% of the population has classic Bipolar I disorder (the old term – manic depressive.) Frequently, they’re psychotic; usually, they require hospitalization.

Much more common is what is now being called Bipolar spectrum disorders. This includes lesser degrees of mania and episodic rage attacks. Antidepressants tend to aggravate Bipolar symptoms, or at least increase the frequency of abnormal mood cycles. Bipolar disorder means that in addition to symptoms of depression, there are symptoms of mania or hypomania (see newsletter on Bipolar Disorder).

Mood stabilizers by definition ideally help depression and/or manic symptoms – but at least help one without making the other worse.  Antidepressants and stimulants aren’t mood stabilizers because they usually aggravate manic symptoms.  Klonopin and the old-fashioned antipsychotics like Haldol and Navane don’t count because they can aggravate depression.

The 1st mood stabilizer available in the U.S. was Lithium Carbonate in 1970.  In the late 70’s, Tegretol (now Carbatrol), an anticonvulsant, was added.  In the early 80’s, Depakote was found to help especially manic symptoms.  Then in the 90’s, we started getting the 2nd generation antipsychotics, “Atypicals”: first Clozaril, then Risperdal, Seroquel, Zyprexa and Geodon, and most recently, the 1st of the 3rd generation, Abilify.  Also in the 90’s we found that an anticonvulsant, Lamictal was especially good for Bipolar Depression.  It reduces manic episodes.  It is not useful in treating acute mania.
What makes these medications so important is that it is estimated that 1/3 of clinical depression is really part of a Biploar Spectrum.  This means 8% of the population could be effected.  Many alcoholics and drug abusers are self-treating a bipolar mood disorder.
Most recently, highly recurrent unipolar depression (NO manic symptoms) may respond better to mood stabilizers than antidepressants, especially if early onset (20’s or younger) plus family history of Bipolar Disorder, frequent or severe episodes, history of less than optimal response or poor tolerance to antidepressants or stimulants.

My ranking of these medications is based on my clinical experience plus my knowledge of the research as well as experience of experts in the field.  The factors I considered were: the range of symptoms treated, the degree of benefit for these symptoms, and relative lack of side-effects, especially in the long term.

To maintain stable mood, before considering formal mood stabilizers address life-style factors:

1. Sleep (ideally 7 hours normal sleep every night) is the single most important.
2. Regular aerobic activity – 30 minutes daily preferable.
3. Maintain good levels of estrogen/testosterone.
4. Keep thyroid level in the high average range.

Hormone Treatments for Mood Disorders

There are 3 categories of mood stabilizers. (The majority of bipolar patients require more than one medication).
They are:

All Atypicals:
Abilify
Seroquel
Symbyax (Zyprexa plus Prozac)
Zyprexa
Risperdal
Geodon
Clozaril

Some Anticonvulsants

Lamictal
Depakote
Carbatrol (Tegretol)

Lithium Carbonate

Click Here to See the Rankings Mood Stabilizers vs. Antidepressants