Mood stabilizers are the most powerful and most important medications that physicians/psychiatrists have to treat the most severe stress disorders, including bipolar disorder, schizophrenia, agitation and/or psychosis associated with many disorders, even Alzheimer’s and other dementias. They are the most effective treatment for all forms of excess anger/aggression. More recently, we have learned that they are effective in highly recurrent clinical depression or depression that doesn’t fully respond to antidepressants. They include all the "atypicals," some anticonvulsants and Lithium. They can be used alone or added to other meds. Atypicals are sometimes added to an SSRI for treatment resistant OCD.
The goal in treating any stress disorder is complete resolution of all symptoms allowing for optimal functioning and quality of life. We first maximize any particular medication – best dose, best time(s) of day. If not helping significantly or not well tolerated, we stop it. After maximizing the benefit of a particular med, if we still have significant symptoms remaining, we will carefully add another med.
In bipolar disorder, multiple meds are the rule not the exception. In one study, less than 20% of bipolar patients needed only 1 med and 35% needed 4 or more.
All of these medical treatments are in the context of counseling about important aspects of lifestyle, especially sleep, physical activity, and general health habits. Addiction counseling or psychotherapy is often but not always needed.
The average person with a stress disorder has an average of 3 different conditions, each of which needs to be considered. Since there’s so much overlap, sometimes we can choose one medication that treats 2 or 3 concurrent conditions. Implicit in all this is that a complete evaluation needs to be done before a decision can be made for what treatment is most likely to work best.
Unfortunately, at our current stage of neuroscience, there is no way to determine with certainty which treatment will be best in any individual. Soon, we will be able to make better choices because we will be able to look at each person’s genetic profile and do brain imaging to show which areas are over or under active. We will also have many new treatment options.
For now, we combine the best current science with the art of medicine to make the best educated guesses. We will use trial and error. We will always start with a complete evaluation and also monitor outcome in a comprehensive manner. If what we are doing isn’t working, we will do something else. We will think systematically, but also listen to our intuition, which is smarter than we are. We will work as a team, and we will not settle for less than the optimal quality of life.
