CLINICAL QUALITY OF CARE – PRACTICE PARAMETERS 

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Mood Stabilizing Medications

Med-05
 
Category: Medication Use 
Published Date: February 2022
  1. GENERAL PARAMETERS
    1. Definition: Mood stabilizing medications in this parameter include: lithium; specific anticonvulsants (carbamazepine (Tegretol), divalproex (Depakote), lamotrigine (Lamictal), and oxcarbazepine (Trileptal)) clozapine (Clozaril), and specific newer antipsychotic medications (aripiprazole (Abilify), quetiapine (Seroquel), olanzapine (Zyprexa), risperidone (Risperdal), paliperidone (Invega), ziprasidone (Geodon), lurasidone (Latuda)). Gabapentin (Neurontin) and topiramate (Topamax) are not included due to a lack of evidence for efficacy for this indication.
    2. Essential Use:
      1. Mood stabilizing medications should be tried during clinically significant manic or mixed mood episodes in individuals with a diagnosis of:
        1. Bipolar I Disorder
        2. Schizoaffective Disorder, Bipolar Type
      2. Mood stabilizing medications should be tried for clinically significant hypomanic episodes in individuals with bipolar II disorder.
      3. Mood stabilizing medications should be tried for prophylaxis against emergent manic episodes in individuals with bipolar mood disorders who are receiving antidepressant medication.
      4. Mood stabilizing medication should be used to treat bipolar disorders, depressed phase.
    3. Optional Use:
      1. Mood stabilizing medications may be tried in individuals with substance-induced bipolar disorders with manic or mixed features when detoxification from the responsible substance alone does not adequately resolve symptomatology or is not possible.
      2. Mood stabilizing medications may be tried in individuals with bipolar disorders with manic or mixed features due to a general medical condition when treatment of the responsible general medical condition alone does not adequately resolve symptomatology or is not possible.
      3. Mood stabilizing medications may be continued for indefinite periods in individuals with a diagnosis of bipolar mood disorders in partial or complete remission, as prophylaxis against recurrent mood episodes.
      4. Mood stabilizing medications may be used for other disorders characterized by mood disturbances only with appropriate additional justification in the medical record.
      5. Lithium, quetiapine, and aripiprazole may be used during depressive disorders to augment the therapeutic response to an antidepressant medication when antidepressant medications alone are not effective.
      6. Pregnant women should not be treated with divalproex or carbamazepine. With lithium and lamotrigine, informed consent about the consideration of risks/benefits should be documented, as these agents have been shown to increase the risk of teratogenicity.
         
  2. MULTIPLE CONCURRENT MOOD-STABILIZING MEDICATIONS
    1. Initially, only one mood-stabilizing medication should be used.
    2. Two mood-stabilizing medications may be prescribed concurrently when monotherapy has proven ineffective after an adequate trial.
    3. More than two mood-stabilizing medications may be prescribed concurrently only with additional appropriate justification in the clinical record.
       
  3. USE OF LITHIUM, DIVALPROEX, LAMOTRIGINE, NEWER ANTIPSYCHOTICS AND OTHER ANTICONVULSANTS FOR BIPOLAR DISORDERS
    1. Clinical judgment, presence of comorbid general medical conditions, patient preference, and the likelihood of adequate compliance should determine the choice of mood-stabilizing medication.
    2. Certain other anticonvulsants (e.g., carbamazepine), may be tried for treatment of bipolar mood disorders if the previous medications are ineffective or are contraindicated.
    3. Gabapentin and topiramate should not be used to treat bipolar disorder, as evidence for their effectiveness as solo agents for this indication is lacking.
       
  4. USE OF ADJUNCTIVE MEDICATIONS WITH MOOD-STABILIZING MEDICATIONS
    1. Benzodiazepines: Benzodiazepines (e.g., lorazepam) may be used in conjunction with mood-stabilizing medications for the treatment of manic episodes during bipolar disorders, substance-induced mental disorders, and mental disorders due to general medical conditions when symptoms of anxiety or agitation are prominent. They should be tapered as soon as clinically appropriate.
    2. Antidepressant Medications:
      1. Antidepressant medications may be used in conjunction with mood-stabilizing medications when treating depressive symptoms in bipolar disorders.
      2. Antidepressants should be used cautiously during depressive episodes in bipolar I disorder with monitoring for the potential risk of rapid cycling induction.
         
  5. MOOD STABILIZING MEDICATION DOSAGES
    1. Clinical presentation and laboratory monitoring of medication blood levels (for anticonvulsants and lithium) should determine dosage schedules of mood-stabilizing medications.
    2. Newer antipsychotics should be used at the lowest effective dose, and should not exceed generally recommended dose ranges.
       
  6. LABORATORY MONITORING FOR MOOD-STABILIZING MEDICATIONS
    1. General laboratory monitoring of individuals taking mood-stabilizing medications should be determined by the clinical situation, including the type of medication, health risk factors, duration of treatment, concurrent general medical condition, and concurrent medications, and should be consistent with Med-07 Parameters For General Health-Related Monitoring and Interventions in Adults.
      1. Lithium:
        1. Prior to initiation of lithium treatment, the following baseline laboratory data should be assessed:
          1. Electrolytes
          2. Creatinine
          3. Pregnancy status
          4. Thyroid functioning (e.g. TSH)
          5. CBC                                                                                                                                                                
        2. EKG should be assessed in individuals with a history of cardiac abnormalities or syncope.
        3. Serum lithium level should be closely monitored during initiation of lithium to ensure therapeutic levels and avoid dose-related toxicity.
        4. Serum lithium level should be monitored at least every 6 months in individuals stabilized on lithium.
        5. Creatinine level and TSH level should be monitored at least every year in individuals stabilized on lithium.
      2. Divalproex:
        1. Prior to initiation of divalproex the following baseline laboratory data should be assessed:
          1. CBC
          2. Liver Enzymes
          3. Pregnancy status
        2. Liver function tests and divalproex should be assessed at 1 and 2 months following initiation of divalproex and at least every 6 months in individuals stabilized on divalproex in order to avoid emergent toxicity and ensure therapeutic levels.
      3. Carbamazepine:
        1. Prior to initiation of carbamazepine the following laboratory data should be addressed for a baseline:
          1. CBC
          2. Liver Enzymes
          3. Pregnancy status
        2. Liver function tests, electrolytes, CBC, and carbamazepine levels should be assessed at one and two months following initiation of carbamazepine and at least every 6 months in individuals stabilized on carbamazepine in order to avoid emergent toxicity and ensure therapeutic levels.
      4. Newer Antipsychotics: Laboratory monitoring should be consistent with DMH Med-07 Parameters for General Health-Related Monitoring and Interventions in Adults.