Module4MoodStabilizers.pdf

Module 4 Mood Stabilizers Yvonne Creighton DNP, APRN, FNP-C, PMHNP-BC 1  Module 4 Student Learning Outcomes At the conclusion of this module, you shou...

Module 4 Mood Stabilizers Yvonne Creighton DNP, APRN, FNP-C, PMHNP-BC 1  Module 4 Student Learning Outcomes At the conclusion of this module, you should be able to: Differentiate the pathophysiology of mania and bipolar disorders Describe the mechanism of action, adverse effects, and monitoring parameters of drugs used to treat mania and bipolar disorders Justify the choice of mood stabilizer for patients with mania and bipolar disorder Create a care management plan for a patient with bipolar disorder Collaborate with classmates regarding issues related to genetic, ethnic, cultural, developmental, and/ or gender that may impact prescribing practices in psychiatric mental health practice 2  Outline Introduction Future Mood Stabilizers Drugs Lithium Summary Anticonvulsants Abbreviations Atypical Antipsychotics Other Agents Resources Antidepressants Mood Stabilizers in Clinical Practice Choosing a Mood Stabilizer First-line Treatments Combinations Bipolar Disorder and Women Children 3  Mood Stabilizers Introduction Mechanisms of action mood stabilizers reviewed What to do when initial treatments fail Combining mood stabilizers Mood stabilizers have different therapeutic actions. They may Treat acute mania and/or stabilize mania Treat and/or stabilize depression 4  Mood Stabilizers Lithium Used to treat mania for over 50 years Mechanism of action (MOA) not well understood May affect signal conduction through inhibition of enzymes May modulate G proteins May regulate gene expression for growth factors and neuronal plasticity Clear evidence that it helps prevent suicide in patients with mood disorders Equal or better efficacy than valproate for manic, depressive, or mixed episodes Less prescribed due to monitoring, narrow therapeutic index, side effects, and long term adverse effects 5  Mood Stabilizers Lithium Mechanism Unknown and complex of Action Alters sodium transport across membranes of nerve and muscle cells Side Ataxia, dysarthria, delirium, tremor, memory problems Effects Polyuria, polydipsia, weight gain, sedation, possible goiter, cardiac arrhythmias Nausea, abdominal cramps, anorexia tend to resolve Persistent vomiting and profuse diarrhea – signs of toxicity Monitoring Therapeutic range 0.6-1.2 mEq/L Parameters Monitor plasma levels every 1-2 weeks initially; then every 2-3 months for first 6 months Monitor for signs of dehydration Notes Before initiating, must get baseline kidney and thyroid function and EKG Use diuretics cautiously; can increase lithium concentrations 6  Mood Stabilizers Anticonvulsants Effective for acute manic phase and stabilization Valproate Carbamazepine Effective for mood stabilization and prevention of mania and depression Lamotrigine 7  Mood Stabilizers Anticonvulsants Valproate Mechanism Blocks voltage-sensitive sodium channels of Action Increases GABA Side Sedation, GI effects, weight gain Effects Tremor, dizziness, ataxia, weakness, HA Monitoring Baseline liver function and coagulation tests Parameters Monitor weight and BMI Monitor plasma levels after each dose increase. Target level 50-125 mcg/mL Notes Rare liver failure and pancreatitis Most patients need combination therapy 8  Mood Stabilizers Anticonvulsants Carbamazepine Mechanism Blocks voltage-sensitive sodium channels of Action Inhibits glutamate release Side Sedation, dizziness, confusion, unsteadiness, HA, NV Effects Rash (rare Stevens-Johnson Syndrome) and aplastic anemia Monitoring Baseline blood count, liver, kidney, and thyroid tests Parameters Plasma drug level every 6 months Notes Extended release better efficacy and tolerability Less weight gain than valproate 9  Mood Stabilizers Anticonvulsants Lamotrigine Mechanism Blocks voltage-sensitive sodium channels of Action Inhibits glutamate release Side Sedation, dizziness, confusion, unsteadiness, HA, NV Effects Rash (rare Stevens-Johnson Syndrome) Monitoring Monitor for rash Parameters Serum levels of concurrent anticonvulsants Notes High tolerability profile Slow titration can reduce risk of rash 10  Mood Stabilizers Atypical Antipsychotics Atypical antipsychotics are effective for bipolar depression Efficacious for psychotic and nonpsychotic manic and hypomanic episodes May work by DA antagonist actions that reduce psychotic symptoms in mania 5HT antagonist and partial agonist actions reduce nonpsychotic manic and depressive symptoms Reduction in glutamate hyperactivity can reduce both manic and depressive symptoms 11  Mood Stabilizers Other Agents Used in Bipolar Disorder Benzodiazepines Used intramuscularly in emergent situations Used PRN for agitation, insomnia, and beginning manic symptoms; careful in comorbid substance abuse Hormones and natural products None approved for bipolar disorder 12  Mood Stabilizers Do Antidepressants Make You Bipolar? Antidepressants can precipitate a manic episode in person with undiagnosed bipolar disorder Depression symptoms may appear first before manic or hypomanic symptoms Important to get complete history (remember: Who’s your daddy? Where’s your mama?) Antidepressant monotherapy discouraged in bipolar disorder Best to start with lamotrigine, lithium, or atypical antipsychotics as monotherapy or in combination 13  Mood Stabilizers in Clinical Practice Choosing a Mood Stabilizer Bipolar disorder is highly recurrent with Mostly depression symptoms Frequent comorbidities Residual symptoms Learn the MOA of mood stabilizers and adjuncts Understand the efficacy and safety of monotherapy medications Treat patients based on individual characteristics 14  Mood Stabilizers in Clinical Practice First-line Treatments Avoid antidepressants in bipolar disorder For bipolar depression: Lamotrigine or atypical antipsychotic or combination of both For antimanic efficacy: Combine lithium or valproate with atypical antipsychotic To achieve remission of symptoms, may take multiple medications 15  Mood Stabilizers in Clinical Practice Combinations Li-vo – lithium and valproate La-vo – lamotrigine and valproate La-li-vo – lamotrigine, lithium, valproate Must carefully monitor lamotrigine and valproate combo (↑rash) Carbamazepine and lamotrigine Lami-quel – lamotrigine and quetiapine (or lurasidone) Geographic-based combos (see textbook) 16  Mood Stabilizers in Clinical Practice Bipolar Disorder and Women Bipolar disorder in women More depressive in nature More suicide attempts More mania and rapid cycling Higher rates of thyroid disorder and comorbid anxiety and eating disorders Pregnancy Not protective against bipolar mood episodes Most anticonvulsants and lithium associated with risk of fetal toxicities Consider atypical antipsychotic in pregnancy for stabilization 17  Mood Stabilizers in Clinical Practice Children Prepubertal and adolescent mania symptoms differ from “classic” mania Characterized by severe irritability, outbursts, and anger Moods are rarely euphoric Pediatric mania may be difficult to distinguish from ADHD, ODD, DMDD, and conduct disorder 18  Summary Mood stabilizing agents Treat mania Prevent relapse Treat bipolar depression Prevent depression relapse Mood stabilizers include Lithium Anticonvulsants Atypical antipsychotics Combination therapy is the norm for treating bipolar disorder 19  Abbreviations ADHD – Attention Deficit Hyperactivity Disorder DA – Dopamine DMDD – Disruptive Mood Dysregulation Disorder DSM-5 – Diagnostic and Statistical Manual of Mental Disorders 5th Edition EKG – Electrocardiogram GABA – gamma (ɣ)-aminobutyric acid GI – Gastrointestinal HA - Headache MOA – Mechanism of Action NE – Norepinephrine NV – Nausea/Vomiting ODD – Oppositional Defiant Disorder PRN – As needed 20  Resources Boland, R., Verduin, M., & Ruiz, P. (2021). Kaplan and Sadock's synopsis of psychiatry: Behavioral sciences/clinical psychiatry (12th ed.). Wolters Kluwer. Stahl, S. (2017). Prescriber's guide: Stahl's essential psychopharmacology (6th ed.). Cambridge University Press. Stahl, S. (2021). Stahl's essential psychopharmacology: Neuroscientific basis and practical applications (5th ed.). Cambridge University Press. Stovall, J. (2019). Bipolar mania and hypomania in adults: Choosing pharmacotherapy. In P. Keck & D. Solomon, (Eds.), UpToDate. https://www.uptodate.com/contents/bipolar-mania-and-hypomania-in- adults-choosing-pharmacotherapy 21