Psychopharmacology: Mood-Stabilizers

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MOOD STABILIZERS
Mood stabilizers are used in the treatment of mood disorders which elevate depressed mood and suppresses elevated mood.
a)      Lithium carbonate
b)      Carbamazepine
c)      Sodium valproate
a) LITHIUM CARBONATE
 It was discovered by FJ Cade in 1949, and is a most effective and commonly used drug in the treatment of mania
Mechanism of action
·         Lithium ion substitutes sodium in neurons. Body cannot distinguish lithium and   sodium.
·         It accelerate pre synaptic reuptake and destruction of catecholamines  it inhibits release of catecholamines at synapse
·         Decreases post-synaptic serotonin receptor sensitivity
·         (all these actions result in decreased catecholamine activity, thus ameliorating mania)
Pharmacokinetics
·         Absorption- well absorbed by oral administration.
·         Distribution- evenly distributed to tissues and body fluids. maximum level in thyroid, saliva, milk, CSF.
·         Metabolism- NOT METABOLISED, found in body as such.
·         Excretion- kidneys
Dosage
·         900-2100 mg given in 2-3 divided doses
·         ideally, the treatment is starded after lithium estimation, done after a loading dose of 600 mg or 900 mg of lithium carbonate, to determine the pharmacokinetics
·         During the treatment, it is essential to estimate blood lithium levels at regular intervals
·         The blood sample for estimation is taken 12 hours after the last lithium dose
·         Tab. Licab 300 mg
·         Tab. Lithosun-SR 400 mg
·         Lithium citrate: 300mg/5ml liquid
Indication
·         Acute Mania
·         Prophylaxis for bipolar mood disorders
·         Schizoaffective disorder
·         Cyclothymia (mild depression and hypomania,never reach the severity)
·         Impulsivity and aggression
·         Other disorders: premenstrual dysphoric disorder, bulimia nervosa, borderline personality disorder, Trichotillomania, Cluster headaches
Contra indications
·         Severe renal disorder
·         Cardiovascular disease
·         Severe dehydration 
·         Pregnancy and lactation
·         Hypothyroidism
·         History of seizure
Blood lithium levels
·         Therapeutic levels: 0.6-1.2 mEq/L
·         Prophylactic levels: 0.6-1.0 mEq/L
·         Toxic levels:  > 2 mEq/L
Side effects
1. Neurological: tremor, muscular weakness, cogwheel rigidity, seizures, neurotoxicity
2. Renal: polyuria,   tubular changes, nephrogenic diabetes insipidus, nephrotic syndrome 
3. Cardiovascular: T wave depression in ECG
4. Endocrine: goiter, hypothyroidism, abnormal thyroid function, weight gain
5. GIT: nausea, vomiting, diarrhoea, metallic taste and abdominal pain
6. Dermatological: acneiform eruptions, papular eruptions, and exacerbation of psoriasis
7. Pregnancy and lactation: Ebstein's anomaly, toxicity in the infant
Sign and symptoms of toxicity:
Ataxia, coarse tremor, nausea, vomiting, impaired memory, impaired concentration, nephrotoxicity, muscle weakness, convulsions. muscle twitching, dysarthria, lethargy, confusion, coma, nystagmus
Management of toxicity
·         Discontinue the drug immediately
·         No antidote available
·         Gastric lavage
·         Instruct the patient to ingest fluids
·         Assess serum lithium levels, serum electrolytes, renal functions and ECG as soon as possible
·         Severe poisioning: forced diuresis or hemodialysis 
Nurse's Responsibility
·         The Pre-Lithium work up: a complete physical history, ECG, blood studies, urine examination, must be carried out
·         Renal function and thyroid function should be tested
·         Serious side effects should be notified to the Psychiatrist immediately  
·         Frequent serum lithium level evaluation
·         Take medication on regular basis even when feeling well.
·         Not to drive dangerous machines , drowsiness and dizziness can occur  
·         Adequate fluid and sodium intake.
·         Notify if vomiting or diarrhea occurs.
·         Be aware of side-effects and symptoms associated with toxicity
·         The patient shourd be told about the importance of regular follow up        
b) CARBAMAZEPINE
Used as a mood stabilizer and anti convulsant
(Tegretol, Mazetol, Zeptol, Zen Retard)
Dose-
Daily dose: 600-1800 mg in divided doses
Therapeutic blood level: 6-12 ug/ml
Toxic level-  > 15ug/ml
Pharmacokinetics    
·         Absorption -GIT
·         Distribution -crosses blood brain barrier and placental barrier.
·         Metabolism -liver      
·         Excretion -kidney
Indication-
·         Bipolar affective disorder
·         Seizure disorder
·         Paroxysmal pain syndrome
Contra indication-
·         Bone marrow suppression
·         Pregnancy and lactation
Side effects
·         Agranuiocytosis, Choiesíatic jaundice          
·         Drowsiness, confusion, headache, ataxia,
·         hypertension, arrhythmia.
·         rashes, urticaria, photosensitivity
·         nausea, vomiting, diarrhea, abdominal pain
·         Thrombocytopenic purpura, leucopenia, aplastic anemia
C) SODIUM VALPORATE
  (Encorate chrono, valparine, Epilex, Epival)
Dosage: 15mg/kg/day-60mg/kg/day
Therapeutic serum level- 50-100ug/ml
Indication: acute mania, schizo affective disorder, BPAD, seizures, bulimia nervosa, compulsive disorder, agitation, PTSD.
Rapid onset of action, drug acts on GABA, an inhibitory neurotransmitter, this reduces neuronal excitability
Side effects: hair loss, weight gain, GI upset, nausea, vomiting, diarrhoea, sedation, ataxia, dysarthria, tremor, thrombocytopenia, platelet dysfunction
Nurses role
l. Advice the patient to take drug immediately after food to avoid GI irritability
2. Advice regular follow up and periodic examination of blood count, hepatic and thyroid function


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notes.nursium.com: Psychopharmacology: Mood-Stabilizers
Psychopharmacology: Mood-Stabilizers
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