Mood stabilisers

If you have a bipolar disorder, you will experience unnaturally large fluctuations in energy and mood. You will have repeated periods of illness with mania, depression or a mixed state. A period of illness may last from a few weeks up to several months.

More information: Bipolar disorders in adults

It is usually painful to experience depression or a mixed state, and both can increase the risk of suicide.

Mania or hypomania may sometimes produce a feeling of euphoria. Nevertheless, most people want to prevent and treat mania or hypomania. There are two reasons for this: First, mania is generally followed by depression, which lasts much longer than the actual mania. Secondly, people often do things in a manic state that they deeply regret afterwards.

For example, someone might argue with his family or do rash, spontaneous things, such as running up large debts.

The purpose of treating your bipolar disorder is to prevent periods of illness, and in this way to improve your quality of life.

When you start taking medication, your risk of periods of illness will be considerably reduced. Nevertheless, you may well experience an episode of mania, depression or mixed state. Here, however, the treatment can still help to subdue and shorten your period of illness. 

To reduce the risk of further episodes of illness, it is important that, besides taking your medication, you also receive psycho-education (education about trigger factors, early signs of illness, etc.)

NB: Antidepressants

When you have bipolar disorder, you should only take antidepressants in combination with mood stabilisers. Taking only antidepressants may trigger a manic episode.

In most people, mood stabilisers may have preventive and healing effects on
depression, mania and mixed states. There are many different kinds of drugs that can be used individually or combined.

The individual drugs stabilise activity in different neurotransmitter systems of
the brain. For that reason, some types of medication are better at preventing
depression than mania – and vice versa. Because the drugs work in different
ways, they also have different side-effects.

Your treatment will be adjusted based on the progression of your illness and
your wishes. Your therapist can explain the advantages and disadvantages of various types of medicine. You will then be better equipped to decide what treatment you want.

It is not possible to definitely predict which medicine will help you the most.
Neither is it possible to know exactly what side-effects you may experience.
It may therefore be necessary to try several types of medicine before you and your therapist jointly arrive at the most suitable drug for you.

There are three main types of mood-stabilising medication:

• Lithium
• Anti-epileptics
• Antipsychotics

Lithium is an element occurring naturally in groundwater, stones and rocks,
among other sources. Lithium has preventive and healing effects on both
depression and mania. Lithium may also prevent suicidal behaviour. It has also been demonstrated that there is a lower incidence of suicide in areas with a high concentration of lithium in the drinking water.

Excessive doses of lithium may be harmful to the kidneys. That is why it is very important for the dose of lithium to be just right for you. When you begin therapy, therefore, you will have regular blood tests during the first 4 weeks.

Once you and your therapist have found the right dosage for you, it is still necessary to check your treatment with a blood test about 1-4 times a year. This allows your therapist to ensure your kidneys are still able to tolerate the
amount of lithium. At the same time, your metabolism will be checked, because in some cases it may be affected by the treatment. If that happens, you may be given a metabolic hormone supplement to take with the lithium.

Not everyone gets adverse effects from treatment with lithium, but many
do experience slight adverse effects. The most frequent are shaky hands,
increased thirst or a tendency towards loose stools. Some people put on a bit of weight or develop acne. In some cases, co-medication can be taken to relieve unpleasant side-effect.

Remember fluids

When you are on lithium therapy, you must make sure you drink fluids
regularly. Otherwise, it is rather like cordial; if you put cordial in a glass,
but not enough water, the beverage will be too strong. It is the same way
if you are taking lithium but forget to drink fluids; the lithium concentration in your blood will be too high.

Therefore, remember to drink more fluids, put more salt in your food or reduce your lithium dose if you have a high temperature or perspire a lot (e.g. when travelling in hot countries). In such a case, it is a good idea to contract your therapist for guidance before you travel.

Anti-epileptics are medicines that have been used for many years to treat
epilepsy. Today, we know that anti-epileptics can also help to prevent and treat bipolar disorder.

There are several types of medicine, with different advantages and disadvantages. Some are best at preventing and treating mania or mixed states, while others are best at preventing and treating depression. Some types of medicine are effective almost immediately, while other types require gradual titration to a therapeutic dose over many weeks.

The most frequently used drugs are Lamotrigine and Valproate.

Lamotrigine:

• Has few adverse effects, but requires gradual titration to a therapeutic dose over 6–10 weeks.
• When you are treated with Lamotrigine, there is a small risk that you may develop a rare, but serious, skin condition. Contact your doctor if you develop a rash after starting treatment with Lamotrigine

Valproate:

• Effective within a few days, but has more frequent sideeffects such as tiredness.
• When you are treated with Valproate, there is a small risk that you may develop hepatitis. Contact your doctor if you experience symptoms of hepatitis such as: lethargy, nausea, vomiting, diarrhoea, abdominal pain (pain in the stomach region), possibly jaundice. One symptom may also be that the medication is not working as desired. You will have regular blood tests done to check your liver values. In the first year after you have started treatment with Valproate, you will have blood tests done four times a year.

NB: Pregnancy and Valproat
If you take Valproate while you are pregnant, this may seriously harm your unborn baby. Therefore, talk to your doctor immediately if you are considering having a child. Always use effective contraception when taking Valproate. And do not stop using contraception until you have talked to your doctor. Never stop taking valproate until you have agreed this with your doctor, as your disorder may otherwise get worse.

Antipsychotics were originally developed to treat psychosis, but may also be used to prevent and treat mania. Some types of medicine may be used to treat depression and mixed states, while others are effective for anxiety and difficulty sleeping. Your GP will work with you to identify the medication and the dose that are right for you.

The various antipsychotics can have different side-effects. Some may produce muscle stiffness or trembling, which may potentially be treated with co medication to mitigate the side-effects. Others may produce increased appetite or changes in the way the body metabolises sugars and lipids.

The side-effects will often depend on the dose. Whereas a relatively small dose may have a preventive effect, a higher dose will often be required to treat acute mania or mixed state. Therefore, people may sometimes choose to accept certain side-effects for a limited time in order to make a faster recovery from a manic episode, for example.

• Lithium and anti-epileptics are only available as tablets to be taken once or twice daily.
• Antipsychotics are available as ordinary tablets or as orodispersible tablets that dissolve when placed under the tongue. Some drugs can be obtained in drinkable solution form.
• Several types of antipsychotics are also available as slow-release medicines, i.e. an injection with long-lasting effect, administered from once every two weeks to once every eight weeks. Slow-release medicines can be a good idea if you do not want to have to take medicine every day, or if you have difficulty remembering to take your tablets.

Your GP will initially suggest one of the drugs that has the fewest side-effects
and that has been documented to have the best effect on the particular type of illness period you experience the most (mania, depression or mixed state).

However, it is impossible to predict which drugs will work best for you. Therefore, it may often be necessary to switch drugs a number of times. There could also be special things to consider, e.g. if you have other chronic conditions or are very concerned about particular side-effects.

Ultimately, a crucial consideration is whether you prefer to take your medicine daily in tablet form or as an injection every few weeks. Various types of medicines can also be combined for a more effective treatment. The dose you need may vary over time. That is why it is important for you to attend regular check-ups with your GP.

When you have treatment with mood stabilisers, your therapist will ask you whether the medication has had the intended effect, and whether you have had any side-effects. Your GP will take care of adjusting your dose and issuing repeat prescriptions. If you take several drugs simultaneously, your GP will ensure that they work together.

Your GP will continuously book and monitor blood tests to ensure you are on the correct dosage, and that you are able to tolerate your medication. Depending on the drug that has been prescribed for you, you will have blood tests at intervals of three to twelve months.

In some cases, it may also be necessary to check your weight and waistline or have an electrocardiogram (ECG) to monitor your cardiac rhythm.

Taking mood stabilisers is generally not harmful – even in the long term. If you are having lithium therapy, however, it is important to remember to go for regular blood tests. Mood stabilisers do not carry a risk of drug abuse or dependency. You will not get withdrawal symptoms if you stop the medication abruptly, but you may risk acute depression or mania if you stop taking your medication overnight.

No harmful effects on brain tissue have been described for prolonged use of mood stabilisers, and the side-effects generally disappear quickly when you stop taking the medication.

Some types of medication should not be taken during pregnancy. Talk to your therapist if you are planning to get pregnant.

Tip: In the podcast ‘Mødregruppen’, Nanna, who has a bipolar disorder, talks about her pregnancy, including her use of medication. The podcast was produced by the psychiatric services in Central Denmark Region.

 #2: Mødregruppen (podbean.com)

Many people are concerned about whether they will have to take mood stabilisers for the rest of their lives. Generally speaking, the more periods of illness you have had, the longer you should continue with treatment. Similarly, the more serious your periods of illness, the longer you should continue taking the medication.

If you have been free of illness for several years, for some people it may be appropriate to try to taper off the medicine in consultation with your therapist. Some people have a strong desire to be free of medication, while others want to do all they can to prevent a relapse. Some people experience side-effects from medication, while others do not. That is why there is no simple answer as to how long you should continue to take mood stabilisers.

Working with your therapist, it is a good idea to continuously weigh up the advantages and disadvantages of treatment. Together, you can clarify whether your treatment is having the desired effect, or whether it should be changed or stopped entirely.

Over time, many people arrive at a treatment they are so happy with that they continue on it for many years or perhaps for life.

If you want to stop taking your medicine, it is a good idea to speak to your GP first. Together, you can plan when and how best to taper off your medicine.

It is a good idea to get to know your early warning signs of mania, depression and hypomania. This way, you will be better able to prevent another period of illness.

To gain an overview of your early warning signs of illness, it is a good idea to write down your experiences. It may also help to ask your family what early warning signs they have noticed in you. Early warning signs can be physical or mental, e.g. palpitations, reduced feeling of pleasure, changes in appetite or the need for sleep, or difficulty falling asleep.

Once you are familiar with your early warning signs, you and your therapist can prepare a prevention plan. Write down in the prevention plan what you can do if you are concerned that another period of illness is on the way.

You can also use a mood recording chart to prevent relapses. Each day, you can record how you feel on the chart. If you can see that you have been feeling worse for a few days, you will know it is time to seek help.

As a patient or relative, you can call the Psychiatric Advisory Hotline on tel. 78 470 470 if you are facing an acute psychiatric crisis. The hotline is open 24/7.