The world of mood stabilizers way too often poses a survival challenge. I mean, anticonvulsants, atypical antipsychotics, and more. How in the heck are you supposed to know what to do? Thing is, if you’re struggling somewhere along the mood spectrum you really need some answers. Maybe this will help…

‘A group of medications which can treat both mania and depression; or at minimum, they treat one of the two and rarely cause the other pole to become worse in the process.’

Through decades of tussling with anxiety and mood kinks, I’ve never had to turn to mood stabilizers.

I’m thankful, as I’ve personally and clinically seen the confusion, frustration, and fear they can generate. ‘Course, I’ve also seen some pretty amazing positive outcomes.

Contemplating what to write about this week, I visited one of my very favorite websites. That would be “PsychEducation: Treating the mood spectrum,” produced by a wonderful psychiatrist, James R. Phelps, MD.

I’ve used his material numerous times here on Chipur, as it’s well-considered, fresh, compassionate, and the good doctor doesn’t take himself too seriously. I’ll zing you a link at the end.

The Mood Stabilizers

In addressing mood stabilizers, Dr. Phelps first reviews definitions. What say we run with this one: “A group of medications which can treat both mania and depression; or at minimum, they treat one of the two and rarely cause the other pole to become worse in the process.”

He then shares a couple of general thoughts. He emphasizes that with the probable exception of fish oil and low-dose thyroid, none of the mood stabilizers he lists are known for sure to be safe during pregnancy. He goes on to say that any woman taking any of the listed meds should have a very reliable plan for avoiding pregnancy. And if in doubt, chat with her doc.

He then announces he’s removed three meds from consideration because randomized trials showed them no better than placebo in the treatment of bipolarity: gabapentin (Neurontin), topiramate (Topamax), and tiagabine (Gabitril).

Dr. Phelps provides so much great reference information. I thought sharing just two of his tables would provide some direction for those who feel a little lost. Trust me, the tables on his site are prettier, but let’s just say I couldn’t pull-off a better transfer…

Dr. Phelps’ Tables: Main Options

Treats manic symptoms and depressionTreats depression without worsening cyclingTreats manic symptoms and cyclingToo much antidepressant effectCan make bipolar worse*
Risperdal; paliperidone/
Light therapy (except dawn simulators)
fish oil/
Tegretol; oxcarbazepine/
High-dose thyroidverapamil?aripiprazole (trade name is too smarmy)/
transcranial magnetic stimulation (TMS)

*along with all the traditional “antidepressants” like fluoxetine (Prozac), sertraline (Zoloft), etc., etc.

Dr. Phelps’ Tables: How Might You Choose?

lamotrigine / Lamictal
  • Depression is the dominant symptom
  • Rapid cycling
  • Need all the antidepressant you can get
  • Afraid of weight gain

  • Classic bipolar I symptom pattern: euphoric mania and severe depressions
  • Significant manic symptoms
  • Need all the antidepressant you can get
  • Suicide risk is a concern
  • Very inexpensive
quetiapine / Seroquel 

  • Depression and agitation are both severe
  • Severe sleep problems
  • Anxiety is a significant symptom also
  • No family history of diabetes
divalproex / Depakote 

  • Need something strong and fast
  • Male, and not afraid of weight gain
  • Rapid cycling
  • Significant manic symptoms
carbamazepine / Tegretol 

  • Rapid cycling
  • Severe sleep problems
  • Can’t take Depakote (e.g. afraid of weight gain risk)
  • Can’t afford Trileptal, or need the stronger option
olanzapine / Zyprexa 

  • Emergency-level symptoms
  • Need help really fast
  • Can use on “as-needed” basis
  • (If you continue to use it regularly) Not afraid of weight gain
oxcarbazepine / Trileptal 

  • Milder symptoms, can risk a possibly weaker agent
  • Significant manic symptoms
  • Alternative to Depakote as a starting place
  • Low long-term risk is appealing
omega-3 fatty acids/fish oil 

  • “Natural”; biggest known risk is “seal burps”
  • Milder symptoms, can risk a weaker agent
  • You want to add a possible mood stabilizer without adding more medication
  • Depression is a major symptom
  • Willing to take a lot of pills, or swallow (flavored) fish oil

  • Possible alternative for pregnancy
  • Low side effect risk
  • Tried many other medications but not ready for clozapine

  • Tried everything else
  • Severe symptoms
  • Ready for major weight gain, weekly blood tests
  • Ready for one of the most effective medications we have
atypical antipsychotics 

  • quetiapine: for sleep and agitation; has weight gain risk
  • risperidone: for elderly, at very low doses; or BPI perhaps — tricky antidepressant effects in some
  • ziprasidone: no clear role; but hey, it causes less weight gain than olanzapine, and really helps an occasional patient
  • aripiprazole: strong antimanic, not so clear regarding depression — but still learning about this one (as of 2014, believe it or not. It’s a weird one)

(the atypicals are low-dose boosters for specific problems (as add-ons to “real” mood stabilizers?))

So There You Have It

The world of mood stabilizers: often confusing, frustrating, and scary. However, maybe Dr. Phelps’ insight and information will help you find your way.

Be sure to check-out his Mood Stabilizers page. Hey, his tables are nicer and there’s more info. And I’ll bet once you’re on his site you won’t be able to leave for a while.

As always, take the time to peruse hundreds of Chipur titles. And if you’d like to read the Chipur articles featuring Dr. Phelps’ work, type Dr. Phelps in the search box.

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