Mood stabilizers are medications used mainly to treat bipolar disorder and to help prevent or soften episodes of mania and depression. According to the National Institute of Mental Health, they are typically used for bipolar disorder and for mood changes associated with other mental disorders.
Part of our guide: A Patient’s Guide to Psychiatric Medication
The term covers a few different drugs that are not chemically alike. The main ones are lithium and certain anticonvulsants, medications also used for seizures. They differ in what they treat, what monitoring they need and what risks they carry, so the useful question is which one fits you, and why.
If you are thinking about suicide or self-harm, or are worried about someone else: call or text 988 (988 Suicide & Crisis Lifeline), call 911 or go to the nearest ER.
What mood stabilizers are used for
NIMH's bipolar disorder guide says mood stabilizers such as lithium or valproate can help prevent mood episodes or reduce their severity. It adds that bipolar depression is often treated with a mood stabilizer or an atypical antipsychotic, and that antidepressants, when used, are not used alone because they can trigger a manic episode or rapid cycling. This is one reason an accurate diagnosis matters so much before treatment for depression begins. Atypical antipsychotics are a separate group, covered in why antipsychotics are prescribed for mood disorders.
NIMH also says bipolar disorder usually requires lifelong treatment, so these are often long-term medications. You may want to raise how long treatment is likely to last, and what would prompt a review, early on.
The main medications compared
This table summarizes FDA labeling. It is not a complete safety list. Your prescriber and pharmacist can go through the full information for any medication you are considering.
| Medication | FDA-labeled use in bipolar disorder | Boxed warning |
|---|---|---|
| Lithium | Manic episodes and maintenance | Lithium toxicity, closely related to blood levels |
| Valproate (divalproex, Depakote) | Manic episodes | Liver failure, fetal risk, pancreatitis |
| Lamotrigine (Lamictal) | Maintenance in bipolar I; not recommended for acute manic or mixed episodes | Serious skin rashes that can be life-threatening |
| Carbamazepine, extended-release (Equetro) | Acute manic or mixed episodes in bipolar I | Serious skin reactions, with an added risk linked to a genetic marker; aplastic anemia and agranulocytosis |
Lithium
The Lithobid label lists lithium for manic episodes of bipolar disorder and for maintenance. NIMH notes that lithium also can decrease the risk of suicide.
Its main challenge is a narrow margin between a helpful and a harmful level. The boxed warning says lithium toxicity is closely related to blood levels and can occur at doses close to therapeutic levels. That is why treatment involves regular blood tests. The label also calls for checking kidney function before and during treatment, and for careful monitoring of thyroid function where low thyroid already exists. NIMH says providers generally ask people on lithium to take part in regular monitoring of lithium levels and of kidney and thyroid function. See which blood tests psychiatric medications need for a broader overview.
Other things can shift lithium levels. The label warns about NSAIDs, a group of common pain relievers, as well as some diuretics and certain blood pressure medications. It also says prolonged sweating or diarrhea, or an infection with fever, may call for a temporary change in treatment, so call your prescriber and do not adjust it yourself. The label also says a normal diet, including salt, and adequate fluids are essential, at least during the initial stabilization period, and that lithium can precipitate serotonin syndrome, with higher risk alongside other serotonergic drugs such as SSRIs and SNRIs. Tell your prescriber before starting any new medication, including over-the-counter ones, and call if you become sick. The label lists diarrhea, vomiting, drowsiness, muscular weakness and lack of coordination as possible early signs of lithium toxicity, so call your prescriber right away if these appear, and seek emergency care if they are severe. The label also warns that lithium may cause fetal harm, and that birth registries suggest an increase in heart and other defects, especially Ebstein's anomaly. It says nursing should not be undertaken except in rare and unusual circumstances. Raise pregnancy plans or breastfeeding early. If you become pregnant, call your prescriber right away and do not stop on your own.
Valproate
The Depakote label lists it for manic episodes associated with bipolar disorder, and says safety and effectiveness for long-term use in mania, meaning more than 3 weeks, has not been shown in controlled trials, so prescribers should keep reassessing it. Its boxed warning covers three serious risks: liver failure, including deaths; major birth defects such as neural tube defects, along with decreased IQ and neurodevelopmental disorders after exposure in the womb; and life-threatening pancreatitis. Liver tests should be done before treatment and often afterward, especially in the first six months, and belly pain, nausea, vomiting or loss of appetite can be signs of pancreatitis that need prompt medical evaluation. Valproate is contraindicated in people known to have mitochondrial disorders caused by POLG gene mutations.
The label is direct about reproductive risk. It says valproate should not be given to a woman of childbearing potential unless other medications have failed to provide adequate symptom control or are otherwise unacceptable, and that effective contraception should then be used, because the harm may occur very early in pregnancy. Anyone who could become pregnant should discuss this in detail before starting and should tell the prescriber right away about pregnancy plans. The Medication Guide says not to stop without first talking to a healthcare provider, so if you find out you are pregnant, call your prescriber right away. This article on psychiatric medication during pregnancy and the page on reproductive psychiatry have more.
Lamotrigine
The Lamictal label lists it for maintenance treatment of bipolar I disorder to delay the time to mood episodes, and says treatment of acute manic or mixed episodes is not recommended. So it is used to help prevent episodes and not to treat mania that is already happening.
Its boxed warning is about serious rashes that can require hospitalization, including Stevens-Johnson syndrome and, rarely, toxic epidermal necrolysis or death. The label puts these rashes at about 0.08% to 0.3% of adults and 0.3% to 0.8% of those aged 2 to 17. It says the risk may be raised by taking it along with valproate, by exceeding the recommended starting dose or rate of increase, or by a genetic marker called HLA-B*1502, though cases have occurred without these factors. That is why starting and adjusting it is done carefully. Nearly all life-threatening rashes have occurred within 2 to 8 weeks of starting, with isolated cases later, and there is no reliable way to tell a mild rash from one that will become serious. Practical points from the label:
- Call your prescriber right away about any rash, even a mild one, and about blistering or peeling skin, hives, or painful sores in your mouth or around your eyes. A clinician should examine you to decide whether you continue, and the label says lamotrigine should ordinarily be discontinued at the first sign of rash unless it is clearly not drug related, so ask what to do about your next dose. If symptoms are severe or you cannot reach anyone, go to the nearest ER.
- Never take more than prescribed or raise the dose faster than prescribed.
- Do not stop on your own for any other reason. The Medication Guide says stopping suddenly may cause serious problems.
- Tell your prescriber if you start or stop estrogen-containing birth control, since the label says this will require dose changes in most patients.
- If you have stopped or missed doses, call before restarting, and do not go back to your old dose on your own. The label says that after a long enough gap, the starting schedule should be followed again.
Carbamazepine
The extended-release form Equetro is labeled for acute manic or mixed episodes in bipolar I disorder. Its boxed warning covers serious and sometimes fatal skin reactions, and two serious blood disorders, aplastic anemia and agranulocytosis. The label calls for a blood count before treatment and periodic monitoring after that. It also calls for testing people with ancestry in genetically at-risk populations for a genetic marker called HLA-B*1502, and for avoiding use in those who test positive unless the benefit clearly outweighs the risk. It says Equetro may decrease the effectiveness of hormonal contraceptives, so ask about birth control if this applies to you, and it warns of a potential increased risk of major birth defects with use in pregnancy. If you become pregnant, call your prescriber right away.
One warning they share
Labels for antiepileptic drugs, including valproate, lamotrigine and carbamazepine, state that this class increases the risk of suicidal thoughts or behavior. People taking them should be watched for new or worsening depression, suicidal thoughts and unusual mood or behavior changes. Agree with your clinician ahead of time on what to do and who to call if any of these appear, and let someone close to you know the signs too.
How a prescriber narrows the choice
The labels above point to the questions that shape the decision. Is the goal to treat a current manic episode, prevent future episodes or both? Could you become pregnant, and do you use hormonal birth control? How are your kidneys, thyroid and liver? Which other medications do you take? Can you keep up with blood tests? Bring your honest answers, and bring your history of what has and has not helped.
Staying on track
NIMH's advice is to avoid stopping medication without talking to your health care provider first. If side effects, cost or doubt are making you want to stop, say so. There are usually options to talk through, and any change should be made only with your prescriber. These articles on sticking with bipolar medication and managing bipolar disorder without medication offer more on those conversations.
Questions worth asking your prescriber:
- What is this medication meant to do for me: treat an episode, prevent one or both?
- Which blood tests will I need, and how often?
- What should make me call right away?
- Does it interact with my birth control or other medications?
- What happens if I want to become pregnant?
If you want to learn more about care for these conditions, see bipolar disorder treatment at Mind Body Seven. You can request a consultation, and the intake team confirms fit, scheduling and costs.
FAQs
Are mood stabilizers the same as antidepressants?
No. They are different medications used for different purposes, though some people take both. NIMH says antidepressants are not used alone in bipolar disorder because they can trigger a manic episode or rapid cycling.
Will a mood stabilizer change my personality?
Worry about feeling flat or different is common and worth raising. Tell your prescriber specifically what you notice, since it may reflect the illness, the medication or the dose. This article on whether medication changes who you are looks at it further.
Do I need blood tests on every mood stabilizer?
Monitoring differs by medication. NIMH says people taking lithium or anticonvulsants are generally asked to participate in regular monitoring. Ask your prescriber what applies to you and how often.
Can a primary care doctor manage these medications?
Some do, and it depends on the person, the medication and the doctor's comfort with it. This comparison of psychiatrists and primary care doctors covers how to think about it.
