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Mood Stabilizers


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Mood stabilizers are the treatment of choice for bipolar disorder, a condition that often accompanies ADHD. However, these drugs have other clinical uses.

Currently, mood stabilizers are being used to treat patients who display symptoms of violent aggression, impulsivity or agitation. These symptoms are quite common in ADHD, especially in those children who suffer from a number of other co-morbid disorders.

Aggression and Impulsivity

Most people have violent thoughts out of frustration, but they will not act on these impulses unless they lose control. People with trouble controlling impulsive behavior frequently act out in an aggressive manner. Aggressive behavior is common in variety of conditions such as:

  • ADHD
  • Conduct disorder
  • Psychotic disorders
  • Mood disorders
  • Intermittent explosive disorder
  • Adjustment disorder
  • Personality disorders (mainly paranoid, antisocial, borderline)
  • Mental retardation
  • Delirium
  • Dementia

Many of these disorders are co-morbid with ADHD and ODD. Mood stabilizers can be used to treat these conditions.

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Agitation is a form of severe anxiety associated with motor restlessness. It may lead to inappropriate verbal, vocal, or motor activity. It is associated with strong emotion, anxiety, tension, urgency, and fear, and it may lead to aimless wandering, pacing, cursing, or arguing.

Agitation may accompany:

  • Psychosis
  • Mood disorders
  • Anxiety disorder
  • Insomnia
  • Dementia

Excessive agitation may occur in a number of disorders that are co-morbid with ADHD and ODD. Mood stabilizers can be used to treat these conditions.

Classification of Mood Stabilizers

There is no agreed-upon definition of the term mood stabilizer. We all use the term, but it is nowhere officially defined.

There are about 4 major classes of drugs that are being used as mood stabilizers. These are:

  • Lithium
  • Anti-epileptics
  • Antidepressants
  • Neuroleptics (Anti-psychotics)

We shall now discuss some of these drugs in depth.


Lithium has been used for the treatment of acute bipolar mania for over 50 years. It is an alkali metal similar to sodium and comes as one of two salt preparations, lithium carbonate or lithium citrate.

In the US, lithium is considered the drug of choice for adults and children with bipolar disorder. However, European psychiatrists do not use lithium in children, and in Israel the largest child psychiatric hospital does not even have lithium on the hospital formulary.

Lithium has multiple complex neurochemical effects, with impact on ion channels, serotonin, dopamine, and norepinephrine neurotransmitter systems, as well as on second messenger systems.

So how does it work? Nobody really knows.

Side effects:

Up to 75% of patients treated with lithium experience some side effects. Most of these are minor and can be reduced or eliminated by lowering the lithium dose or changing the dosage schedule.

Endocrine: Lithium has been associated with thyroid abnormalities. Hypothyroidism occurs in up to 35% of patients treated with lithium.

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Renal: Lithium inhibits reabsorption of water leading to excessive urination and thirst. There have been some reports of structural kidney damage with long-term lithium use.

Cardiovascular: Lithium disrupts the cardiac conduction system and can cause arrhythmias. These changes are usually not significant.

Dermatological: Lithium can induce or exacerbate acne, which is a problem for adolescent patients. It is also associated with hair loss.

Neurological: Lithium may produce a variety of neurological effects, including muscle weakness, tremor, lethargy, cognitive blunting, and headaches. In children, lithium has been reported to alter EEG patterns and to decrease performance on cognitive testing.


Even though lithium has a very long list of side effects, that is not what concerns most physicians. The real concern is the toxicity. The blood levels in which, lithium becomes toxic are not much higher than the levels that are necessary for treatment. This combined with the fact that patients who require lithium treatment usually are not particularly reliable or compliant, makes treatment with lithium somewhat precarious.

Toxic effects of lithium include marked tremor, nausea and diarrhea, blurred vision, vertigo, confusion, and increased deep tendon reflexes. With higher levels, patients may experience more severe neurological complications and eventually experience seizures, coma, cardiac arrhythmia, permanent neurological damage, and death.

Hemodialysis is the only reliable treatment for lithium overdose.


You are probably wondering by now after reading this list, why would anyone want to go near this stuff. The bottom line is this. Lithium works, and it probably works better than anything else that we have. This is very important. These conditions, bipolar disorder, aggressive personality disorders, conduct disorder, psychotic disorders, etc., are serious psychiatric conditions. Left untreated, they have serious life long and sometimes life terminating consequences.


Valproic acid (Depakene, Valprotate)

Valproic acid is a simple bracket chain carboxylic acid currently available in two preparations; valproic acid, and divalproex sodium a combination of valproic acid and valproate. Some physicians feel that overall this drug is just as effective as lithium and has less serious side effects. Valproate may have a quicker onset of action than lithium.

Side effects:

  • Weight gain
  • Tremor
  • Dizziness
  • Sedation
  • Headache
  • Nausea
  • Indigestion
  • Bruising
  • Hair loss

Rarely, valproic acid has been associated with fatal hepatic toxicity, hemorrhagic pancreatitis, and agranulocytosis.

Valproic acid may increase testosterone levels in teenage girls and produce polycystic ovary syndrome in women who began taking the medication before age 20.

Continued on Page 2

Anthony Kane, MD
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