Q:  BP II , Mood Stabilizers & Hyponatremia

Dear Dr. Phelps,

I was diagnosed with Bipolar Type II a few years ago. I've been through a number of mood stabilizers and side effects: lithium (tremors); Depakote (significant weight gain on both regular and extended release); Topamax (cognitive distortion); Lamictal (itching); Neuronton (I can't recall what the issue was); and finally, carbamazepine.

Carbamazepine at 900 mg per day became my savior and really helped me. However, after about three years on Tegretol, I developed severe hyponatremia. I've been told never to take it again.

Now, my psychiatrist and I are casting about for a reliable mood stabilizer that won't add to my weight/cholesterol issues or throw me back into the low sodium dilemma.

What would you recommend we try now? Are there any mood stabilizers that help with Bipolar Type II without exacerbating these conditions?

Thank you very much,


Dear KS -- 
Without knowing some of the other factors that might make one of these preferable over the others, here's the list of the remaining candidates that are generally regarded as mood stabilizers: quetiapine (Seroquel) is widely regarded as having all three qualities one would look for (antimanic, antidepressant, and likely -- but not officially proven yet -- preventive effects as well, based on our experience with it); aripiprazole (I refuse to use their trade name when I can avoid it) is also getting widely used in this role though we have less data on whether it has antidepressant effects (it at least has short-term preventive effects, i.e. helps you stay well once well, though that's not been studied in bipolar II).  Those are the two best studied agents amongst the so-called atypical antipsychotics. Also in that category is risperidone. In older folks it has a nice balanced effect, at very low doses. But somehow I'm not so confident it has that balance -- between antimanic and antidepressant effects -- in younger people, who generally require the routine doses. So it's lower on my list anyway, especially for bipolar II where I've not had much good luck with it, especially by itself. 

Finally in that gang there's Geodon but it is a very odd medication. Hard to predict what it's going to do, can't tiptoe in from low doses, quite a few side effects and lots of people get them. So I hardly use it at all but I have seen one gal with severe bipolar II do very well on it. 

The there's the less commonly used stuff, in part because most of 'em are generic and so not researched and ballyhoo'd.  These include zonisamide, another antiseizure medication (the other one sort of like this is Trileptal (oxcarbazepine) but it's really just a carbamazepine variant and if you had hyponatremia, you'd be somewhat more likely to get it on this one, so it's probably out too); and high-dose thyroid hormone; and verapamil. There's also "dark therapy" to look into (see the single case report, very stunning; and the whole story about bipolar disorder and light, including using a nifty variation on "darkness" as a treatment (largely unstudied but harmless if it doesn't work, and cheap and painless, so worth knowing about anyway). 

All of these options are summarized and compared on my mood stabilizers page, which gives you a way of sorting among them. Good luck with the next move. 

Dr. Phelps