11- Mood Stabilizers

Source: https://app.lecturio.com/#/lecture/c/7526/59632/33052

Correct answer: D. Remission of mood symptoms

Explanation:
The goal is remission, meaning resolution of mood symptoms or only minimal residual symptoms. Stabilization alone is insufficient and considered an intermediate step.

Goal of treatment in bipolar disorder

The primary goal of pharmacologic treatment in bipolar disorder is:

A. Partial symptom reduction
B. Sedation
C. Mood stabilization without relapse prevention
D. Remission of mood symptoms
E. Prevention of depressive episodes only

Correct answer: C. Antimanic agents used for acute mania and relapse prevention

Explanation:
Mood stabilizers are antimanic medications used to treat acute mania and prevent manic relapse, and many are useful in mixed episodes and rapid cycling.

Definition of mood stabilizers

Which of the following best describes mood stabilizers?

A. Medications used only for bipolar depression
B. Sedatives used in acute agitation
C. Antimanic agents used for acute mania and relapse prevention
D. Antidepressants with antipsychotic properties
E. Medications that permanently prevent mood episodes

Correct answer: C. 0.6–1.2 mEq/L

Explanation:
Lithium has a narrow therapeutic window. Most patients are maintained between 0.6–1.2 mEq/L. Levels outside this range risk inefficacy or toxicity.

Lithium therapeutic range

Which lithium serum level is most appropriate for maintenance treatment?

A. 0.1–0.4 mEq/L
B. 0.4–0.6 mEq/L
C. 0.6–1.2 mEq/L
D. 1.5–2.5 mEq/L
E. >2.5 mEq/L

Correct answer: C. Toxicity can occur at levels below 2.0 mEq/L

Explanation:
Lithium toxicity can begin below 2.0 mEq/L, especially in older adults or those with renal impairment. Severe toxicity (>2.5–3.0) may require dialysis.

Lithium (Eskalith) toxicity threshold

Which statement about lithium toxicity is TRUE?

A. Toxicity only occurs at levels above 3.0 mEq/L
B. Toxicity begins only when seizures occur
C. Toxicity can occur at levels below 2.0 mEq/L
D. Lithium toxicity is unrelated to renal function
E. Toxicity is usually asymptomatic

Correct answer: C. NSAIDs

Explanation (important correction):

• NSAIDs, ACE inhibitors, and thiazide diuretics increase lithium levels

• Theophylline, acetazolamide, and osmotic diuretics decrease lithium levels by increasing renal clearance

This is a classic exam trap.

Drugs that increase lithium levels

Which of the following medications INCREASES lithium levels?

A. Theophylline
B. Acetazolamide
C. NSAIDs
D. Osmotic diuretics
E. Caffeine

Correct answer: D. Excreted unchanged by the kidneys

Explanation:
Lithium is not metabolized. It is excreted unchanged by the kidneys, making renal function critical for safe use.

Lithium metabolism

Lithium (Eskalith) is primarily:

A. Metabolized in the liver
B. Metabolized by cytochrome P450
C. Metabolized in the GI tract
D. Excreted unchanged by the kidneys
E. Converted to an inactive metabolite

Correct answer: D. Hemodialysis

Explanation:
Severe lithium toxicity (>2.5–3.0 mEq/L) or neurologic symptoms require hemodialysis, especially because lithium is renally cleared.

Lithium toxicity management

A patient presents with confusion, coarse tremor, and a lithium level of 3.1 mEq/L. The best next step is:

A. Oral hydration only
B. Increase lithium dose
C. Activated charcoal
D. Hemodialysis
E. Observe for 24 hours

Correct answer: C. Ebstein anomaly

Explanation:
Lithium is associated with Ebstein anomaly, a congenital cardiac defect.
It is generally avoided, especially in the first trimester, but not absolutely contraindicated.

Lithium and pregnancy

Lithium exposure during pregnancy is most strongly associated with:

A. Neural tube defects
B. Limb abnormalities
C. Ebstein anomaly
D. Cleft palate
E. Omphalocele

Correct answer: B. Hyponatremia due to SIADH

Explanation:
Carbamazepine can cause SIADH → hyponatremia, along with leukopenia, rash, and rare aplastic anemia.

Carbamazepine adverse effects

Which adverse effect is MOST characteristic of carbamazepine?

A. Stevens–Johnson syndrome only when combined with valproate
B. Hyponatremia due to SIADH
C. Hyperthyroidism
D. Nephrogenic diabetes insipidus
E. Weight loss

Correct answer: E. Both C and D

Explanation:
Both valproic acid and carbamazepine are associated with spina bifida. Valproate carries the highest risk.

Teratogenicity of anticonvulsant mood stabilizers

Which mood stabilizer is MOST strongly associated with neural tube defects?

A. Lithium
B. Lamotrigine
C. Carbamazepine
D. Valproic acid
E. Both C and D

Correct answer: C. Bipolar depression

Explanation:
Lamotrigine (Lamictal) is particularly effective for bipolar depression and prevention of depressive relapse.

Lamotrigine key indication

Lamotrigine (Lamictal) is MOST useful for:

A. Acute mania
B. Rapid tranquilization
C. Bipolar depression
D. Alcohol withdrawal
E. Acute psychosis

Correct answer: D. Slow dose titration

Explanation:
Slow titration with low starting doses and gradual increases significantly reduces the risk of Stevens–Johnson syndrome.

Lamotrigine safety strategy

The best way to reduce the risk of Stevens–Johnson syndrome with lamotrigine is:

A. Combine with valproate
B. Start at high dose
C. Rapid titration
D. Slow dose titration
E. Use only short-term

Correct answer: C. Mania with impaired judgment

Explanation:
Mania is a medical and psychiatric emergency due to impaired judgment, impulsivity, and high risk behaviors.

Bipolar disorder as an emergency

Which situation BEST qualifies as a psychiatric emergency?

A. Mild hypomania with insight
B. Stable bipolar disorder on lithium
C. Mania with impaired judgment
D. Bipolar disorder in remission
E. Mild depressive symptoms

Correct answer: D. Is a danger to self or others

Explanation:
Inpatient care is indicated when patients are unsafe, unable to care for themselves, or pose danger to self or others.

Level of care decision

Inpatient hospitalization is MOST appropriate when a patient:

A. Has good insight and family support
B. Can care for basic needs
C. Is mildly symptomatic
D. Is a danger to self or others
E. Requests outpatient treatment

Correct answer: C. Renal function tests and thyroid function tests

Explanation:
Lithium (Eskalith) is renally excreted and commonly causes hypothyroidism. Baseline and ongoing monitoring must include:

• Renal function (BUN, creatinine)

• Thyroid function (TSH)

CBC and LFTs are not primary baseline requirements for lithium.

Baseline investigations before lithium

Before initiating lithium therapy, which set of baseline investigations is MOST appropriate?

A. CBC, lipid panel, fasting glucose
B. LFTs, coagulation profile, ammonia
C. Renal function tests and thyroid function tests
D. ECG only
E. Urine toxicology screen

Correct answer: C. Benign leukocytosis

Explanation:
Lithium commonly causes benign leukocytosis due to stimulation of granulocyte production. This is not dangerous and does not require discontinuation unless clinically indicated.

Benign laboratory finding with lithium

A patient on long-term lithium therapy has an elevated white blood cell count but no symptoms of infection. The MOST likely explanation is:

A. Agranulocytosis
B. Aplastic anemia
C. Benign leukocytosis
D. Bone marrow suppression
E. Acute infection

Correct answer: C. Renal resistance to ADH

Explanation:
Lithium causes nephrogenic diabetes insipidus by making the kidneys unresponsive to ADH, leading to polyuria and polydipsia.

Nephrogenic diabetes insipidus

Lithium-induced polyuria is primarily due to:

A. Increased ADH secretion
B. Central diabetes insipidus
C. Renal resistance to ADH
D. Increased aldosterone secretion
E. Glomerulonephritis

Correct answer: D. Hemorrhagic pancreatitis

Explanation:
Hemorrhagic pancreatitis is a rare but fatal adverse effect of valproic acid and requires immediate cessation.

Valproic acid serious adverse effect

Which adverse effect of valproic acid is life-threatening and requires immediate discontinuation?

A. Weight gain
B. Alopecia
C. Tremor
D. Hemorrhagic pancreatitis
E. Sedation

Correct answer: C. Resolution of psychosis

Explanation:
If psychotic features are present, psychosis must be treated first, typically with antipsychotics, because it poses immediate safety risks.

Treatment priority in manic episode with psychosis

A patient presents with acute mania and prominent psychotic symptoms. The MOST appropriate initial treatment focus is:

A. Mood stabilizer only
B. Antidepressant therapy
C. Resolution of psychosis
D. Psychotherapy
E. Observation only

Correct answer: C. Acute agitation and insomnia

Explanation:
Benzodiazepines are adjunctive, short-term agents used for acute agitation, anxiety, and insomnia, especially in mania. They are not mood stabilizers.

Role of benzodiazepines in bipolar disorder

Benzodiazepines are MOST appropriately used in bipolar disorder for:

A. Long-term mood stabilization
B. Treatment of bipolar depression
C. Acute agitation and insomnia
D. Maintenance therapy
E. Prevention of relapse

Correct answer: D. Patient with symptoms but strong home support

Explanation:
Partial hospitalization is appropriate when the patient:

• Is not an immediate danger

• Has adequate home support

• Needs intensive daytime treatment

Partial hospitalization program

Which patient is MOST appropriate for a partial hospitalization program?

A. Actively suicidal patient
B. Patient unable to care for basic needs
C. Patient with severe psychosis
D. Patient with symptoms but strong home support
E. Patient with violent behavior

Correct answer: C. A common non-toxic side effect

Explanation:
Metallic taste and polydipsia are common, non-toxic side effects of lithium and do not indicate toxicity unless accompanied by neurologic symptoms or elevated levels.

Metallic taste and thirst with lithium

A patient reports excessive thirst and a metallic taste shortly after starting lithium. This finding is best described as:

A. An allergic reaction
B. A sign of lithium toxicity
C. A common non-toxic side effect
D. Indication to stop lithium immediately
E. Evidence of renal failure