Mood Stabilizers/Pharmacology

Summary

This video script delves into the realm of mood stabilizers, focusing on their role in managing bipolar disorder. It introduces five key medications: lithium, valproic acid, lamotrigine, carbamazepine, and oxcarbazepine, and their specific applications for manic or depressive episodes. The script highlights the importance of understanding the 'two poles' of bipolar disorder and how it influences medication choice. It also emphasizes the significance of recognizing adverse drug reactions, which often form the crux of exam questions, providing insights into the clinical application of this knowledge beyond test-taking.

Takeaways

• 💊 Mood stabilizers are a group of drugs primarily used to treat different aspects of bipolar disorder.
• 🌐 Bipolar disorder has two poles: the manic and depressive poles, and patients can experience episodes of either.
• 🤔 It's important to distinguish bipolar disorder's depressive episodes from major depressive disorder, as treatment differs.
• 💡 The test writer's portrayal of a patient's bipolar episode (manic or depressive) can influence the correct answer on exams like USMLE and COMLEX.
• 🌟 Lithium is the gold standard treatment for the manic phase of bipolar disorder.
• 🌿 Lamotrigine is the preferred treatment for the depressive phase of bipolar disorder.
• 🔄 Valproic acid is used for mixed or rapid cycling bipolar disorder where patients experience alternating mania and depression.
• 💡 Carbamazepine and oxcarbazepine are used when other mood stabilizers are not effective.
• 🧠 Lithium's mechanism of action involves modulation of the phospholipinositol pathway, which is important for exams.
• ⚠️ Adverse drug reactions and precautions are crucial to understand, as they are frequently tested and can be severe.
• 📚 Understanding the adverse reactions of mood stabilizers can help in clinical practice and on exams, emphasizing the need for careful monitoring.

Q & A

What are mood stabilizers and why are they important in the context of bipolar disorder?

Mood stabilizers are a group of drugs used to treat different aspects of bipolar disorder. They are crucial because they help manage the extreme emotional states characteristic of the disorder, which includes both manic and depressive episodes.

What are the five primary mood stabilizers mentioned in the video?

The five primary mood stabilizers discussed are lithium, valproic acid, lamotrigine, carbamazepine, and oxcarbazepine.

Why is it significant to understand the 'two poles' of bipolar disorder?

Understanding the 'two poles'—manic and depressive—is important because it helps in determining the appropriate treatment. Patients may experience episodes of mania or depression, and the type of episode can influence the choice of medication.

How does the manic phase of bipolar disorder typically respond to treatment?

The manic phase of bipolar disorder is commonly treated with lithium, which is considered the gold standard for patients who predominantly experience mania.

Which mood stabilizer is primarily used for the depressive phase of bipolar disorder?

Lamotrigine is primarily used for the depressive phase of bipolar disorder.

What is the significance of knowing the different poles in answering questions related to USMLE and COMLEX exams?

Knowing the different poles helps in reasoning through questions, especially when the test presents a patient scenario. It can guide the choice of the correct mood stabilizer based on whether the patient is in a manic or depressive episode.

What is the mechanism of action for lithium as mentioned in the video?

Lithium modulates the phospholipinositol pathway, which is a key insight for understanding its function in mood stabilization.

Why are adverse drug reactions and cautions important to know for mood stabilizers?

Adverse drug reactions and cautions are important because they constitute a significant portion of exam questions and are critical for patient safety in clinical practice.

How can one memorize the mechanism of lithium's action more effectively?

The video suggests using the phrase 'phospholipinositol pathway' and associating 'lip' with the chemical symbol for lithium (Li) to make it easier to remember.

What is the clinical significance of the adverse drug reactions associated with valproic acid?

Valproic acid can cause thrombocytopenia, elevated liver function tests, neural tube defects, and pancreatitis. Recognizing these reactions is crucial for patient monitoring and management.

How can practice questions with lab printouts and physical exam pictures help in understanding mood stabilizers?

Practice questions with lab printouts and physical exam pictures can simulate real-life clinical scenarios, helping to apply knowledge of mood stabilizers and their adverse effects in a practical context.

Outlines

00:00

💊 Introduction to Mood Stabilizers and Bipolar Disorder

This paragraph introduces the topic of mood stabilizers, focusing on their role in treating bipolar disorder. It highlights five key drugs: lithium, valproic acid, lamotrigine, carbamazepine, and oxcarbazepine. The importance of understanding the 'two poles' of bipolar disorder—manic and depressive—is emphasized, as it influences medication choice. The paragraph also discusses how the patient's current state (manic or depressive) can affect the correct answer on medical exams like USMLE and COMLEX, providing a strategy for test-takers to deduce the appropriate medication based on the patient's condition.

05:01

📊 Bipolar Disorder Treatment Strategies and Drug Reactions

The second paragraph delves into the specifics of which mood stabilizers are used for treating the manic or depressive phases of bipolar disorder. Lithium is the gold standard for mania, while lamotrigine is preferred for depression. Valproic acid is highlighted as a treatment for mixed or rapid cycling bipolar disorder. The paragraph also underscores the importance of recognizing adverse drug reactions and cautions associated with these medications, which is crucial for exam preparation and clinical practice. It suggests using lab printouts and physical exam pictures to practice identifying drug-induced reactions, with examples given for lithium, valproic acid, lamotrigine, and carbamazepine.

10:01

⚠️ Adverse Reactions and Clinical Reasoning for Mood Stabilizers

In the final paragraph, the focus is on understanding the adverse reactions and toxicities associated with mood stabilizers, which form a significant portion of exam questions. The paragraph provides a rapid review of these reactions, such as nephrogenic diabetes insipidus and thyroid issues for lithium, thrombocytopenia for valproic acid, Stevens-Johnson syndrome for lamotrigine, and agranulocytosis for carbamazepine. It also discusses how test writers may present these adverse reactions in exam questions, using lab results or physical exam findings to challenge test-takers' clinical reasoning skills. The goal is to prepare students not only for exams but also for real-world clinical decision-making.

Keywords

💡Mood stabilizers

Mood stabilizers are a class of drugs used primarily to treat bipolar disorder by managing the extreme emotional fluctuations between mania and depression. In the video, they are the central theme, with a focus on five specific drugs: lithium, valproic acid, lamotrigine, carbamazepine, and oxcarbazepine. The script discusses how these drugs are used differently depending on whether a patient is in a manic or depressive episode.

💡Bipolar disorder

Bipolar disorder is a mental health condition characterized by alternating episodes of mania and depression. The term 'bipolar' refers to the two poles of the illness, which are the manic and depressive states. The video script emphasizes the importance of understanding these poles, as they influence the choice of mood stabilizer and the interpretation of test questions related to the disorder.

💡Manic pole

The manic pole refers to the elevated, energized, and often irritable state experienced by individuals with bipolar disorder during a manic episode. The script mentions that lithium is the gold standard treatment for patients who predominantly experience mania, illustrating the connection between the pole of the illness and the choice of medication.

💡Depressive pole

The depressive pole is the opposite end of the spectrum in bipolar disorder, where patients experience symptoms of depression. The video script explains that lamotrigine is the primary treatment for patients who are mostly in the depressive phase, highlighting the importance of matching treatment to the specific pole of the disorder.

💡Valproic acid

Valproic acid is one of the mood stabilizers discussed in the video, which is particularly useful for treating mixed or rapid-cycling bipolar disorder where patients experience alternating episodes of mania and depression. It is an example of how certain drugs are more appropriate for specific presentations of bipolar disorder.

💡Lithium

Lithium is a mood stabilizer that is highlighted in the script for its well-established use in treating the manic phase of bipolar disorder. The video also discusses lithium's mechanism of action, which involves modulation of the phosphoinositol pathway, and its various adverse drug reactions, such as nephrogenic diabetes insipidus and thyroid dysfunction.

💡Lamotrigine

Lamotrigine is another mood stabilizer mentioned in the video, which is primarily used for treating the depressive phase of bipolar disorder. The script warns of its association with a serious adverse reaction, Stevens-Johnson syndrome, which is a severe skin reaction that can be a critical consideration in treatment decisions.

💡Carbamazepine

Carbamazepine is a mood stabilizer that is also an anti-seizure drug. The video script points out that it can cause agranulocytosis, a decrease in white blood cells, which is a significant adverse effect that clinicians must monitor for in patients taking this medication.

💡Oxcarbazepine

Oxcarbazepine is related to carbamazepine and is also used as a mood stabilizer. While not detailed in the script, it is implied to be used in situations where other mood stabilizers are not effective, indicating its role as an alternative treatment option.

💡Adverse drug reactions

Adverse drug reactions are unwanted and harmful effects caused by medications. The video script emphasizes the importance of recognizing these reactions for mood stabilizers, as they are a common focus in exam questions. Examples given include nephropathy caused by lithium, thrombocytopenia caused by valproic acid, and liver function test abnormalities associated with the same drug.

Highlights

Mood stabilizers are a group of drugs primarily used to treat different aspects of bipolar disorder.

Five key mood stabilizers to know for USMLE and COMLEX: lithium, valproic acid, lamotrigine, carbamazepine, and oxcarbazepine.

Bipolar disorder has two poles: the manic and depressive ends of the disease spectrum.

Understanding the patient's current pole in bipolar disorder is crucial for determining the correct medication choice.

Lithium is the gold standard treatment for patients primarily experiencing mania.

Lamotrigine is the preferred treatment for patients in the depressive phase of bipolar disorder.

Valproic acid is used for mixed or rapid cycling bipolar disorder where patients experience alternating mania and depression.

Carbamazepine and oxcarbazepine are used when the primary mood stabilizers do not yield a good response.

Lithium's mechanism of action involves modulation of the phosphoinositol pathway.

Adverse drug reactions are a significant focus in questions about mood stabilizers, accounting for about 75% of the content.

Lithium can cause nephrogenic diabetes insipidus, hyper and hypothyroidism, Ebstein's anomaly, and chronic kidney disease.

Valproic acid may lead to thrombocytopenia, elevated liver function tests, neural tube defects, and pancreatitis.

Lamotrigine is associated with Stevens-Johnson syndrome, a severe skin reaction.

Carbamazepine can cause agranulocytosis and is a potent inducer of the cytochrome P450 system.

Practice questions with lab printouts and physical exam pictures help to identify the drug causing adverse reactions.

Test writers often use clinical scenarios to challenge test-takers on adverse drug reactions and toxicities of mood stabilizers.

Memorizing the adverse reactions and understanding the clinical presentation can help reason through questions on test day.

Transcripts

in today's video we're going to be

talking about mood stabilizers

and we'll also touch a little bit on

bipolar disorder since the conversations

go hand in hand

now in this video we're going to talk

about mood stabilizers and primarily

when we use the word mood stabilizers

what we are referring to

is a group of drugs that treats

different aspects of bipolar disorder

and that group of drugs is shown here on

this slide

certainly this is not an all-inclusive

list there are more drugs than what you

see pictured on this

slide that in real life are actually

used to treat bipolar disorder

but as far as usmle and complex goes

and what you should be responsible to

know

you want to know these five so you've

got lithium valbroic acid

lumotrigine carbamazepine and

oxcarbazepine

before we talk about each of these drugs

individually it's important to point out

one really important fact about bipolar

disorder

that's high yield enough to help you get

some free points on test day

for those who don't know bipolar

disorder is named bipolar

because it has two poles one pole being

the manic pole or the manic end of the

disease

and the other pole being the depressive

or end of the disease

and patients can fall into either of

these two poles if you're

having an episode of depression it

doesn't mean that you have major

depressive disorder

necessarily you could just be in the

depressed

phase or at the depressed pull of

bipolar disorder

and likewise somebody who's manic is not

necessarily having a psychotic illness

if they're manic they could just be on

the

manic pole of bipolar disorder

and the reason that this is really high

yield for us emily and comlex is because

oftentimes when the test writer writes

the question

depending on which pull of the illness

they're putting a patient in

in that example that's going to affect

what the correct answer choice is going

to be

and what i'm saying is that the person

who writes this question

for us emily or complex obviously in

real life has familiarity

with bipolar disorder and in real life

depending on if the patient is manic or

if the patient is depressed so

that is to say depending on which pole

they're currently at within

bipolar disorder it affects the

medication

choice so if the question writes about a

patient who's manic

it's possible that the question is

pointing to a drug that primarily treats

mania

whereas if the question puts a patient

in the depressed poll

the test writer might be going for a

different answer

so how does that help you well this

isn't written in first aid this isn't

written in question banks but if you

know this

and this is just good clinical

information it can help you reason

through these

questions if you otherwise don't know

the information that you needed to

memorize

about the mood stabilizers so with that

in mind let's talk briefly about what

drugs treat mania

what drugs treat depression and what the

test writer might be hinting at

depending on how they paint the picture

for you in the example

so in the manic phase of the illness the

gold standard treatment is lithium for

patients

who are just manic most of their life

and don't really

experience the depressed pole you want

to treat them with

lithium now patients who are on the

depressed phase of the illness they're

better served by treatment with

lamotrigine

so i'm showing you i'm illustrating this

for you by using different lines if

you're on the top part of the graph you

spend most of your time at the manic

pole

and those patients usually get treated

with lithium first

and depressed pole patients well they're

going to be treated with lamotrigine

there is a variant where there is a

mixed or rapid

cycling bipolar disorder where the

patient actually experiences

alternating mania and depression and

those patients are better treated with

valproic

acid so these are the three main mood

stabilizers that we utilize

and then of course there's carbamazepine

and ox carbazepine

which don't necessarily fit into a manic

or depressive

pole per se but they're sort of used

when these three

aren't really getting a good response so

again

the reason that i'm telling you this is

not because you need to memorize this

for usmle or complex

but because if you care at all enough to

reason through the question

if the question is writing about

somebody and the question tells you that

this patient

spends you know 90 of their time in the

depressed phase of bipolar disorder but

has only been diagnosed with bipolar

disorder

if that's a question about mood

stabilizers i would bet my house that

they're gonna

talk about lamotrigine because that is

the drug that is primarily used for the

depressed

phase or the depressed pull of bipolar

disorder so this graph can be useful to

you clinically and i would encourage you

once you're a third year and

beyond to come back and look at this

because this will help you

not only on usmle and comlex but on your

psych rotation as well

so that's a little bit about bipolar

disorder and about which mood stabilizer

goes for which

pole which the treatment of which pole

let's go through and fill out this graph

because this is really the takeaway from

today's video

it's understanding not only the

mechanism of these mood stabilizers

but also what cautions you should be

looking out for because those cautions

and those adverse drug reactions

is going to be about probably what 75

percent of the questions on mood

stabilizers

are about so i do have a video

on anti-seizure drugs and because most

of the mood stabilizers are

anti-epileptics

i would encourage you to look at that

video if you want all of my silly

mnemonics for

memorizing the mechanisms of all of

these different drugs

the exception obviously being lithium

which doesn't treat seizures at all

so i'm going to just fill in this chart

and i'm not going to talk about the

mechanisms at

all again if you want mnemonics for the

mechanisms

check out the anti-epileptic video

because i've already gone through all of

that before

what's incredibly important for you to

take away from this video

are two things one one mechanism i will

talk about is the lithium's

mechanism so lithium if you you know if

you look in first aid

i'm gonna bet that it says mechanism

unknown and that's technically not true

we do

we do know how lithium works it

modulates the phosphoenocetal pathway

it does a lot of other things as well

but this is what could start to show up

on usmle on complex on your shelf exams

we're learning more and more about this

as as continuous research comes out

so in order to memorize that instead of

saying phospho-inositol

pathway i think you should say

phospholipin-acetal pathway because the

lip

is the chemical symbol for lithium the

li

so lithium lithium modulates

phospholipinositol

and that's just a stupid easy way to

memorize that

again the important takeaway from this

slide is all of the adverse drug

reactions all of the cautions

for lithium it's a ton of stuff right

you've got nephrogenic diabetes

insipidus

hyper and hypothyroidism ebstein's

anomaly chronic kidney disease

for valproic acid you have

thrombocytopenia

elevation of your lfts neural tube

defects and pancreatitis

for lamotrigine you've got the famous

stevens johnson syndrome

for carbamazepine you'll see a

granulocytosis you could see s-i-a-d-h

and this is an extremely extremely

potent

p450 inducer now

instead of just going through this i

think the best way to approach this is

to give you practice questions with lab

printouts and

physical exam pictures and ask you

what is the drug that they're talking

about so the way that this will work on

test day is you'll get a question

that'll look something like this it'll

tell you that a male

has a med has a medical history of an

unknown mood disorder maybe they'll say

bipolar maybe they won't

they'll tell you that he's got some

medical problem right they're going to

be vague about it they're going to be

like good headache gi upset whatever

it's going to be non-specific

but what's really specific is they'll

say on review of his labs

you note the following and they'll give

you that little lab printout

and that'll have a little area where you

can check the normal values so don't

worry if you don't know what's normal

for all of these but we'll go through

this and assume that you do

and then it'll ask you which of the

following medications is responsible

for this adverse drug reaction or which

of the following medications was this

patient prescribed

and what the question is basically

asking you is

what mood stabilizer is causing the

problem

that i've written about in this question

that's what the test writer is going for

and your choices will be lithium vaporic

acid lamotrigine carbamazepine or ox

carbazipine

or maybe they'll be really annoying and

they'll throw in other distractors like

you know ssris etc etc so

let's start with this example so you've

got this printout and obviously there's

some problem

with one of these labs and if you've

been doing enough practice questions you

can probably look at this and i

already identify what the problem is the

problem is that the white cell count is

low and therefore the answer here is

carbamazepine because what the test

writer might be going for

is agranulocytosis or neutropenia so

in this one that is the drug that's

responsible for the reaction so we're

going to go through this rather quickly

this is sort of rapid review

what about this one i didn't change the

vignette at all i did was change the

labs around

so which of the following medications is

responsible for this

adverse drug reaction you can pause the

video if you want to think about this

but the

answer is going to be lithium so you see

that the creatinine

is elevated and lithium does cause

nephropathy

it causes a chronic interstitial

nephritis

it causes nephrogenic diabetes insipidus

and in all of those cases you could see

a bump in your creatinine

so the fact that we're seeing an

elevation of creatinine on this lab

printout

shows you that lithium is the drug

responsible because none of these other

medications are really going to do that

what about this example

pause the video if you'd like some more

time to think about it

but if you've been doing enough practice

questions you'll probably recognize that

in this example

platelets are low and the only

medication that causes

thrombocytopenia profoundly

on this list is going to be valprolic

acid so b

valpric acid now in this question

i left the the vignette pretty much the

same and i changed one sentence

i wrote on physical exam you know the

following and then there's a picture

and the question is now which of the

following medications is responsible for

this adverse stroke reaction and what

you're seeing

here if you're even if you're not sure

that this is stevens-johnson syndrome

you should assume that it is given the

five answer choices because no drug

besides lamotrigine

causes stevens-johnson syndrome or a

malignant appearing rash on the mucosal

surfaces

so you can safely assume because we're

talking about mood stabilizers that this

is probably

sjs or stevens-johnson syndrome

and therefore the answer is lamotrigine

now let's do this practice question so

we're going back now to the review of

labs

and on this lab pronoun we're looking at

liver function tests or lfts and we're

looking at pancreatic enzymes

and the question now is which of the

following medications or

mood stabilizers is responsible for this

adverse drug reaction

so obviously because lipase and amylase

are both

normal you can assume if you're not

already comfortable enough to recognize

the actual values themselves you can

assume that these lfts are elevated and

the only mood stabilizer

that's going to classically cause what

we refer to as a transaminitis where

that is to say that the lfts are

elevated

the only mood stabilizer that will do

that is valproic

acid let's move on to another example so

i know guys rapid review but i'm trying

to get your brain to process this so

that you get the point on test day

um same thing and now our lfts are

normal

but our pancreatic enzymes are high

and again the only mood stabilizer that

is known to cause pancreatitis

is b valproic acid so i know i went

through that really really quickly

i understand that you may need to watch

this a few times to really get those

adverse drug reactions down

but this is really going to be the bulk

of your questions when you sit

on test day again adverse drug reactions

toxicities that is what the test writers

love to go after because these drugs

these mood stabilizers for the most part

all have such a narrow

therapeutic index so what should you

take away from this video well

obviously the mechanism of lithium the

phospholipinositol pathway

and then all of the adverse drug

reactions that we talked about

think about the different ways that test

writers could present them to you on

test day and how they could tie these

into different questions

if they want to talk about epstein's

anomaly with lithium they'll talk about

reproductive and embryo

and embry um embryology if they want to

talk about stevens-johnson syndrome with

lemichtel they'll show you a picture

right they could just show you a picture

of someone's lips or someone's eyes

if they want to go for a granulocytosis

with carbamazepine

they could show you the lab print out

and give you the low white count or

they could talk about an opportunistic

infection and link it to hiv

in some way and then ask you about

treatment or ask you about what other

disease process might you see this

in so there's a lot of different ways to

connect all this material

and it all becomes really high yield

because the test writer wants to

challenge you

to think clinically and to think and

reason through the information

that you need to know so yes mood

stabilizers are high yield yes mood

stabilizers are important but if you

if you know the up and down side chart

that i showed you

at the beginning of this video you can

actually reason through a lot through

all of this

a lot faster