Table 4.

Guidelines on how to select a mood-stabilizing medication for bipolar disorder

Indication	Lithium	Carbamazepine oxcarbazepine	Valproate	Lamotrigine	Risperidone	Olanzapine	Quetiapine	Ziprasidone	Aripiprazole
Mania FDA approval Euphoric Irrit./Mixed	+ + ?	± + +?	+ + +	- ? ?	+ + ?	+ + +	+ + ?	+ + +	+ + ?
Rapid cycling	±	+?	+	+	?	+	?	?	?
Use in hepatic disease	+	±	?	+	+	+(1)	+	+	+
Use in renal disease	-	+	+	+	-	+	+	+	+
Use in rash patients	+	±	+	?	+	+	+	+	+
Medical-induced mania	-	+	+	?	+?	+	?	+	+
Violence/rapid stabilization	?+	?+	+	-	+?	+	?	+	?
Substance comorbidity	-	+	+	?	?	+	?	?	?
Long-term depression	+	?	?	+	?	+(2)	?	?	?
FDA Class	D	D/C	D	C	C	C	C	C	C
Breastfeeding	-	+	+	-	-	-	-	-	-
Hormone effects	-	Ind. OC(3)	?	-	Prolactin	-	-	-	-
Short-term side effects	Cognition Polydip. Tremor	Sedation Anemia LFT elev.	Sedation Weight gain LFT elev.	Rash Headache	Wt. gain EPS(4) Gluc. elev.(5)	Weight gain Sedation Gluc. elev	Gluc. elev	Agitation Sedation	Agitation
Long-term side effects	Thyroid Renal	Anemia	Pan's? PCO	-	T.D.? Chol. elev.	T.D.? Chol. elev.	T.D.? Chol. elev.	T.D.?	T.D.?
Dosing	600-2400 (0.6–1.2) QD or BID	400–1200/ 600–1800 BID	750–2500(6) (50–125) BID	100mg BID	2–6mg BID	5–20mg HS	300–600mg BID	40–80mg BID	10–30mg AM

Notes: Evidence base—haloperidol and thioridizine also FDA-approved for mania, but not commonly used.

(1)

Olanzapine—Rare reports of LFT elevation

(2)

Option to use combined form (olanzapine/fluoxetine = Symbyax).

(3)

Induction of oral contraceptives—carbamazepine oxcarbazepine and topiramate.

(4)

Risperdone—EPS = extrapyramidal side effects and TD = tardive dyskinesia.

(5)

Glucose and cholesterol elevation—may be more for olanzapine, risperidone, and quetiapine than for ziprasidone and aripiprazole.

(6)

Valproate ER dosed 500–3000mg HS.