MOOD STABILIZERS

Topiramate (Topamax)

 

HALF-LIFE: 19-25 hours
STARTING DOSE: 12.5mg-25mg per day
TARGET DOSING RANGE: 50mg-200mg per day
BEST TIME TO DOSE: Any
HOW TO DOSE:
> Initial 12.5mg-25mg per day
> Increase dose by 25mg per week
> For weight loss/prevent weight gain: 50mg-150mg/day
> For Mood effects: Usually 100mg-200mg per day in divided doses
> Max dose usually 400mg/day
PREGNANCY: Minimal data on safety.
BREASTFEEDING: Minimal date on safety.
FDA INDICATIONS:
1) Epilepsy
2) Prophylaxis of Migraine headaches

 

ADDITIONAL INFORMATION

 

  • Used in children with Lennox-Gastaut Syndrome
  • Carbamazepine increases elimination of topiramate
  • Topiramate may increase plasma levels of phenytoin
  • Topiramate is a weak inhibitor of CYP219
  • Topiramate is weak inducer of CYP3A4
  • Alcohol enhances sedation and may increase risk of seizures

 

Proposed Mechanisms of Action:

 

  • Blocks voltage sensitive sodium channels
  • Inhibits glutamate release
  • Potentiates activity of GABA
  • Blocks calcium channels
  • Topiramate inhibits carbonic anhydrase (increased risk of metabolic acidosis and kidney stones)
  • Topiramate may have prophylactic properties, but appears to exert little benefit during acute bipolar depression or mania.

 

 

Topiramate has also been used off label for:

 

  • Antipsychotic-induced weight gain (usually 50mg-150mg daily)
  • Neuropathic pain
  • Borderline personality disorder
  • Alcohol use disorders
  • Cocaine use disorders

 

Common side effects:

 

  • Psychomotor slowing
  • Decreased concentration
  • Somnolence
  • Fatigue
  • Anorexia
  • Kidney stone formation
  • Cognitive side effects (“Dope-a-max” or topamax “fog”) most common reason for discontinuing

INFORMATION ABOUT MOOD DISORDERS

 

What Does “Mood” Mean?

 

Mood is defined as a person’s internal emotional state that is sustained over time. Mood is subjective and experienced by the person. Terms used to describe mood: Normal, Sad, Angry, Irritable, Anxious, Happy

 

What Does “Affect” Mean?

 

Affect is a term used to describe the outward expression of a mood state. In other words, an individual’s affect is visible to others. Healthcare providers obtain important information about an individual’s internal emotional experience (mood) based on their emotional expression (affect). Terms used to describe an individual’s affect: Dysphoric, Happy, Excited, Irritable, Angry, Tearful, Blunted, Euthymic, Flat, Blunted, Constricted, Restricted, Appropriate, Congruent.

 

What Are Mood Disorders?

 

Mood disorders are group of psychiatric disorders in which disturbances of mood or affect are severe and persistent enough to cause significant problems in an individual’s life. Moods by themselves are not pathological and many of us have experienced a wide range of mood states. When moods become severe and persistent enough to cause dysfunction and issues in an individual’s life, then we use the term “mood disorder.”  Mood disorders are better defined as syndromes consisting of a cluster of signs and symptoms that often “come and go” in “episodes” which persist for weeks, months, or even years. During these “episodes,” there is a significant change in the individual’s mood which may negatively impact work performance, relationships, or other important areas of functioning. The most common mood disorder is major depressive disorder (MDD), often referred to as “Unipolar depression.” Bipolar disorders are also mood disorders that differ from unipolar depression by the presence of elevated mood states called hypomania or mania.

 

What is Mania?

 

Mania is characterized by a distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary). During this period of elevated/expansive mood/energy, individuals may experience any combination of the following: Inflated self-esteem or grandiosity; Decreased need for sleep (e.g., feels rested after only 3 hours of sleep); More talkative than usual or pressure to keep talking; Flight of ideas or subjective experience that thoughts are racing; Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed; Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (i.e., puroseless non-goal-directed activity); Excessive involvement in activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). As with any “disorder,” the mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. If the mood disturbance can be attribute dto a drug, medication, or medical condition then the term “manic episode” should not be used. 

 

What is Hypomania?

 

Hypomania is a less severe form of mania and is characterized by a distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day with the same symptoms that characterize mania (see above). 

 

Subtypes of Bipolar Disorder:

Bipolar 1 Disorder: Manic or Mixed episode +/- Major Depressive Episode (Only manic episode required) 

Bipolar 2 Disorder: Hypomanic episode + Major Depressive Episode (both are required)

With rapid cycling: 4 or more mood episodes in a 12-month period

 

 

 

Neurobiology of Bipolar Disorder 

 

The underlying biochemical abnormalities that cause or contribute to bipolar disorder remain unclear. However, studies have suggested neurobiological differences between unipolar and bipolar depression which is further supported by the relative lack of efficacy of classic antidepressant monotherapy in the treatment and prevention of bipolar depression. Human studies have found increased concentrations of noradrenaline (norepinephrine) and dopamine (DA) and decreasedconcentrations of serotonin (5-HT) in manic patients which suggests that norepinephrine and dopamine dysregulation may play a primary role in manic symptoms. In patients with unipolar depression, both serotonin (5-HT) and norepinephrine concentrations are low. Perhaps the imbalance partially explains bipolarity? Lastly, glutamate and GABA dysregulation have been implicated in the pathophysiology of bipolar disorder. Animals studies suggest increased glutamatergic neurotransmission via NMDA receptors in manic patients. In addition, the efficacy of anticonvulsants and benzodiazepines in the treatment of bipolar disorder suggests the likelihood that glutamate and GABA systems are involved in uncertain ways. 

 

It is likely that the combination of vulnerable genetics and environmental stressors lead to intracellular changes in transcription, signal transduction, and synaptic functioning that ultimately give rise (via poorly understood mechanisms) to symptoms of bipolar disorder.

 

 

Functional Imaging Studies

 

Functional Connectivity Studies have demonstrated or suggested

 

(1) Decreased connectivity between the amygdala and anterior cingulate cortex

(2) Increased connectivity between the amygdala and the supplemental motor area

 

Functional Neuroimaging Studies have demonstrated or suggested

 

(1) Decreased size and activity in the PFC of patients with bipolar disorder—similar to that found in patients with unipolar depression.

(2) Increased gray matter volume in bipolar patients after 4 weeks of lithium treatment (Note: Valproic acid (depakote) has not been shown to have the same effect.

(3) Amygdala are larger and more active in the bipolar patients.

(4) Bipolar disorder may be the result of abnormal interactions between the PFC and subcortical regions such as the amygdala—an abnormality not usually seen with unipolar depression.

 

References:

  1. Cooper, J. R., Bloom, F. E., & Roth, R. H. (2003). The biochemical basis of neuropharmacology (8th ed.). New York, NY, US: Oxford University Press.
  2. Iversen, L. L., Iversen, S. D., Bloom, F. E., & Roth, R. H. (2009). Introduction to neuropsychopharmacology. Oxford: Oxford University Press.
  3. Puzantian, T., & Carlat, D. J. (2016). Medication fact book: for psychiatric practice. Newburyport, MA: Carlat Publishing, LLC.
  4. J. Ferrando, J. L. Levenson, & J. A. Owen (Eds.), Clinical manual of psychopharmacology in the medically ill(pp. 3-38). Arlington, VA, US: American Psychiatric Publishing, Inc.
  5. Schatzberg, A. F., & DeBattista, C. (2015). Manual of clinical psychopharmacology. Washington, DC: American Psychiatric Publishing.
  6. Schatzberg, A. F., & Nemeroff, C. B. (2017). The American Psychiatric Association Publishing textbook of psychopharmacology. Arlington, VA: American Psychiatric Association Publishing.
  7. Stahl, S. M. (2014). Stahl’s essential psychopharmacology: Prescriber’s guide (5th ed.). New York, NY, US: Cambridge University Press.
  8. Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY, US: Cambridge University Press.
  9. Whalen, K., Finkel, R., & Panavelil, T. A. (2015). Lippincotts illustrated reviews: pharmacology. Philadelphia, PA: Wolters Kluwer.

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