Mood destabilizers?: A review of mood stabilizer-associated mania

Abstract: Mania is associated with significant morbidity and mortality. Mood stabilizing medications are typically used to prevent manic episodes, yet in some cases can precipitate them. The literature on this rare but potentially serious paradoxical reaction is lacking. A structured literature review was performed to identify case reports of adults experiencing manic symptoms associated with the routine use of medications with mood stabilizing properties (i.e., valproate, lithium, carbamazepine, lamotrigine, oxcarbazepine, and topiramate). A total of eight articles describing 12 unique patients were included in the analysis. The majority of patients (58%) had a previous diagnosis of bipolar spectrum disorder. The most frequent offending agent was lamotrigine (58%), followed by topiramate (33%), and carbamazepine (8%). Most patients (92%) were taking concomitant medications, mainly antipsychotics (50%) and other mood stabilizers (50%). The mean time between treatment initiation or dose escalation of the mood stabilizer and the onset of mania was 7 days. In all but two cases, the mood stabilizer was discontinued upon presentation. Improvement in symptoms was observed within a mean of 9 days following intervention. Mood stabilizer-associated mania appears to be relatively acute in onset and can be reversed by discontinuation. It commonly, but not exclusively, occurs in patients with a history of bipolar spectrum disorder who are already prescribed medications with mood stabilizing properties. In cases of new onset or worsening mania following the initiation or dose escalation of a mood stabilizer (especially lamotrigine and topiramate), this paradoxical reaction should be considered.