Question: Are the terms “antipsychotic” and “mood stabilizers” the same?

– R.M.

Answer: There is no consensus about the definition of mood stabilizer - but at the least, it includes helping either mania or depression without worsening the other.

The term antipsychotic at this point means medications that block certain brain receptors (D2) that have been found to be overly active during classic psychosis including hallucinations and delusions. Abilify is one exception in that it doesn’t block D2 receptors but modulates them, i.e. decreasing activity when too high but increasing activity when too low. The term “antipsychotic” was reasonable with the older medications like Thorazine, Stelazine, Mellaril, and Haldol. They are not considered mood stabilizers because although they can help mania they can worsen depression.

The term “atypical antipsychotic” is misleading because these medications (Risperdal, Seroquel, Zyprexa, and Geodon) have many uses in addition to helping psychotic symptoms. They are used for treatment resistant depression and Obsessive Compulsive Disorder. They are also used for agitation, extreme anger and aggression. They may be helpful for addictions. Clozaril is different in that it has potential severe side effects that limit its use. Abilify is unique as previously discussed. These medications meet the standard of helping mania without worsening depression.

There is inadequate research to determine whether the “atypical” antipsychotics meet the stricter definition of mood stabilizer - help mania, help depression and help prevent future episodes of both - which means beyond 6 months after an episode. Seroquel has one good study for helping Bipolar depression. Abilify has evidence for preventing relapse up to 6 months. Zyprexa also has an indication for maintenance. At this time Lithium has the most supporting evidence as a mood stabilizer - but it’s been studied for 50+ years (on the U.S. market for 35 years).

Risperdal in the U.S. has FDA approval for mania and mixed episodes (mania and depression) but it doesn’t have controlled studies for Bipolar depression or maintenance. As I discussed in my article Ranking the Mood Stabilizers, my issues with Risperdal have to do with moderate risk for weight and metabolic problems and frequently elevation of the hormone prolactin. Since prolactin lowers hormones (estrogen and testosterone) it can cause decreased libido, increased risk of long term osteoporosis and possibly many other long term problems. Of course if it’s working well with no apparent side effects and other medications haven’t worked then on the basis of benefits vs. risks it makes sense to take it on a long term basis.

There are other options for treatment resistant depression. Making sure thyroid, estrogen and testosterone levels are good is important. Thirty minutes per day of vigorous physical activity and at least thirty minutes of bright outside light exposure are also important. Cognitive therapy can also be helpful. Sometimes adding a stimulant like Adderall, Concerta, or Provigil can be extremely helpful especially if there are problems with motivation, interest, and focus. Wellbutrin XL can be combined with an SSRI or Effexor or Cymbalta. Combining antidepressants or adding a stimulant have greater long term safety than most of the atypicals.

It’s important that you are getting adequate (7-8 hours) quality sleep(See sleep articles) but avoid excessive sleep because this can worsen depression. Of course all options need to be explored by your physician.

FAQs: Comparing Meds

This article will serve as an index to some of the most Frequently Asked Questions my patients and medical professionals ask me about comparison between meds. Which is better? What’s the difference between x and y? Etc. The most recent question is listed first.