Mood stabilizers explained — lithium, lamotrigine, and what's behind the swings

Why "mood stabilizer" isn't one single thing

A mood stabilizer is a medication that prevents mania, hypomania, bipolar depression, or cycling without consistently pushing the client toward the opposite pole. Importantly: a mood stabilizer doesn't mean it treats every phase equally.

Lithium has the strongest evidence for acute mania and maintenance treatment, and requires regular monitoring of blood levels and kidney function. Lamotrigine is favored mainly for preventing depressive episodes, has a lower metabolic burden, but carries a risk of a rare, serious skin reaction if titrated too quickly. Valproate helps with agitation and mixed states, but carries a serious risk to fetal development in pregnancy. Carbamazepine is used for cases resistant to other medications and has significant drug interactions. Atypical antipsychotics act quickly for severe symptoms but carry metabolic risks (weight, blood sugar, lipids).

Why antidepressants alone can be risky

With a predisposition to bipolar disorder, antidepressants without a concurrent mood stabilizer can trigger a "switch" into an activated state — racing thoughts, unusually rapid speech, new impulsive spending, or multiple unrealistic projects at once. That's why antidepressants are usually not given alone in bipolar disorder, but only in combination with a mood stabilizer and under a psychiatrist's supervision.

Sleep as part of treatment, not just a result of it

Sleep isn't just rest — it activates repair mechanisms in neurons that reduce accumulated oxidative damage. Poor sleep therefore may not just be a consequence of instability, but can itself contribute to cellular stress that further disrupts stability.

Even a short but significant reduction in sleep can, in a predisposed person, precede racing thoughts, unusual self-confidence, impulsivity, irritability, or a full manic episode. A regular bedtime and wake time, regular meals, and morning light are among the strongest non-pharmacological supports for stability.

The Walsh view — biochemical patterns that lower resilience

The Walsh approach doesn't treat these patterns as an alternative diagnosis to bipolar disorder, but as identifiable vulnerabilities that can compound genetic risk under stress:

• Undermethylation — high blood histamine, obsessive and perfectionistic traits, inner tension, seasonal allergies, low stress tolerance.
• Pyroluria — increased need for zinc and B6, oxidative stress, poor dream recall, social withdrawal, sensory sensitivity.
• Copper-zinc imbalance — elevated free copper or insufficient zinc can amplify norepinephrine activity, anxiety, irritability, insomnia, and overstimulation.
• Toxic burden and elevated SAH — mold, chemicals, gut toxins, medications, and inflammation can raise oxidative demand and disrupt methylation.

Which lab values are monitored

During mood stabilizer treatment, the doctor routinely monitors things like blood lithium level, kidney function, thyroid (TSH, free T4), calcium, blood count, liver enzymes, and other parameters specific to the medication — this is entirely within the treating psychiatrist's scope.

Alongside this, it can also make sense to add biochemical context per the orthomolecular approach — copper, ceruloplasmin, zinc, whole-blood histamine, or possibly a plasma methylation panel — not as a replacement for psychiatric monitoring, but as supplementary context.

Recognizing early warning signs

Early warning signs of an approaching manic phase tend to recur in a similar pattern for the same person — a reduced need for sleep without feeling tired, faster thinking and speech, greater irritability, unusually large plans or spending, or heightened self-confidence. Recognizing one's own personal pattern of these signs (ideally together with someone close who may notice them sooner than the person themselves) allows contacting a psychiatrist before the episode fully develops.

It's equally important to recognize early signs of a depressive phase — social withdrawal, slowing down, loss of interest, sleep changes in the opposite direction. Both directions deserve equal attention.

Never stop suddenly

Abruptly stopping a mood stabilizer is among the riskiest situations in all of psychiatric pharmacotherapy — it risks a relapse into mania, severe depression, psychosis, and with some medications (e.g. carbamazepine, valproate) also seizures. Dose reduction always happens gradually, according to a precise plan set by the treating psychiatrist, never on your own and never from one day to the next.

A practical first step

Never change or stop mood stabilizer treatment on your own — sudden discontinuation can trigger mania, depression, psychosis, or hospitalization. Any adjustment is made solely by the treating psychiatrist.

1. Fill out the free screening — as supplementary biochemical context alongside psychiatric care.

2. If copper overload or undermethylation is suspected, consider a histamine test (€149).

3. Once you have the result, book a 45-minute consultation (€75) — to see what's worth discussing with your psychiatrist.

More on how sleep and stress resilience relate to biotypes can be found in the article Can't get up in the morning — cortisol and the adrenals.