Editing Mental Health and Psychosocial Nursing (section)

=== Mood Stabilizers ===
* '''Lithium''': therapeutic serum level 0.6 to 1.2 mEq/L for maintenance; acute mania is often managed at 1.0 to 1.5 mEq/L. '''Toxicity begins above 1.5 mEq/L and is severe above 2.0 mEq/L.''' Narrow therapeutic index.
** Early toxicity: nausea, vomiting, diarrhea, coarse hand tremor, drowsiness, muscle weakness.
** Moderate to severe: ataxia, confusion, blurred vision, giddiness, slurred speech, nystagmus, seizures, arrhythmias, coma.
** Teaching: maintain '''consistent sodium intake and 2 to 3 liters of fluid daily'''. '''Sodium loss raises lithium levels''' because lithium is reabsorbed in place of sodium. Caution with vomiting, diarrhea, sweating, fever, exercise in heat, and low-sodium diets. Avoid '''NSAIDs, thiazide diuretics, and ACE inhibitors''', which raise lithium levels. Baseline and periodic renal and thyroid studies. Draw levels 12 hours after the last dose. Contraindicated in pregnancy in most cases because of cardiac malformation risk (Ebstein anomaly).
* '''Valproate/divalproex''': monitor liver function, ammonia, platelets, and pancreatitis symptoms. '''Highly teratogenic''' (neural tube defects); confirm contraception.
* '''Carbamazepine''': monitor for agranulocytosis and aplastic anemia, hyponatremia, and Stevens-Johnson syndrome (screen for HLA-B*1502 in clients of Asian ancestry). Strong enzyme inducer that lowers oral contraceptive efficacy.
* '''Lamotrigine''': effective for bipolar depression. '''Titrate slowly''' to reduce the risk of serious rash including Stevens-Johnson syndrome. Any rash requires immediate provider notification and usually discontinuation.