Mood Instability and Irritability

Often the complaint of mood instability comes from the collateral source. First priority: assess safety. Severe mood instability can lead to suicide. Next, determine whether the problem is actually mood instability, as opposed to sustained major anxiety, depression, or post-traumatic stress disorder. Nonpharmacological interventions are the most important, and include education, sleep management, prescription for cardiovascular exercise, pain control, cessation of alcohol and other disinhibiting substances, such as levetiracetam and cognitive behavioral therapy. Preferred pharmacological options that do not substantially impair cognitive recovery include lamotrigine (Lamictal) and oxcarbazepine (Trileptal). Other options include carbamazepine (Tegretol) when cost is an issue, propranolol (Inderal) when violence is a concern, and low-dose atypical antipsychotics.