Oxcarbazepine is probably weaker than lithium, valproate and lamotrigine, and its trial evidence is thin, but it acts close to carbamazepine and some patients who fail other mood stabilizers respond to it. It is well tolerated apart from twice-daily dosing; warn about SJS and watch for low sodium.
When we reach for it
You have to actually try it. Treat enough bipolar disorder and you will see people who do not respond to one mood stabilizer and do respond to another.
“you have to actually try to use it. And if you treat enough bipolar disorders, you're going to know that some people don't respond to one mood stabilizer and respond to another. I've had people not respond to lithium”
53:53Mood Stabilizers for Bipolar Disorder: Lithium, Lamotrigine, Depakote & MoreJul 2026
Compared with others
Probably less efficacious than Depakote, lamotrigine and lithium. At higher doses it may actually beat lamotrigine, and in the right patient it is not that bad.
“Is it probably less efficacious than Depakote, Lamotrigine, and Lithium? Probably. But I also think that at higher doses, it may actually be more efficacious than Lamotrigine. If it's the right patient, it's actually not that bad”
54:15Mood Stabilizers for Bipolar Disorder: Lithium, Lamotrigine, Depakote & MoreJul 2026 The evidence is old and mixed and people say they do not like it, but there is at least some, and its action is meaningfully close to carbamazepine.
“there's at least some evidence for it. And yes, it's old mixed evidence and people say, oh, I don't like it. But the action is, you know, at least meaningfully close to the carbamazepine”
24:20The Best Bipolar Medication Review From The Best Bipolar ExpertJan 2025 A more skeptical view: there is only one large randomized trial, and it was negative, so the randomized evidence says it does not work.
“it only has one randomized trial that I know of, one large one anyway. It was negative. So you're using something that has randomized trial evidence for it. It doesn't work”
57:08Dr. Jim Phelps’ Bipolar Treatment Tier List: Lessons from 30+ Years in PsychiatryJul 2026Guest episode
Dosing and titration
For tolerability, the only real downside is that you have to give it at least twice a day.
“In terms of adverse effects and tolerability, the only real downside is that you do have to give it at least twice a day, in my opinion”
54:29Mood Stabilizers for Bipolar Disorder: Lithium, Lamotrigine, Depakote & MoreJul 2026
Side effects and safety
Assume the same SJS risk as lamotrigine. You cannot tell whether it is higher, because lamotrigine is used so much more that it collects most of the SJS cases.
“SJS, same SJS risk. You can't tell if it's higher or not because they don't use oxcarbazepine as much as lamotrigine. Lamotrigine is used so much more that is then associated with a lot of SJS cases”
57:58Mood Stabilizers for Bipolar Disorder: Lithium, Lamotrigine, Depakote & MoreJul 2026 Sooner or later someone on it will get dizzy and nauseous, and it will be low blood sodium.
“One of these days, you're going to have somebody get dizzy and nauseous. And it'll be because they have developed type 1 atremia, low blood sodium”
56:23Dr. Jim Phelps’ Bipolar Treatment Tier List: Lessons from 30+ Years in PsychiatryJul 2026Guest episode
Monitoring
Warn about SJS. You do not need oxcarbazepine levels; some people get them, but they are not very helpful clinically.
“Just warn about it. You don't need to get levels on oxcarbazepine, but you can. Some people do that. I don't find that very helpful clinically”
58:20Mood Stabilizers for Bipolar Disorder: Lithium, Lamotrigine, Depakote & MoreJul 2026
It also comes up on
- Stevens-Johnson syndromeSome ethnic groups have a higher risk of SJS with lamotrigine, oxcarbazepine and carbamazepine, and testing is available for the gene that puts them at particularly high risk. For Asian patients starting carbamazepine, the FDA recommends testing for HLA-B*15.
- CarbamazepineSome ethnic groups carry a higher Stevens-Johnson risk with lamotrigine, oxcarbazepine and carbamazepine, and there is genetic testing for the high-risk gene.
- Mood stabilizersThe core list: lithium, Depakote, lamotrigine, carbamazepine and oxcarbazepine.
From these episodes
- Mood Stabilizers for Bipolar Disorder: Lithium, Lamotrigine, Depakote & MoreJul 2026 · 5 points
- Dr. Jim Phelps’ Bipolar Treatment Tier List: Lessons from 30+ Years in PsychiatryJul 2026 · 2 points
- The Best Bipolar Medication Review From The Best Bipolar ExpertJan 2025 · 1 point
Every point above is something said on the Psychofarm podcast, with the words as spoken and a link to the moment in the episode. It is education, not medical advice, and an episode reflects what we thought when we recorded it.