Q:  Moban - a First Generation Antipsychotic

I am a 17 yr. old living with bipolar disorder. I have been given many drugs none of which have made a significant improvement in my illness. I have still not been put on the "big two" (Lithium and Depakote). I suffer from PCOS so there has been a tendency to avoid drugs that induce weight gain. My doctor has mentioned a very old typical antipsychotic called Moban. I can't seem to find any literature on this medication. Do you know anything about it?

~Peggy


Dear Peggy --

In case you or other readers might need it, a little background: Moban is one of the "first-generation antipsychotics." 

Here are some typical first-generation antipsychotics:

 For comparison, here are the second-generation medications:

*"Abilify", yuck. 

Antipsychotics generally have anti-manic properties. Some second-generation antipsychotics have been demonstrated to prevent the recurrence of episodes in Bipolar I (because their manufacturers spent the money to conduct the research to get the FDA approval so that they can market their drugs for this purpose.  The lack of such evidence for the first-generation antipsychotics is because of the lack of research of this kind for those medications; from experience using them, it appears that they do indeed have the capacity to prevent recurrent episodes, but that has not been tested directly).

 The first-generation antipsychotics used to be part of the standard treatment for bipolar disorder when lithium did not work -- because we really didn't have anything else.  Later, two anti-seizure medications were recognized to have effects similar to lithium: Depakote (valproate) and carbamazepine. I was not around for this period of research in psychiatry.  I only know of one direct comparison of these "mood stabilizers" (lithium, Depakote, carbamazepine) versus a first generation antipsychotic.  In that study, Depakote worked as well as Haldol for psychotic mania. I think the impression at that time was that antipsychotics were needed to treat psychotic mania -- but I do not know if the mood stabilizers looked clearly better than the first-generation antipsychotics in terms of overall bipolar disorder control.  That was just slightly before my time. 

When I began practicing, the mood stabilizers were already the established treatment for bipolar disorder, but I do not know if that was based on solid evidence that they are better.  They do not cause "tardive dyskinesia", a concern with the first-generation antipsychotics. But, as you know, most of the mood stabilizers have been associated with a risk of weight gain.  This can pose long-term health risks similar in magnitude to tardive dyskinesia. Likewise, the second-generation antipsychotics are also commonly associated with weight gain and thus with long-term risk, with the exception of ziprasidone, which may be relatively weight-neutral. Aripiprazole is less likely to cause weight gain than the other three.

Because these second-generation antipsychotics are thought to cause tardive dyskinesia less frequently than they first-generation antipsychotics, they are often considered nowadays for long-term treatment of bipolar disorder.  However, whether this difference in tardive dyskinesia arrest is really all that large is still in doubt.  Further, aripiprazole has a different mechanism of action, so the extent to which it causes tardive dyskinesia is even more unclear: it might be less than all the rest of them.

As for Moban in particular, I must admit: this is not an antipsychotic I used at all.  Among the first-generation antipsychotics, I used the rest of the table above, but not that one.  When we were using that family extensively, there was a fairly strong impression that perphenazine might be the best of the gang.  For example, it was selected as the comparison medication in a large test of the second-generation versus first-generation antipsychotics.^Lieberman

I hope that something in that answer might be of use to you.

Dr. Phelps