Conclusion
Topiramate appears a very useful drug for weight reduction in patients with bipolar disorders. The mood stabilizing effect of topiramate is however questionable. The very different results obtained from the controlled monotherapy trials of topiramate in mania and the open add-on trials summarised in the Background indicate that topiramate should not be prescribed as monotherapy in bipolar disorders as it has no acute antimanic effect. In our opinion the current place of topiramate in the treatment of affective disorders is as an add-on treatment for patients who experience clinically significant weight gain, which could either compromise their physical health, or influence them to stop taking established mood stabilizers.

Recommendations
Topiramate should not be used in monotherapy and unless new research shows otherwise, psychiatrists should assume that it has no mood-stabilizing properties.

Dose titration
Topiramate dose should be increased gradually and in two-weekly intervals.

Cognitive function
Topiramate is known to cause neurocognitive side effects. Psychiatrists should monitor their patients carefully for the emergence of such side effects.

Pregnancy
As with most other mood-stabilizers (anticonvulsants and lithium), women who may become pregnant should be warned of the possible consequences of taking such drugs during pregnancy [37].

Adequate hydration
Patients should be advised to ensure adequate hydration, especially if they are predisposed to nephrolithiasis [37].