Algorithm for patient management of acute manic states: lithium, valproate, or carbamazepine?

Doses of carbamazepine and valproate in bipolar affective disorder

Carbamazepine and valproate are now well established treatments for bipolar affective disorder (BAD). Both drugs are used in the acute treatment of mania and, more frequently, as longer-term mood stabilisers. The British National Formulary (BNF, Vol. 32, 1996) provides information on the use of carbamazepine in the ‘prophylaxis of manic depressive illness' and suggests that the ‘usual range’ of doses is between 400 mg and 600 mg daily. No guidance on the use of valproate in BAD is given in the BNF because the drug is not licensed for this indication in the UK.

Extended-Release Divalproex Sodium for Mood Stabilization

STUDY OBJECTIVE

To evaluate the efficacy, safety, and tolerability of extended-release divalproex sodium.

DESIGN

Prospective, open-label, 4-week study

SETTING

Long-term care facility of the Missouri Department of Mental Health.

PATIENTS

Ten hospitalized patients (mean age 39.4 yrs) with mood or thought disorders who were experiencing adverse effects from delayed-release divalproex sodium.

INTERVENTION

All participants were switched from delayed-release to extended-release divalproex sodium.

MEASUREMENTS AND MAIN RESULTS

Efficacy was monitored with the Brief Psychiatric Rating Scale (BPRS), and safety and tolerability were monitored with the Systematic Assessment for Treatment Emergent Events (SAFTEE). Frequently reported adverse effects before conversion were sedation, stomach upset, and tremor. At study conclusion, no differences were seen in total BPRS scores or individual BPRS items, although a trend pointed to decreased somatic complaints (p=0.057). The mean serum concentration of valproic acid among participants did not change significantly in the transition from the delayed-release formulation to an equivalent dose-adjusted extended-release formulation (90.5 mg/L vs 95.5 mg/L, p=0.493). At study conclusion, significant decreases in low-density lipoprotein cholesterol (p=0.010) and potassium (p=0.043) levels were identified. Three categories of adverse effects decreased significantly after patients switched to the extended-release form of divalproex sodium: sedation (p=0.022), stomach or abdominal discomfort (p=0.045), and tremor (p=0.004).

CONCLUSION

This preliminary investigation suggests that patients receiving delayed-release divalproex sodium for mood lability can be converted successfully to extended-release divalproex sodium. Moreover, these findings imply that this transition is associated with a reduction in some of the adverse effects associated with divalproex sodium.

Antidepressant properties of anticonvulsant drugs for bipolar disorder

A growing number of anticonvulsant drugs are receiving attention as possible mood stabilizers. This attention is based mainly on the assumption that the antimanic efficacy of anticonvulsants makes them suitable as mood stabilizers. However, their antidepressant properties have received less scrutiny. In this review, current evidence concerning the acute and prophylactic efficacy of divalproex, carbamazepine, gabapentin, lamotrigine, and topiramate in bipolar depression is evaluated. Clinical outcome data are considered, together with limitations of existing studies and the concept of unmet clinical needs. Findings in placebo-controlled trials suggest an acute and prophylactic antidepressant effect with lamotrigine monotherapy and more modest antidepressant benefits with other agents administered as monotherapies. Results of published studies are considered with respect to the conceptualization of mood stabilization as arising from antimanic and antidepressant efficacy in bipolar disorder.

Valproic acid increases cerebrospinal fluid zidovudine levels in a patient with AIDS

Valproic acid is an anticonvulsant drug known to inhibit the glucuronidation of zidovudine (AZT) in human liver microsomes. Zidovudine is metabolized by glucuronidation to the inactive 5'-glucuronide with a short plasma half-life (1.0 +/- 0.2 hour). This case presentation confirms that valproic acid inhibits glucuronidation in vivo, and this is the first documented observation of increased cerebrospinal fluid levels of zidovudine because of an interaction with valproic acid in a patient with acquired immune deficiency syndrome (AIDS). The peak plasma AZT level for the control period was 119 ng/mL, which increased almost 3-fold to 344 ng/mL with valproic acid (1.5 g/day). The plasma AZT trough was 47 ng/mL, which also increased almost 3-fold to 124 ng/mL with valproic acid. The molar ratio of plasma 5'-glucuronide/AZT at the peak was reduced from 1.77 (control) to 1.07 with valproic acid. The 5'-glucuronide/AZT ratio at the trough was reduced markedly from 5.0 (control) to 0.93 with valproic acid, suggesting in vivo inhibition of glucuronidation. Cerebrospinal AZT levels, drawn 30 minutes after peak plasma levels, increased from 27 ng/mL for the control to 47 ng/mL with valproic acid, which paralleled the change in peak plasma concentrations. This interaction with valproic acid may contribute to higher AZT levels in the brains of patients with human immunodeficiency virus-related (HIV) encephalopathy.

The Use of Anticonvulsants in Psychiatry

The use of anticonvulsants in psychiatry has steadily increased in recent years. Two anticonvulsants in particular, carbamazepine (CBZ) and valproate (VPA), have become commonplace in psychiatric practice for the treatment of bipolar disorder. Schizoaffective dis order and aggression have also been treated with these agents. Indications, pharmacokinetics, drug inter actions, side effects, and monitoring of the anticonvulsants are discussed. Copyright © 1996 by W.B. Saunders Company

When lithium does not help: the use of anticonvulsants and calcium channel blockers in the treatment of bipolar disorder in the older person

Although anticonvulsant agents and calcium channel blockers do not have any clear advantages over lithium, they do offer patients who cannot (or will not) take lithium another treatment option. It is not yet clear from the literature who will respond best to which drug or combination of drugs. The nurse should be supportive to the patients and family, in what may be a drawn out process, to find the best treatment. Optimism is justified because a lack of response to one drug is not indicative of nonresponse to other drugs. It is important to actively treat bipolar disorder because each episode of mania increases the risk of progression of the illness, with increasingly severe episodes occurring closer together. Bipolar disorder has high social costs (legal, financial, and relationship problems) that make improvements in treatment important for the patient and society. Anticonvulsant agents and calcium channel blockers may also be useful in treating depression. The number of people whose depressive symptoms respond is far less (25% to 30%) than the number who respond to the anti-manic effects, but this is an option when antidepressants and electroconvulsive therapy are not effective.

Mania due to general medical conditions: frequency, treatment, and cost

OBJECTIVE

Mania due to general medicine conditions may occur in patients in a variety of settings.

METHODS

We reviewed the charts of patients admitted to an adult psychiatric service over a nine-year period (Jan. 1985 to Dec. 1993). Patients were diagnosed with Organic Affective Syndrome (ICD-9 code 293.83) in 241 episodes (N = 227 patients). There were forty-seven manic or mixed episodes in forty patients (0.72% of all admissions).

RESULTS

When DSM-IV criteria for Mood Disorder due to a General Medical Condition manic or mixed type (MDGMC) was applied, we found twenty-five patients with twenty-seven episodes (N = 30 treatment trials). Irritable mood predominated in twenty-seven (90%) of the thirty trials.

CONCLUSIONS

Treatment included anticonvulsants in 63 percent, neuroleptics 63 percent, and lithium 40 percent. Favorable responses to anticonvulsants were seen; however combination therapy was used more frequently. Further research in this area is needed.

The emerging role of valproate in bipolar disorder and other psychiatric disorders

Although valproate, a simple branched-chain fatty acid, is generally considered to be an antiepileptic agent, a large literature dating back to 1966 describes its use in primary psychiatric disorders. The significant role that gamma-aminobutyric acid plays in mood provided the rationale to examine valproate in this regard. Numerous uncontrolled as well as placebo- and lithium-controlled studies verified the drug's efficacy in the short-term management of bipolar and schizoaffective disorders. The response appears to be independent of response to traditional therapies such as lithium, neuroleptics, and carbamazepine, and may be maintained for extended periods of time. Valproate should be considered not only in patients with mood disorders who are intolerant of or nonresponsive to traditional therapies, but also in those with rapid cycling, electroencephalographic abnormalities, head trauma antedating the onset of psychiatric illness, or any other factor suggesting an organic component. Preliminary uncontrolled studies suggest that the drug may also eventually play a role in the management of panic disorder and behavioral dyscontrol (agitation, aggression, temper outbursts). Its adverse event profile is well known from years of experience in the management of epilepsy and does not appear to be altered in the presence of psychiatric disorders. Similarly, the drug-drug interaction potential of valproate is reasonably well known, although further research into interactions with psychotropic agents is warranted.

Use of lithium, carbamazepine, and valproic acid in a state-operated psychiatric hospital

OBJECTIVE

To examine the prescribing of mood stabilizers (lithium, carbamazepine, and valproic acid) in a 500-bed state-operated psychiatric hospital in New York.

METHODS

All 129 inpatients receiving mood stabilizers were identified and their medical records reviewed using a standardized drug use evaluation form. Diagnosis, other indications, and prior experience with mood stabilizers were examined, as well as outcome and adverse effects.

RESULTS

Approximately one-quarter of the inpatient population received a mood stabilizer. The frequency of carbamazepine use exceeded the use of lithium, with 72 patients receiving carbamazepine and only 62 receiving lithium. Twenty-eight patients received valproic acid. Indications found most frequently for carbamazepine use included assaultive or aggressive behavior (70% for those receiving carbamazepine as the only mood stabilizer). Of those patients with bipolar or schizoaffective disorder and receiving either lithium, carbamazepine, or valproic acid, 36% were prescribed carbamazepine (10% as a first-line agent) and 50% lithium (26% as a first-line agent). None of these indications for carbamazepine has been approved by the Food and Drug Administration. In general, positive outcomes were documented but without supporting objective measures. Significant adverse effects were documented in the medical record in one-quarter of the patients.

CONCLUSIONS

There was widespread use of the three mood stabilizers examined, singly and in combination, for a variety of indications. Lithium and valproic acid remain more frequently prescribed for the treatment of bipolar and schizoaffective disorders. Monotherapy with carbamazepine or valproic acid results in statistically significantly fewer adverse effects than lithium or combination therapy (p values between p = 0.00038 and p = 0.006). Current clinical practice has endorsed the use of carbamazepine for aggressive or assaultive behavior, although there does not appear to be sufficient proof of effectiveness in the literature. Formal studies of carbamazepine's antiagressive effects should be conducted.

Treatment of manic episodes in Scandinavia: the use of neuroleptic drugs in a clinical routine setting

To provide longitudinal data on the treatment of acute mania with neuroleptics in a routine setting, 125 consecutively admitted manic patients were examined. Out of the 125 patients, 111 (89%) were primarily treated with neuroleptics during the index episode, and a substantial use of drug combinations was observed. Of the 111 patients, 27% were still hospitalized and in a manic state after 10 weeks. Our results indicate that treatment under routine conditions is an outcome variable which is determined by the severity and persistence of the manic symptoms. If typical neuroleptics are used as first choice antimanic agents, dosages can be minimized by the concomitant use of a benzodiazepine. In non-responders, a mere shift from one neuroleptic to another does not seem rational, so to improve outcome, a mood stabilizer should be added.