One needs to taper the lithium gradually over 2 weeks or more to avoid precipitating new episodes, and then introduce divalproex. There is no standard, cookbook approach on when to initiate divalproex. My personal preference is to overlap the drugs. One could extrapolate from the oral loading data and argue that divalproex can be introduced rapidly getting the dose up quickly. The guiding principle is to try to use as few drugs as possible, but that is not possible in the majority of cases.
Acute mania is characterized by behavioral dyscontrol and psychoses.
Clinicians often try antipsychotics to reduce behavior disinhibition and then institute a mood stabilizer, such as lithium or divalproex, in the acute manic phase, and this phase can rarely be treated with monotherapy. This oral loading strategy presents a potential opportunity to avoid neuroleptics and needs further study. Acute depression is a big problem in bipolar illness, and lithium and divalproex do not have established efficacy in controlling this. Often the patient has been on either lithium or divalproex and has had a breakthrough episode of depression, and one could increase the dose of monotherapy, but usually a second compound is needed, such as another mood stabilizer or an antidepressant. Medical Education Network Canada Inc. All rights reserved.