Those patients that were treatment resistant to lithium or carmazepine tended to respond nicely to valproate either alone or in combination with other agents. Certainly, these numbers are optimistic, however, when compared with placebos in each category, they were far superior. It should be clear that sodium valproate is not for all patients with bipolar disorder. As the natural course of bipolar disorder evolves toward rapid cycling, lithium has been shown to be very poorly effective. The scientific data now support the use of valproate in lithium refractory patients with rapid cycling, mixed states, dysphoric mania, EEG changes, and perhaps schizo-affective disorder.
Recent data supports the following algorhythym or decision tree for the clinical use of valproate.