Mixed episode

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I have a 49 y/o male that's cycling into a mixed episode. C.C. of dysphoric agitation and depressed aggression. Stable for years on Depakote 2000mg BID and Lamictal 150mg daily. Recent VPA level of around 100. He's now non functional at work and has been verbally aggressive toward family and friends, with difficulty preventing physical aggression. Tried to convince him hospitalization would be best for safety, but he refused, and is not committable at this point. Added olanzapine 10mg qhs and 5mg in the am.

Any experience and/or recommendations at this point.

Why not lithium?

Depakote is considered to be a better medication for mixed episode and especially that he was stable on it, I'd say you can still advance the dose of depakote with close monitoring of s/e's without worrying to much about VPA levels !

Furthermore , therapeutic level of valproate is between 50 and 125 mmol/litre.

Originally Posted by Piaget

Depakote is considered to be a better medication for mixed episode and especially that he was stable on it, I'd say you can still advance the dose of depakote with close monitoring of s/e's without worrying to much about VPA levels !

The folks at Case Western who said this first don't say that depakote is better for mixed episodes anymore (only true in one early study, subsequently has NOT been true). I've heard Calabrese talk about it, right before he told me my research ideas would never get funded and I should just give up (more or less).

Which isn't to say it's a bad medicine for a mixed episode. But yeah, lithium.

Originally Posted by billypilgrim37

The folks at Case Western who said this first don't say that depakote is better for mixed episodes anymore (only true in one early study, subsequently has NOT been true). I've heard Calabrese talk about it, right before he told me my research ideas would never get funded and I should just give up (more or less).

Which isn't to say it's a bad medicine for a mixed episode. But yeah, lithium.

Good to know this information. Lithium isn't a bad choice but given that patient was stable on Depakote, I'll probably try optimizing the dose prior to switching

Originally Posted by Piaget

Good to know this information. Lithium isn't a bad choice but given that patient was stable on Depakote, I'll probably try optimizing the dose prior to switching

Large study a few years ago that lithium + depakote was better than lithium alone (on absolute scale, wasn't statistically significant), which was better than depakote alone (clinically and statistically significant). Totally brain farting which study it was, it was a big deal. And the combo was well-tolerated.

was it BALANCE? which my reading of is that lithium or lithium and depakote were better than depakote in maintenance treatment of bipolar I. no significant difference between lithium monotherapy vs lithium and depakote.

Hmm. If you have a blood level of depakote of 100 I'm not sure pushing it higher will have the effect you desire.

Assuming it really is a mixed episode. Haven't heard much as far as an MSE. Call me skeptical with too many lame "bipolar" diagnoses who then get aggressive as their primary complaint and it's called mania.

Substances?

I daresay there is no evidence that pushing to a blood level above 100 in someone previously stable at that level will have any benefit. Add lithium or bump the zyprexa.

And btw fascinating 4000mg of depakote a day. Have never seen higher than 3000mg, and that was pretty rare.

Oops I didnt realize that he is on 4000 mg daily !

Originally Posted by nitemagi

Hmm. If you have a blood level of depakote of 100 I'm not sure pushing it higher will have the effect you desire.

Assuming it really is a mixed episode. Haven't heard much as far as an MSE. Call me skeptical with too many lame "bipolar" diagnoses who then get aggressive as their primary complaint and it's called mania.

Substances?

I daresay there is no evidence that pushing to a blood level above 100 in someone previously stable at that level will have any benefit. Add lithium or bump the zyprexa.

And btw fascinating 4000mg of depakote a day. Have never seen higher than 3000mg, and that was pretty rare.

I agree. Blood levels for depakote are for seizure d/o not for bipolar d/o anyways. Make sure it's not medical, check lfts, ammonia, med interaction etc. Make sure your diagnosis is right. I frequently see personality, adhd and substance called bipolar. Worst case scenario Add lithium or zyprexa/seroquel/abilify. On exams depakote is better for rapid cycling. Looking back it's now thought that lithium is pretty much the go to for bipolar even rapid cycling.

Originally Posted by splik

was it BALANCE? which my reading of is that lithium or lithium and depakote were better than depakote in maintenance treatment of bipolar I. no significant difference between lithium monotherapy vs lithium and depakote.

THAT'S IT! (in my linus voice)

Well, the combination was not statistically significantly better, but on absolute terms was a tad bit better. Just as they teach us that statistically significant does not equal clinically significant, they don't do as good a job teaching people that not statistically significant does not mean not clinically significant, for various reasons that it really shouldn't take an epidemiology degree to learn, but our EBM teachers prefer to dumb things down into "yes's" and "no's" when no such categories exist.

(triple negative ftw!)

Originally Posted by Dapplegrey

I have a 49 y/o male that's cycling into a mixed episode. C.C. of dysphoric agitation and depressed aggression. Stable for years on Depakote 2000mg BID and Lamictal 150mg daily. Recent VPA level of around 100. He's now non functional at work and has been verbally aggressive toward family and friends, with difficulty preventing physical aggression. Tried to convince him hospitalization would be best for safety, but he refused, and is not committable at this point. Added olanzapine 10mg qhs and 5mg in the am.

Any experience and/or recommendations at this point.

Like others have said, I'd have to see and hear a little more about this than agitation/agression associating with depression. Depressed patients are often irritable.

That said, if I was confident this was a bipolar patient I'd probably add Lithium. Also not really clear what Lamictal is doing(I know what you probably think it is doing Im just not sure what it is doing), so I'd probably taper that down to nothing as I added lithium