A pilot study of rapid lithium administration in the treatment of acute mania

OBJECTIVES

The use of rapid lithium dosage administration, a strategy that could lead to rapid improvement in mania, has been largely unexamined. In this open-label, pilot, acute-treatment study, we sought to determine the safety and tolerability of lithium administered at 20 mg/ kg/day. A secondary aim was to provide preliminary data regarding the efficacy of this strategy in ameliorating manic, depressive, and psychotic symptoms.

METHODS

Fifteen patients hospitalized with DSM-IV bipolar disorder, manic or mixed, and who provided written informed consent, received lithium 20 mg/kg/day for up to 10 days. Patients were evaluated for adverse effects daily. Lithium levels were obtained on days 2, 3, 4, 5, 7, and 10 or at study termination. Electrocardiograms (EKGs) were performed at baseline and on days 1-5, 7, and 10 or at study termination. Symptomatic improvement was assessed daily using the Young Mania Rating Scale, 24-item Hamilton Depression Rating Scale, and the Scale for Assessment of Positive Symptoms (SAPS).

RESULTS

Five of the 15 patients completed the 10-day study period. Two patients dropped out due to adverse events. Seven patients did not complete the inpatient trial because of improvement sufficient to allow hospital discharge. All patients achieved serum lithium concentrations > or =0.6 mEq/L after 1 day of treatment; the mean + SD concentration on day 5 was 1.1 (+/- 0.1) mEq/L on day 5. There were significant reductions from baseline to endpoint on all rating scales, except the SAPS bizarre behavior subscale.

CONCLUSIONS

These pilot data suggest that lithium 20 mg/kg/day was well tolerated and that this strategy may produce rapid improvement in affective and psychotic symptoms. These impressions require confirmation in double-blind, randomized trials.

Valproate as a loading treatment in acute mania

Evidence from earlier studies indicates that the antimanic action of valproate becomes most apparent within 1-4 days of achieving serum concentrations 50 micrograms/ml, that valproate can be orally loaded with achievement of therapeutic serum concentrations within the first several days of treatment, there is a rapid onset of response, and minimal side effects. To provide further data on the safety and efficacy of valproate oral loading in the treatment of acute mania, we evaluated 13 consecutive patients with acute manic syndromes who received valproate initiated at a dosage of 20 mg/kg/day. In most cases, valproate was added to other psychotropics. All 13 patients received at least 5 full days of valproate maintained at or above 20 mg/kg/day, and valproate serum concentrations were 50 micrograms/ml (mean +/- SD = 88 + 25) by the second or third day of treatment. Ten (77%) patients displayed a moderate or marked response. Side effects were infrequent and minor. Consistent with our earlier study, these findings suggest that valproate can be safely administered via a loading dose of 20 mg/kg/day to patients with acute mania, including those on other psychotropics, and that it may produce a rapid response with minimal side effects.

Antiepileptic drugs for the treatment of panic disorder

Evidence from preclinical studies, preliminary clinical reports, pharmacologic challenge studies and a small number of controlled trials suggests that several antiepileptic agents--valproate, carbamazepine, and clonazepam--may have therapeutic effects in the treatment of patients with panic disorder. We review the theoretical basis and available clinical data supporting the use of these agents in panic disorder.

Twelve-month outcome after a first hospitalization for affective psychosis

BACKGROUND

We studied the 12-month course of illness after a first hospitalization for affective psychosis to identify potential outcome predictors in this rarely studied patient population.

METHODS

For this study, 109 patients consecutively admitted for their first psychiatric hospitalization for treatment of affective psychosis were recruited. Diagnostic, symptomatic, and functional evaluations were obtained at the index hospitalization and at 2, 6, and 12 months after discharge to assess syndromic, symptomatic, and functional outcome predictors. Factors associated with outcome were identified by means of multivariate analyses.

RESULTS

Fifty-six percent of the patients achieved syndromic recovery during the 12-month follow-up. Full treatment compliance was associated with more frequent and rapid syndromic recovery. Full compliance was more common in white patients and in patients without substance abuse. Only 35% of these patients achieved symptomatic recovery during this same 12-month interval, and, similarly, only 35% achieved functional recovery. Symptomatic recovery was delayed in patients with substance abuse and was associated with higher socioeconomic status. Higher socioeconomic status was also associated with functional recovery, as was good premorbid function.

CONCLUSIONS

Few patients achieved a favorable outcome in the year after a first hospitalization for an affective psychosis. Low socioeconomic status, poor premorbid function, treatment noncompliance, and substance abuse were associated with lower rates or delayed onset of recovery.

The effects of race and information variance on disagreement between psychiatric emergency service and research diagnoses in first-episode psychosis

BACKGROUND

Previously, we reported that patient race was associated with disagreement between research and clinical diagnoses. To extend this work, we studied whether disagreement was specifically due to associations of patient race with information or criterion variance.

METHOD

Ninety-nine patients consecutively admitted through the University of Cincinnati Psychiatric Emergency Service (PES) for a first hospitalization for psychosis were evaluated using the Structured Clinical Interview for DSM-III-R. Diagnoses made in the PES were compared with those obtained from the structured interview. We examined the contributions of information variance and criterion variance to the association between race and diagnostic agreement of PES and research diagnoses.

RESULTS

Agreement in PES and research diagnoses was present in only 42% of patients. Diagnostic agreement was less common in non-white patients than white patients, even after controlling for other sociodemographic and clinical variables. Information variance was the cause of diagnostic disagreement in 58% of cases and was associated with patient race. Criterion variance, occurring in 42% of cases, was not associated with race.

CONCLUSION

Patient race may contribute to the diagnostic process in the psychiatric emergency service by influencing the information obtained from patients during clinical evaluations.

Factors associated with pharmacologic noncompliance in patients with mania

BACKGROUND

Studies of noncompliance with pharmacotherapy in bipolar disorder have primarily involved outpatients receiving lithium. There are limited data to date regarding the rates of noncompliance in patients with bipolar disorder and schizoaffective disorder hospitalized for recurrent mania. Similarly, the influence of race, illness phenomenology, and comorbid psychiatric and medical disorders and the treatment with antipsychotics, antidepressants, and mood-stabilizing agents other than lithium on noncompliance in this population have not been systematically examined.

METHOD

Patients hospitalized for acute mania (N = 101) were evaluated by the Structured Clinical Interview for DSM-III-R to establish diagnosis and comorbidity and the Young Mania Rating Scale and Hamilton Rating Scale for Depression to assess severity of manic and depressive symptoms, respectively. Compliance was assessed by responses to a clinician-administered questionnaire administered to the patient, treaters, and significant others and by admission plasma concentrations of mood-stabilizing agents.

RESULTS

Sixty-five patients (64%) were noncompliant with their pharmacologic regimen in the month prior to admission as defined by criteria for full compliance and partial or total noncompliance. Noncompliance was significantly associated with greater severity of mania upon admission (p = .02) and treatment with combinations of mood stabilizers (p = .01).

CONCLUSION

Noncompliance with pharmacotherapy was present in the majority of patients admitted for acute mania and was associated with greater severity of mania upon admission and treatment with combinations of mood stabilizers.

A randomized comparison of divalproex oral loading versus haloperidol in the initial treatment of acute psychotic mania

BACKGROUND

Uncontrolled evidence suggests that divalproex administered via the oral loading strategy of 20 mg/kg/day may produce clinically significant antimanic response within 3 days of treatment in some patients. We conducted a prospective study to compare the antimanic response of divalproex oral loading with that of haloperidol in the initial treatment of acute psychotic mania.

METHOD

After a < or = 1-day screening period, 36 consecutive hospitalized patients with bipolar disorder, manic or mixed phase and with psychotic features, were randomly assigned to receive either divalproex 20 mg/kg/day or haloperidol 0.2 mg/kg/day for 6 full days, without other psychotropic agents except lorazepam up to 4 mg/day for management of agitation. Serum valproate concentrations were measured after 1 day of treatment. Response was measured daily by a blind rater using the Young Mania Rating Scale and the Scale for Assessment of Positive Symptoms.

RESULTS

Divalproex oral loading and haloperidol were equally effective in acutely reducing manic and psychotic symptoms. The greatest rate of improvement for both drug regimens occurred over the first 3 full days of treatment. Side effects were infrequent and minor for both treatments, except for extrapyramidal side effects which were significantly more common with haloperidol.

CONCLUSION

Divalproex oral loading may produce rapid onset of antimanic and antipsychotic response comparable to that of haloperidol and with minimal side effects in the initial treatment of acute psychotic mania in a subset of bipolar patients.

Valproate oral loading in the treatment of acute mania

BACKGROUND

Evidence from earlier studies suggests that the antimanic activity of valproate becomes most pronounced within 1 to 4 days of achieving serum concentrations of 50 mg/L or greater. We conducted a prospective study to assess the onset of antimanic activity of oral loading dosages of valproate administered to achieve serum concentrations above 50 mg/L within 24 hours.

METHOD

Nineteen patients with bipolar disorder, manic phase, received divalproex sodium 20 mg/kg/day in divided dosages for 5 days, without other psychotropic agents except lorazepam up to 4 mg/day. Serum valproate concentrations were measured after 1 and 4 days of treatment. Improvement was measured daily by a blind rater using the Young Mania Rating Scale (MRS).

RESULTS

Serum valproate concentrations greater than 50 mg/L were reached in all 15 patients completing the study. Ten (53%) of the 19 patients who received at least one complete loading dose displayed a significant (greater than 50%) reduction in MRS scores by study termination. These responders displayed the greatest percent change in MRS scores over the first 3 days of treatment. Side effects were minimal.

CONCLUSION

Valproate can be safely administered by oral loading and may produce rapid onset of antimanic response in some patients.

Valproate treatment of panic disorder and lactate-induced panic attacks

Several lines of evidence suggest that the anticonvulsant drug valproate may have antipanic properties: (1) It enhances gamma-aminobutyric acid activity in the brain; (2) it has anxiolytic effects in animal models of anxiety; and (3) it has been reported to be effective in panic disorder in several preliminary studies; however, valproate has not been studied in the prevention of lactate-induced panic attacks. Sixteen patients with panic disorder underwent a lactate infusion followed by a 28-day treatment period with valproate and subsequent rechallenge with lactate. Response was measured by change in panic attack frequency and Hamilton Anxiety Scale (HAS) scores and by the ability of valproate to block lactate-induced panic on rechallenge. Of the 14 patients completing the 28-day trial, 10 (71%) experienced a greater than 50% reduction in the weekly frequency of panic attacks. Six (43%) had complete remission. HAS scores dropped significantly from a baseline mean of 30.8 +/- 9.4 (SD) to 12.6 +/- 7 after 4 weeks of treatment. Valproate blocked reinduction of panic symptoms on lactate rechallenge in 10 (83%) of 12 patients who had initially experienced panic symptoms on initial infusion. The significant reduction in spontaneous panic attacks and the blockade of lactate-induced panic symptoms by valproate support earlier studies suggesting that the drug may be an effective treatment for panic disorder.