Dear Dr. Phelps,

I recently was diagnosed as bipolar II and am on 750 mg of depakote.  My aunt also is on 750 mg of depakote for migraines.  We both have experienced significant, disturbing weight gain, but both agree that we haven't experienced an increase in appetite or noticed that we are eating more.  I've read the same complaint on some message boards online.  My doctor wants me to get to the point where I'm exercising one hour daily, but I have three small children and do not think that is realistic.  I am wondering if I should try to reduce my dose to 625 mg or 500mg and see if I drop some weight without the reoccurence of the intense anxiety symptoms (I never had a problem with depression until after going on meds. and that was minimal).  Would I be able to regain the therapeutic effectiveness of the depakote if my symptoms returned and I had to increase my dosage again?  Trying an equivalent dosage of Depakote ER interests me, but I'm wondering if it would make any difference as I haven't noticed the appetite increase on the regular depakote, just the weight gain.   I won't try any of this without consulting with my doctor. 

Thanks

 
Dear Ms. H' -- 
You are among the very few from whom I've heard of weight gain without appetite increase.  For those with appetite increase at least, the ER formula can make a big difference.  Before you switch, you should definitely try it, as that's a "what's to lose?" proposition (the ER dose is not fully absorbed, so there's a potential small dose drop to account for: apparently, per Abbott Labs, the average absorption is 85% but that can vary.)  You can make small increments between 500 and 1000 mg ER by using a 500 ER plus one or several 125mg "sprinkles".  The latter, which must be specified as there's a 125mg standard release also, has slow release properties similar to the big 500ER, allowing 625/750/875mg options in the "ER" format to try before you give up and look at alternatives. 

These would include switching entirely to something like Trileptal which is supposedly (have to see in your case) weight neutral, or Lamotrigine, or perhaps even a look at the very untested thyroid approach I've had some success with -- all to avoid turning to lithium, which has the track record to beat everybody in this race but also causes weight gain quite commonly.  Thanks for pointing out you'll discuss these with your doc'; the thyroid approach in particular is not really a routine alternative at your stage, so bears considerable examination from the pro/con; risk/benefit point of view.  

Dr. Phelps