Q:  Increase in Cycling

I have been taking depakote for over 6 years and have been successful in achieving good results, objective view of my "gift" etc.  However i have recently noticed that the cycle is speeding up and deepening (becoming more intense).  this has been a slow gradual realization...although now that i am aware...it seems that it is progressing faster.  Should I request an uppage in dosage (currently at 500 mg 2x a day) or consider alternatives.  I have only 1 kidney, so that kinda limits things a wee bit.

Thank you
 

Dear PJ -- 
Usually we move the dose of one agent up until it has reached near maximal blood levels for that agent (e.g for Depakote, blood levels of 125 mcg/dl; not the 100 mcg/dl level that is usually reported as the "lab range" for this medication); unless you've run into intolerable side effects before you get to that blood level, or gotten better on the way up.  As you know, the big side effect we watch out for with Depakote is an appetite that leads to tremendous weight gain.  There appears to be a "threshold" beyond which the appetite thing kicks in, and you're probably below that threshold at this point.  If as the dose went up you were to notice a dramatic increase, you should talk with your doc' about going back down to lower doses and adding something (and of course you should talk to your doc' and agree on a plan to increase, not just do that on your own).  

If necessary, what should you add?  As you may have gathered, often we'd use lithium in this role.  Your internal medicine doctor might be able to give you an opinion on whether it would be safe to try very low dose lithium; I've not had to research that particular question (the one-kidney/lithium question) yet.  I don't think it's an absolute "rule out", but you'd probably end up trying other mood stabilizers with Depakote first, eh?

Dr. Phelps