Dr Phelps,
I have just come out of hospital after a breakthrough episode and my consultant has put me on depakote, trazadone and amisulpride. My question is this - I am still getting thoughts that other people are acting towards me in a hostile manner nature which can be difficult to deal with and there are  a lot of anxious feelings about as well. Will the depakote deal with these thoughts or are the other meds more helpful. I take 1000mg of depakote, 450mg trazadone and 200mg amisulpride. Many thanks in advance.

Hugh.

Hello Hugh -- 
There is evidence that Depakote can "deal with these thoughts" all right.  Here's the abstract on that study, in which Depakote and Haldol (an old-generation antipsychotic) worked equally well in acute psychotic mania.  I'm one of the only psychiatrists I know who thinks that a mood stabilizer like lithium or Depakote might be effective on "voices", however.  Virtually every psychiatrist I know personally would rely on an antipsychotic in this role (we don't have amisulpiride here in the U.S. so I can't comment on that particular one), although the most widely recognized "algorithm" for treating bipolar mania also starts with a mood stabilizer alone as the treatment even for psychotic mania (see the Texas algorithm; psychotic mania on the right column). 

So, the point is, you can go either way from where you are (as I understand it from your letter): you could increase Depakote or add an additional mood stabilizer like lithium (the combination approach after maximizing Depakote short of side effects is described in the treatment section of my website on BPII); or you could switch to a different antipsychotic if raising the dose of the one you're taking didn't solve the problem.  As you might gather, I lean toward the former approach, primarily because most patients, in my experience, don't like how they feel on full-dose antipsychotics, compared to full dose mood stabilizers.  Generally speaking.  All that's for discussion with your doctor, of course. 

Dr. Phelps