Q:  Depakote & Rapid Cycling

Dr. Phelps, I was diagnosed with BP2 about 4 weeks ago and was put on Depakote. It's the only medication I take. I cycle very rapidly, and right now I'm mostly in a hypo-manic stage with mixed episodes sprinkled in between. Initially the Depakote at 500mg a day was working great and it did so for about 1 week. Now I've had to increase the dose to 750mg a day and I'm STILL cycling and very hypo-manic, I have trouble sleeping and I feel just as I did prior to having started the Depakote. Do dosage increases take time to work? Should I be taking more? I haven't increased the dose because I'm concerned with hairloss at higher dosages. I am a 32 year old female, I'm 5'8" and I weight 125, I thought that perhaps given that Im relatively small framed, I could get away with less dosage, but I feel terrible. AS though I hadn't even taken anything! Any thing I should suggest to my pdoc? I ve been hypomanic for about 2 1/2 months now!

Dear I' -- 
Most doc's I know would raise your Depakote dose until your symptoms were controlled or your appetite started to increase.  If you use the ER version of Depakote, you might be able to get as high as 1500 before the appetite thing happens; or at least 1000 -- few people on the ER version get that problem at 1000 mg in my experience.  If you're using the ER now, you're really on quite a small dose compared to what is usually used (according to the manufacturer, about 10% of people use as little as 1000 mg; the other 90% taking Depakote take more than that); and the ER loses about 15% that's not absorbed, so even at 1000 mg you're really getting somewhere closer to about 850 mg compared to the older Depakote version (CR). 

Generally speaking the approach to bipolar disorder is to get hypomania under control pretty aggressively, so you're a little behind the curve in that respect so far.  Remember that if you don't like what happens at a higher Depakote dose (in terms of side effects) you can lower the dose and add a little lithium, or switch to some other mood stabilizer.  So getting a little more determined to get the hypomania under control might be worth it in the long run (in many people, a depressive episode of similar magnitude can follow, as you may have experienced in the past...).  So I'd suggest that you suggest to your pdoc that you're willing to get a little more aggressive now, and formulate a plan for what you'll do if higher Depakote doses don't work out.  Good luck with that. 

Dr. Phelps

Published January, 2004