Algorithm for patient management of acute manic states: lithium, valproate, or carbamazepine?

Lithium remains the mainstay of pharmacologic therapy for the majority of patients with bipolar disorder; however, significant numbers of patients with both classical bipolar disorder and syndromal variants fail to respond to lithium therapy. The discussion that follows outlines subgroups of patients who are likely to be nonresponsive to or have poor tolerance for lithium therapy either because of disease type (rapid cyclers and schizoaffectives) or patient characteristics (the elderly or those with psoriasis or organic brain syndrome). Alternate therapy with valproate and carbamazepine is discussed. The relative efficacy of lithium versus valproate is briefly evaluated through a retrospective review of current case material. Algorithms for patient management are presented based on experience in our center for mood disorders. Valproate and carbamazepine were found to have an important clinical role for the treatment of bipolar spectrum disorders with the initial preference for treatment based on broad clinical phenomena.