Rapid Titration of Mood Stabilizers Predicts Remission From Mixed or Pure Mania in Bipolar Patients
J Clin Psychiatry 1998;59(4):151-158
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Background: Recent investigations have suggested
that the antimanic agents divalproex sodium and carbamazepine may
each hasten hospital discharge and be especially beneficial in
treating mixed-state mania. This study retrospectively compared
the time to remission for pure versus mixed manic bipolar
inpatients who were taking lithium, divalproex, or carbamazepine,
or their combination, under naturalistic conditions.
Method: Records were reviewed for 120 bipolar
inpatients from 1991 to 1995. Research DSM-III-R diagnoses of
pure or mixed mania were assigned along standardized guidelines.
Data were obtained on daily symptoms, medication doses, and blood
levels. Weekly improvement was evaluated by Kaplan-Meier survival
analysis of Clinical Global Impressions scale scores. Variables
associated with "remission" versus
"nonremission" were examined by logistic regression.
Results: Mixed mania (N=70) was more common than
pure mania (N=50). No significant differences were observed in
the time to remission for mixed or pure manic bipolar patients
who took lithium compared with those who took divalproex or
carbamazepine. In patients who remained symptomatic with lithium
as a single-agent mood stabilizer despite therapeutic serum
lithium levels, the addition of a second mood stabilizer led to
rapid symptom improvement. Among all medication subgroups, the
speed with which patients achieved therapeutic blood levels of
any of these agents significantly affected the time to remission.
Conclusion: Mixed manic bipolar patients taking
lithium, divalproex, or carbamazepine under naturalistic
conditions remit at comparable rates. Those failing to respond to
single-agent mood stabilizers often receive combinations of mood
stabilizers. However, delays in optimizing
a medication regimen may attenuate short-term outcome, regardless
of the mood stabilizer selected. Rapid achievement of therapeutic
blood levels of any antimanic agent appears to be strongly
related to swift symptom remission.