Initial Triple Therapy of Acute Mania, Adding Lithium and Valproate to Neuroleptics

In a closed inpatient unit, valproate and lithium were initially combined in the treatment of 12 severely manic patients (ICD-10 F30, F31, F25). Onset of response and the use of additional neuroleptic medication were analyzed. For 5 patients a comparision was performed between the index episode and a pre-treatment period during which lithium therapy was administered without valproate. Outcome criteria for the analysis were the latency of response and remission, as well as the dose of neuroleptic medication necessary for additional sedation. The mean severity of mania syndrome (AMDP-System) in the study patients was comparable to the mean mania score of the total manic patient population of the inpatient unit. All patients responded to the combination of valproate and lithium, and the mean total-remission time was 30 days for the whole group. Mean serum levels were 0.8 mmol/L for lithium and 73.8 mg/L for valproate. The mean remission time for the 5 readmitted patients was 22.8 days under combination treatment compared to 35.6 days in the pre-treatment episode without additional valproate (p = 0.06). It was possible to markedly reduce the use of neuroleptic medication in these patients from 18 601.6 mg CPZ equivalents to 3927.6 mg (p < 0.025). Initially combining valproate and lithium thus appears to be an effective therapeutic option for the inpatient management of severe manic syndromes.