Anticonvulsant Medications for Bipolar Disorder

Many anticonvulsants (those medications used to prevent or control seizures) can also act as mood stabilizers and have been approved by the FDA for this use in bipolar adults. At this writing, however, no anticonvulsant has received FDA approval for treatment of Bipolar Disorder in children. But the various anticonvulsants available have been studied and used for treatment of different types of seizure disorders in both children and adults. Therefore, safe blood-level ranges have been established, and in many cases, the side effects are well documented. In general, a child's blood levels are taken before the morning medication is administered (generally twelve hours after the last dose of medication); levels are then checked as the medication dose is increased (perhaps once every one to two weeks) until there is clinical improvement or the medication is at the highest acceptable level. Thereafter, blood levels can be repeated in two to four weeks and then, if they are clinically stable, once every few months, unless there is a reason to check them sooner. The anticonvulsants discussed here have all been used as mood stabilizers in adults, some with very good results.

Depakote (Divalproex Sodium) or Depakene (Valproic Acid)

Depakote (the enteric-coated form of valproate) has been in use since 1983 in the treatment of epilepsy and has been approved for the treatment of acute mania in adults since the mid-1990s. Studies indicate that it is a good treatment option for mania and more effective than lithium in treating adults with mixed states or rapid cycling (the therapeutic blood level for Depakote in the treatment of seizure disorders is 50 to 100 mg/L [milligrams per liter]). Overall, Depakote appears to be safer than lithium because there is a bigger range between its therapeutic and toxic blood levels. In adults with Bipolar Disorder, it's clear that both lithium and Depakote are effective mood-stabilizing agents. Similarly, physicians who treat bipolar children find these agents can be quite effective in their young patients. (Future studies will give us much more information on the comparative effectiveness and limitations of lithium versus Depakote in the treatment of manic-depressive disorder in youth.)

On the minus side of the ledger, Depakote has weak antidepressant properties, making lithium preferable to Depakote as a treatment for bipolar depression. I tell parents that they should also be aware that Depakote's more common side effects include headache, nausea, vomiting, sedation, weight gain, agitation, tremor, and confusion. On occasion, Depakote may also cause hair loss (though vitamins with selenium and zinc can help with this side effect) and also a drop in a child's platelet count (platelets are needed for blood clotting to occur). Very infrequent but serious side effects also may include lowered blood counts, hepatitis, and, rarely, pancreatitis (an inflammation of the pancreas). There is some concern that Depakote may cause polycystic ovary syndrome, a hormonal disorder in females associated with ovarian cysts and menstrual irregularities, but the jury is still out on this matter.

At other times, Depakote may cause overwhelming fatigue in children, but the fatigue can also be due to elevated ammonia levels. Ammonia is a normal by-product of protein metabolism and is generally eliminated by a normally functioning liver. Elevated ammonia levels may result in irritability, sedation, and other central nervous system problems. So, if a child experiences extreme exhaustion while on Depakote, she should have her ammonia levels checked.

In general, a child taking Depakote should have her blood levels tested as the dose is increased. Once a clinically therapeutic level is reached, I'd recommend repeating testing in two to four weeks and then, if they prove clinically stable, once every few months.

Parents should be especially aware that some serious side effects can result if Depakote and Lamictal (lamotrigene), another anticonvulsant, are combined. If the two are used at the same time, the child's Lamictal dose should be lowered. Depakote is available as sprinkle capsules (beads that can be sprinkled on food) and in tablet, capsule, liquid (Depakene), and extended-release forms.

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