Depakote Dose: Go by Symptoms or Lab Values?
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Q:  Depakote Dose: Go by Symptoms or Lab Values?

My 17 year old son (200 lbs) is on 2000 mg Depakote qd, 900 mg Eskalith CR qd and Ambien 3 or 4 x aweek prn and 0.1 mg Synthroid qd.  New doctor reduced Depakote to 1500 qd as lab value was 150 mg.  However, that lab was drawn about 4 hours after he took 1000 mg morning dose.  Previous dr. had us hold the meds for lab draw.  Lab says to hold med as the "normal 50 to 100" range is for a trough value.  New dr says take meds and friend who is psych nurse says OK to take meds before draw. Some articles on nets say max dose for mania isn't set so just go by symptoms.  Right now he isn't manic but mostly sleeps during the day, not in school, not working, becomes very anxious at any attempt to try to study for GED or driver's permit etc. Any advice for me?  Thank you for your time, I do appreciate it. New doctor is enthused to try to help my son but I worry the labs are not being monitored correctly.  Perhaps it is OK as long as the draw is consistently after the meds?

Dear Ms. V' -- 
You've got all the possible points of view racked up there, don't you?  The one I particularly favor is the "treat the patient, not the lab value" one.  If he was doing great, I'd focus there not on the number.  But since he's not; since some of his current status could be from high Depakote levels; I'd pay more attention to the numbers than otherwise.  So, now we need more reliable numbers.  

For starters, the range of valproate levels that most mood experts go by these days is 50-125, as there are some people whose mood symptoms will respond between 100 and 125, but not lower; and the side effects don't seem to really jump up in frequency until beyond 125.  Thus we psychiatrists, as opposed to the neurologists, use the higher "top end". 

Secondly, in my experience that number refers to a "trough" sample, all right, from the convention the neurologists have followed for years.  However, with the new Depakote ER pills, blood levels are not supposed to fluctuate much so I'll sometimes just grab an afternoon level if I don't really need a precise number -- as is more the issue now in your son's case.  Even then, though, I'd do some discounting of the value if it were drawn about 4 hours post dose. 

But at this point it sounds like it's time to go back to "how's the patient doing?"  Too high a Depakote dose can produce drowsiness, though usually patients can recognize it as:  blurred vision, mild; headache, mild, kind of an odd one; and "fuzzy" or "spacey" thinking.  Maybe your son at 150 is beyond those more subtle signs; or maybe it's what they're trying to treat that makes him thus, and with less Depakote he'll cycle more, or show other signs of bipolar mood instability.  

At this point, the new doc' has launched on a trial of lower Depakote.  Let's see how that works.  Now that the dose has come down a bit, the blood level questions are even more moot, no?  But, these are reasonable questions, especially if you ever have to think about going up on the dose; or if your son's better, but not better enough, and you're wondering if you should go lower (although that step I'd probably do even without another level. I generally use levels if something's wrong and I'm trying to figure out what, like I think it should be working and it's not; or if we're changing medications and I want to get a marker in place as something to go back to later, if necessary, kind of a "stick in the sand").  

Last thought:  if the Ambien is needed "prn", i.e. not all the time; and he's sleeping during the day; it sounds like at minimum his circadian rhythm is disturbed, which is common in adolescents but sounds more out of whack here.  And it sounds like he might still be cycling, if the Ambien is not needed sometimes, but sometimes is?  This, and the anxiety you describe, look to me like the main targets, maybe even more important than the daytime somnolence, which would be a secondary issue that could be due to the circadian problem or the cycling problem (and those two could be related or one and the same).  In that case I'd look, at minimum, at the "Social Rhythm Therapy" approach:  regular sleep, eating, and activity schedules; even to the point of considering some variant of the "dark therapy" approach used at the NIMH (read down to Biological Clocks and Treatment.)  All of that has the advantage of no additional medications, of course.  Beyond that, if he's cycling for sure, then maybe switch T4 to T3/T4?  (very guesswork level data on that, as reported here: Thyroid and Bipolar Disorder) or add low dose of an additional mood stabilizer?  or bump lithium up to a level (and here all the issues about when to draw, and what the level is, really do matter!) of 0.8 or 0.9, at least for a while?  

Congratulations on having found a doc' who's enthused to help your son!  You can pass along my thoughts as simply ideas to consider, since I'm commenting from left field here, or not even mention them if things are going smoothly. Good luck with all that.  

Dr. Phelps

Published March, 2003


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