Higher Risk of White Blood Cell Problems?
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Q:  Higher Risk of White Blood Cell Problems?

I have just been diagnosed as Bipolar I.  My psychiatrist asked me which mood stabiliser I would prefer, Lithium or Sodium Valproate. He said although Lithium is the standard protocol here in the UK, Valproate is increasingly the preferred option in the USA. I have taken Lithium in the past for a major depressive episode, without any problems. My doc said the only downside of Valproate is the risk of some white cell disorder (I can't remember exactly what he said). My mother (who was manic depressive) died of myelodysplasia. I wonder if I am at a higher risk of white cell problems, and subsequently wonder which mood stabiliser you would advise? 

Thanks in advance

Dear Mo'-- 
The association between valproate and blood problems such as you describe is very weak. Another medication which is regarded as an option at your stage in this process, called carbamazepine, has a much stronger association with white cell production problems. But even for carbamazepine, the mechanism of this problem is probably completely unrelated to the mechanism of myelodysplasia (you'd have to find a hematologist to get a more definitive comment on that relationship), so I think most doctors would not hesitate to use even carbamazepine in your situation.  What was more striking about your note is that you had taken lithium in the past for depression, and it sounded as though maybe it worked (you took it long enough to say it had no problems). So, if it helped, and caused no trouble, then surely that would be a good starting place? Hard to beat, actually. Since you're writing, I'm forced to presume that there must be something more to the story: lithium helped, but not enough, for example -- in which case often we might think to add low-dose valproate to the lithium, rather than switch all the way to valproate. Either way, combining the two is a very common way to get more benefit without more side effects. As your doctor may have pointed out, there is a research study underway in your country, comparing lithium versus valproate, trying to figure out if one is clearly better than the other as a place to start for newly-diagnosed bipolar disorder (the
BALANCE trial). 

There, did I duck your question well enough? Sorry, I can't really advise your choice one way or the other. There are a lot of other factors to account for in such a decision. But I hope this little bit of information will help some. Good luck from here. 

Dr. Phelps

Published April, 2006


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