Dosing strategies and time course of response to antimanic drugs

Mania is one of the few emergent conditions in psychiatry. Vigorous treatment, aimed at achieving symptom control as promptly as possible while avoiding adverse effects, is therefore important. Strategies to accomplish this aim are possible, but differ for each of the three antimanic drugs principally employed. For lithium, uncomplicated manic patients can be started at 15 mg/kg of body weight, with dosage increase every 3 to 4 days until response, complicating adverse effects, or a serum level of 1.2 to 1.4 mEq/L occurs. Valproate, if administered as divalproex, can usually be initiated at a dosage of 20 mg/kg of body weight, which is associated with earlier improvement than that observed with lithium. Carbamazepine requires a relatively slow dosage escalation from an initial 200 mg once or twice daily, due to the possibility of neuromuscular and cognitive adverse effects. Adjunctive medications are frequently necessary and add to the importance of a thorough knowledge of the dosing strategies needed at different points in early therapy of bipolar disorder.