RAPID TITRATION OF MOOD STABILIZERS PREDICTS REMISSION FROM MIXED OR PURE MANIA IN BIPOLAR PATIENTS

Background: Recent investigations have suggested that the antimanic ag ents divalproex sodium and carbamazepine may each hasten hospital disc harge and be especially beneficial in treating mixed-state mania. This study retrospectively compared the time to remission for pure versus mixed manic bipolar inpatients who were taking lithium, divalproex, or carbamazepine, or their combination, under naturalistic conditions. M ethod: Records were reviewed for 120 bipolar inpatients from 1991 to 1 995. Research DSM-III-R diagnoses of pure or mixed mania were assigned along standardized guidelines. Data were obtained on daily symptoms, medication doses, and blood levels. Weekly improvement was evaluated b y Kaplan-Meier survival analysis of Clinical Global Impressions scale scores. Variables associated with ''remission'' versus ''nonremission' ' were examined by logistic regression. Results: Mixed mania (N = 70) was more common than pure mania (N = 50). No significant differences w ere observed in the time to remission for mixed or pure manic bipolar patients who took lithium compared with those who took divalproex or c arbamazepine. In patients who remained symptomatic with lithium as a s ingle-agent mood stabilizer despite therapeutic serum lithium levels, the addition of a second mood stabilizer led to rapid symptom improvem ent. Among all medication subgroups, the speed with which patients ach ieved therapeutic blood levels of any of these agents significantly af fected the time to remission. Conclusion: Mixed manic bipolar patients taking lithium, divalproex, or carbamazepine under naturalistic condi tions remit at comparable rates. Those failing to respond to single-ag ent mood stabilizers often receive combinations of mood stabilizers. H owever, delays in optimizing a medication regimen may attenuate short- term outcome, regardless of the mood stabilizer selected. Rapid achiev ement of therapeutic blood levels of any antimanic agent appears to be strongly related to swift symptom remission.