Karen C. Tugrul

Valproate treatment of panic disorder and lactate-induced panic attacks

Several lines of evidence suggest that the anticonvulsant drug valproate may have antipanic properties: (1) It enhances gamma-aminobutyric acid activity in the brain; (2) it has anxiolytic effects in animal models of anxiety; and (3) it has been reported to be effective in panic disorder in several preliminary studies; however, valproate has not been studied in the prevention of lactate-induced panic attacks. Sixteen patients with panic disorder underwent a lactate infusion followed by a 28-day treatment period with valproate and subsequent rechallenge with lactate. Response was measured by change in panic attack frequency and Hamilton Anxiety Scale (HAS) scores and by the ability of valproate to block lactate-induced panic on rechallenge. Of the 14 patients completing the 28-day trial, 10 (71%) experienced a greater than 50% reduction in the weekly frequency of panic attacks. Six (43%) had complete remission. HAS scores dropped significantly from a baseline mean of 30.8 +/- 9.4 (SD) to 12.6 +/- 7 after 4 weeks of treatment. Valproate blocked reinduction of panic symptoms on lactate rechallenge in 10 (83%) of 12 patients who had initially experienced panic symptoms on initial infusion. The significant reduction in spontaneous panic attacks and the blockade of lactate-induced panic symptoms by valproate support earlier studies suggesting that the drug may be an effective treatment for panic disorder.

Valproate as a Loading Treatment in Acute Mania

Evidence from earlier studies indicates that the antimanic action of valproate becomes most apparent within 1-4 days of achieving serum concentrations 50 micrograms/ml, that valproate can be orally loaded with achievement of therapeutic serum concentrations within the first several days of treatment, there is a rapid onset of response, and minimal side effects. To provide further data on the safety and efficacy of valproate oral loading in the treatment of acute mania, we evaluated 13 consecutive patients with acute manic syndromes who received valproate initiated at a dosage of 20 mg/kg/day. In most cases, valproate was added to other psychotropics. All 13 patients received at least 5 full days of valproate maintained at or above 20 mg/kg/day, and valproate serum concentrations were 50 micrograms/ml (mean +/- SD = 88 + 25) by the second or third day of treatment. Ten (77%) patients displayed a moderate or marked response. Side effects were infrequent and minor. Consistent with our earlier study, these findings suggest that valproate can be safely administered via a loading dose of 20 mg/kg/day to patients with acute mania, including those on other psychotropics, and that it may produce a rapid response with minimal side effects.

Antiepileptic Drugs for the Treatment of Panic Disorder

Evidence from preclinical studies, preliminary clinical reports, pharmacologic challenge studies and a small number of controlled trials suggests that several antiepileptic agents--valproate, carbamazepine, and clonazepam--may have therapeutic effects in the treatment of patients with panic disorder. We review the theoretical basis and available clinical data supporting the use of these agents in panic disorder.

The nurse's role in the assessment and treatment of bipolar disorder ☆

The prevalence of bipolar disorder is underestimated, and the condition is often misdiagnosed as depression. Because bipolar disorder does not appear to respond to standard treatments for depression, misdiagnosed patients may suffer increased morbidity and mortality. Nurses have the ability to significantly impact the successful care of these patients by recognizing and assessing bipolar disorder, managing treatment with appropriate mood stabilizers and therapies, and educating patients and their families. Bipolar disorder diagnosis, the consequences of misdiagnosis and mismanagement, lifestyle factors that may increase the risk for episode recurrence, and useful interventions are discussed.

Pharmacologic Treatment of Schizophrenia: A Review

Standard antipsychotic agents, such as haloperidol and chlorpromazine, continue to be the mainstay of pharmacologic treatment for schizophrenia. However, standard antipsychotics, although effective for the positive symptoms of schizophrenia, have little or no effect on the negative symptoms of this disease. Standard antipsychotics also are associated with the development of potentially disabling side effects, such as extrapyramidal symptoms and tardive dyskinesia. Newer agents, such as clozapine and risperidone, are effective for both positive and negative symptoms. They also are less likely to cause extrapyramidal symptoms.