Generic (Trade) Name

Initial Dosage

Final Dosage

Sedative Potential

Precautions

Advantages

Anticonvulsants

Divalproex sodium (Depakote, Depakote ER)

250 mg bid; ER: 500 mg hs

1000 mg bid; ER: 1000 mg hs

Moderate

Delayed onset of action, drug interactions

GI upset, tremor, weight gain, edema, thrombocytopenia

Inhibits hepatic enzymes; increases other drug levels

Hepatoxicity, pancreatitis

Better tolerated than carbamazepine

Therapeutic level 50–100 μg/mL

Carbamazepine (Tegretol, Epitol)

100 mg bid

400 mg bid

Moderate

Delayed onset of action, drug interactions

Dizziness, unsteady gait, rare agranulocytosis

Enhances cytochrome P-450 activity and decreases other drug levels

Not FDA approved for bipolar disorder

Therapeutic level 4–12 μg/mL

Available as a liquid

Antipsychotics

Olanzapine (Zyprexa, Zyprexa Zydis [oral dissolving])

2.5 mg qd

5–15 mg qd

Moderate

Anticholinergic as dose increases

Cost

Weight gain, hyperglycemia

FDA approved for acute mania and maintenance monotherapy for bipolar I disorder but not for bipolar depression

Quetiapine

(Seroquel)

25 mg bid

100 mg bid

More than moderate

Slit-lamp examination for cataracts

Sedative, not anticholinergic, fewer EPS, less TD

FDA approved for mania

Risperidone

(Risperdal, Risperdal

Consta [injectable])

0.25 mg qd

Inj: 25 mg q 2 weeks

6 mg qd

Inj: 50 mg q 2 weeks

Moderate

EPS likely at doses above 2 mg, high potency, cost, reports of stroke

Available in liquid form

FDA approved for acute mania

Benzodiazepine

Clonazepam (Klonopin)

0.5 mg bid

5 mg bid

Moderate

Long half-life

Fall risk limits use in elderly patients

May exacerbate confusion in dementia

Not FDA approved for bipolar disorder

Calming, sedation

Lithium

Lithium carbonate (Eskalith, Eskalith CR)

300 mg qd; CR: 450 mg qd

300 mg tid; CR: 450 mg bid

Low

Renal clearance is sole route of elimination

Toxicity may appear below therapeutic range

Nausea, vomiting are signs of toxicity

Risk of hypothyroidism with long-term use

Drug interactions

Patient preference, otherwise, none

Therapeutic level 0.4–1.0 mEq/mL