Depakote (Divalproex Sodium) Dosage for Bipolar Disorder Type 2
For bipolar disorder type 2, divalproex sodium (Depakote) should be initiated at 125 mg twice daily and titrated to a therapeutic blood level of 40-90 mcg/mL, which typically requires doses between 125-500 mg daily for cyclothymia/bipolar II patients.1, 2
Initial Dosing and Titration
- Starting dose: 125 mg twice daily 1
- Titration: Increase dose gradually based on clinical response and side effects
- Target blood level: 40-90 mcg/mL 1
- Dosing schedule: Can be given as divided doses or once-daily dosing (especially with extended-release formulation) 3
Dosing Considerations Based on Severity
Research indicates that bipolar II patients may respond to lower doses than those typically used for bipolar I disorder:
- Mild to moderate bipolar II: 125-500 mg daily (mean 351 mg) corresponding to lower serum levels (mean 32.5 mcg/mL) 2
- More severe symptoms: May require higher doses within the therapeutic range 2
- Maintenance treatment: Should be continued for at least 2 years after the last episode 4
Monitoring Parameters
Regular monitoring is essential when using divalproex:
- Blood levels: Check serum valproate levels regularly to ensure therapeutic range (40-90 mcg/mL)
- Liver function: Monitor liver enzymes regularly 1
- Hematologic monitoring: Check platelets, prothrombin time, and partial thromboplastin time 1
- Weight and metabolic parameters: Monitor weight, BMI, blood pressure, glucose, and lipids 4
Special Considerations
- Depressive episodes: Divalproex has shown efficacy in bipolar II depression, with studies showing response rates of 63% overall (82% in medication-naïve patients) 3, 5
- Combination therapy: For depressive episodes, may need to be combined with an antidepressant (preferably an SSRI like fluoxetine) 1, 4
- Extended-release formulation: Consider for improved adherence and tolerability with once-daily dosing 6
Common Pitfalls and Caveats
- Avoid underdosing: Ensure blood levels reach therapeutic range for optimal efficacy
- Avoid rapid titration: Gradual dose increases minimize side effects
- Monitor for side effects: Weight gain, sedation, tremor, gastrointestinal disturbances
- Pregnancy considerations: Divalproex has teratogenic potential and should be used with caution in women of childbearing age
- Medication interactions: Be aware of potential interactions with other medications that may affect valproate levels
Divalproex is generally better tolerated than other mood stabilizers like carbamazepine, making it a preferred option for many patients with bipolar II disorder 1.