What antiepileptic (anti-seizure) medication also has antipsychotic properties?

From the Guidelines

Valproic acid (Depakote) is the primary anti-seizure medication that also has established antipsychotic properties, and it is recommended as the first-line treatment for patients with seizures and psychiatric comorbidities, such as bipolar disorder or schizoaffective disorder, due to its efficacy in controlling both seizure activity and mood stabilization 1.

Key Points

• Valproic acid is commonly used at doses of 750-2000mg daily, divided into two or three doses, with therapeutic blood levels between 50-125 μg/mL.
• Carbamazepine and lamotrigine also have some antipsychotic effects but are less commonly used for this dual purpose.
• Valproic acid works by increasing levels of the inhibitory neurotransmitter GABA and blocking sodium channels, which helps control both seizure activity and mood stabilization.
• When starting valproic acid, it's typically initiated at a lower dose (250-500mg daily) and gradually increased to minimize side effects like nausea, sedation, and tremor.
• Regular blood monitoring is essential to check liver function, platelet count, and drug levels.

Considerations

• The use of valproic acid in patients with intellectual disability and epilepsy should be individualized, and it may be considered as a first-line treatment due to its lower risk of behavioral adverse effects compared to phenytoin or phenobarbital 1.
• In patients with status epilepticus, valproate has been shown to be effective and safe, with potentially fewer adverse effects compared to phenytoin 1.
• The European Federation of Neurological Societies' evidence-based guideline for status epilepticus in adults recommends the use of valproate as a second-line treatment for refractory status epilepticus 1.

From the Research

Anti-Seizure Medication that is also Antipsychotic

• Valproate is an anticonvulsant drug that has been shown to be effective in acute mania and is frequently used in maintenance treatment of bipolar disorder 2.
• Valproate has some advantages over lithium in treatment of mania for persons with more severe illnesses, and it benefits a broader spectrum of bipolar conditions than lithium 3.
• Valproate may be more effective as an antimanic rather than prophylactic agent, and it might be a better choice in patients with many previous affective episodes/hospitalizations and psychiatric comorbidities 4.
• Carbamazepine and valproate are two anticonvulsants that are effective in the treatment of acute mania and suggest efficacy as maintenance therapy in bipolar disorder 5.
• Valproate was more effective than placebo in preventing new BD episodes of mania or depression, and not significantly different from lithium, second-generation antipsychotics, or other anticonvulsants 6.

Key Findings

• Valproate is effective in preventing study withdrawal due to any mood episode, and it is associated with fewer participants dropping out of treatment for any cause when compared with placebo or lithium 2.
• Valproate has a different adverse event profile compared to lithium, with valproate being associated with increased sedation and infection, while lithium is associated with more frequent diarrhoea, polyuria, increased thirst, and enuresis 2.
• The efficacy of valproate in the long-term treatment of bipolar disorder is supported by limited evidence, and clinicians and patients should consider acceptability and tolerability profile when choosing between lithium and valproate 2.
• Valproate is an effective and useful treatment for bipolar disorder, and studies clarifying its spectrum of efficacy, its safety and efficacy in combination regimens, and its mechanisms of action are warranted 3.