Mood Stabilizer Loading Versus Titration in Acute Mania: Audit of Clinical Practice

Abstract

Objective: The aim of the present study was to investigate whether the use of a loading strategy with lithium or valproate followed recommended practice and second, whether this had any impact on indicators of outcome in acutely manic inpatients. Method: A 12 month retrospective review of admissions to two adult psychiatric units in Auckland, New Zealand, was conducted. Demographic, legal status, psychiatric admissions, outcome indicators (length of stay, intensive care and seclusion use) and medication data were collected for all patients with a diagnosis of acute bipolar mania who started mood stabilizer treatment within 3 days of admission (n=93). Serum levels and adverse effects were also recorded. Results: In 46.2% of admissions a loading strategy was prescribed, and lithium was the treatment choice in two-thirds of admissions. Serum levels were taken inconsistently, particularly for valproate. No difference was found between loading and titrating for the assessed outcomes in routine practice; average length of stay was 30.2 days; most patients (71.0%) spent time in intensive care (average 8.4 days) and 33.3% spent time in seclusion. More adverse effects occurred with loading (51.2%) compared to titrating (36.0%), particularly with lithium. Conclusion: The literature supports a strong link between rapidly attained high serum levels and positive outcomes. The present study found inconsistent and infrequent measurement of levels, which was not in accord with recommended practice. Frequent monitoring of serum levels to support dosing decisions is important to inform better clinical decision making, especially when a loading strategy is used. This may explain the less than optimal outcomes (with respect to rapid resolution of mania and hospital discharge) that were found, irrespective of dosing strategy.