Recently I've had a patient with slight tremor, delirium, and confusion instaled durring high lithium carbonate associated with venlafaxine and duloxetine în mid range dosage.
After withdrawal of lithium in favor of valproate and 5 mg of olanzapine, after a week of fatigue and sleepines, I've withdrawn olanzapine, and pacient became functional.
After a week of low dosage of venlafaxine and duloxetine, whom would've been witdrawn after a month, in favor of valproat and lorazepam pacient became reastless, with mild simptoms of hypomania.
Question is If antiphychotic treatment and low dosage lithium seem more usefull having in mind the sever symptoms of dowsiness?
A little more information would be helpful, but in general, it sounds as though your patient benefitted from the switch to valproate, but showed signs of hypomania when the antidepressants were added/increased. In most US settings, one can obtain serum levels for both lithium and valproic acid, which can be helpful in guiding dosage (do you have levels?). It can be a very good strategy to find which mood stabilizer is best tolerated and most effective for each patient (it might be valproate in your patient's case), and then to add one antidepressant when mood becomes depressed (and withdraw it when mood improves. Similarly, one might add a second-generation antipsychotic like olanzapine when manic symptoms appear, and taper it when they ease. Best of luck.
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