The Effectiveness of High-Dosage Amisulpride Combined With Moderate-Dosage Sodium Valproate Treatment for an Overweight Patient With Psychotic Bipolar Disorder

To the Editor: Several atypical antipsychotics were approved for the treatment of bipolar affective disorder.¹ However, the data of amisulpiride in this field is still limited. I want to share a case of psychotic bipolar disorder with successful control of symptoms under the combined treatment of high-dosage amisulpiride and moderate-dosage sodium valproate.

Case Report

Miss Y is an overweight case of psychotic bipolar disorder with unstable symptom control under several atypical antipsychotics, such as olanzapine, risperidone, quetiapine, or aripiprazole in recent 2–3 years. She also received several mood stabilizers, such as lithium or sodium valproate, but with undesirable body weight gain side effects. The bipolar symptoms (mostly mania) and psychotic symptoms (delusion of reference) still did not respond to the above medications [Young Mania Rating Scales (YMRS) scores: 36; Brief Psychiatric Rating Scale-18 (BPRS-18) scores: 38]. The medications were abruptly switched to amisulpiride 800 mg/day with sodium valproate 1000 mg/day to avoid previous body weight gain side effects under high dose of sodium valproate [body mass index (BMI): 31.21]. Her symptoms improved with residual delusion of reference and irritability after 3 weeks of the above-mentioned therapy (YMRS scores: 15; BPRS-18 scores: 20). She requested for more amisulpiride to control residual symptoms; the dose of amislpiride was increased to 1000 mg/day with significant improvement since the use of amisulpiride and sodium valproate for 6 weeks (YMRS scores: 9; BPRS scores: 12). No intolerable side effects were mentioned under high-dosage amisulpiride combined with moderate-dosage sodium valproate (BMI: 29.98). There was no relapse of symptoms under this regimen at the next 3-month follow-up.

Discussion

The role of atypical antipsychotics in manic phase is discussed and compared with typical antipsychotics in recent years.^1,2 Even though there is some controversy about the intolerable side effects and the efficacy of atypical antipsychotics,² the lower relapse rate of mania during maintenance therapy of atypical antipsychotics is still an advantage for bipolar disorder treatment.¹ Yatham mentioned that atypical antipsychotics, such as olanzapine, quetiapine, ziprasidone, aripiprazole, and risperidone, can be an alternative to or combined with the mood stabilizers.^3,4 However, among the atypical antipsychotics, there is no well-controlled study of amisulpiride for bipolar disorder. In this case, the effectiveness of 1000 mg/day amisulpiride in the control of psychotic and manic symptoms has been shown with combination of 1000 mg/day sodium benzoate. The dopamine-related pathophysiology of bipolar disorder are dopamine D2 and D3 receptors.^5,6 As we know, amisulpiride is a compound with actions over dopamine D2 and D3 receptors,⁷ the treatment effect might be associated with dopamine mechanisms. Amisulpiride has a favorable profile for metabolic syndrome or body weight gain side effects, which is an unfavorable consequence of previous antipsychotics in this patient. To my knowledge, this is the first case report about high-dosage amisulpiride combined with medium-dosage sodium valproate for bipolar disorder. It can be an option for our patients while facing such dilemma of treatment.