Valproate | Mood Stabiliser For Mania

Medication name

Valproate ("VAL-pro-ate")
Brand name

Depakote ("DEP-a-coat"), Episenta (“EP-i-sen-ta”), Epival (“EP-i-val”), Epilim (“EP-i-lim”) , Dyzantil (“DI-zan-til”)
Medication type

Mood stabiliser

Tablets: Valproate semisodium (Depakote) is available as tablets (250mg and 500mg strengths)

Sodium valproate, if used, is available as crushable tablets (100mg strength), gastro-resistant (enteric-coated) tablets (200mg and 500mg), controlled release tablets (150mg, 200mg, 300mg and 500mg strengths), liquid (sugar-free), syrup (both containing 200mg sodium valproate in 5ml) and granules.

If you are 18 or over, the doctor can prescribe sodium valproate (like the brand Episenta) or valproate semisodium (like the brand Depakote) for you as a licensed medicine for mania that occurs with bipolar disorder.

Epilim and Dyzantil brands are not licenced for the treatment of manic episodes in bipolar disorder, or continuation of treatment after a manic episode, but may still be prescribed.

Other preparations of sodium valproate (like the brand Epilim) are very commonly used for mania. This is because liquid forms are available which make for easier swallowing. Valproate is likely to be used longer term to help prevent the return of symptoms of mania.

Sodium valproate can also be used to treat other conditions such as severe aggression.

If you are under 18, a specialist doctor may still consider valporate as a treatment option.

Valproate is now only licensed for the treatment and prevention of a manic episode (as part of bipolar disorder) when other treatments don’t work or are not tolerated because of side effects. This has to be agreed by two specialists.

Valproate must no longer be used by anyone able to have children unless they have a pregnancy prevention programme (‘Prevent’) in place. This is designed to make sure all patients are fully aware of the risks and the need to avoid becoming pregnant.

Read our guide to mania and hypomania

About valproate

Valproate is a type of mood stabiliser used to treat bipolar disorder. With bipolar disorder, a person's mood changes from very high (mania) to very low (depression). Valproate helps to treat the symptoms of mania by reducing feelings of excitability and over-activity. It is also used to prevent these symptoms from coming back. It is less effective at preventing the symptoms of depression in bipolar disorder from returning, but there are other medicines that can help with this.

We do not fully understand how valproate works for mania and bipolar disorder, but we have some ideas about it.

Valproate blocks the breakdown of a chemical in the brain called gamma-aminobutyric acid (GABA). GABA is a chemical that calms nerve excitability in the brain. If valproate blocks its breakdown, there is more GABA to create this calming effect.

There are gateways in the brain called ‘sodium channels’, which can be open or closed. When they are open, chemicals go through that can make us excited. Valproate may also work by locking on to closed sodium channels and keeping them closed.

Valproate and everyday life

It usually only takes a few days for valproate to start working. It may take several weeks or months for you to feel the maximum effects on stabilising your mood.

If you are having a manic episode, the doctor is likely to increase your dose quite quickly over a few days.

Your dose is likely to be reduced in the longer term to get the best effect for you. This is because you are unlikely to need the same high dose as you would in a manic episode to provide longer-term benefit.

Your weight can be affected by valproate.

Valproate can make some people feel hungrier than usual. If you are eating more than usual, you can put on weight.

It is not possible to predict how valproate will affect each person before they start taking it. Talk to your doctor or pharmacist if you are concerned about your weight, or changes to your weight, while taking valproate.

Making sure you do enough exercise and eat a healthy diet (with vegetables and fibre) can help you to avoid putting on too much weight. Exercise is also good at helping with your mood.

Mental health conditions like bipolar disorder can make being active and eating healthily more of a challenge. Talk to your doctor, pharmacist and specialist healthcare team for lifestyle advice and where to get support if this would be helpful.

A common side effect of valproate is gingival disorder. This is a mild form of gum disease, also called periodontal disease. It causes irritation, redness, swelling and bleeding of your gum around the base of your teeth. You might have symptoms of swollen or puffy gums, gums that are tender and bleed easily when you brush or floss or bad breath. Make sure you brush your teeth well and have regular dental check-ups. Speak to your dentist, doctor or pharmacist about things you can do to help.

You may want to let your family and friends know you are taking valproate so they can support you and help you look out for side effects.

For guidance on this, check out our page on getting support with your medication.

Alcohol

It is recommended that you don’t drink alcohol while taking valproate because the two together might make you feel very sleepy and unsteady on your feet, especially when you first start taking the medication.

However, you may be able to drink a small amount of alcohol in moderation.

During the first few weeks of treatment, it is recommended that you don’t drink alcohol until you know how the medicine affects you.

If you want to drink alcohol, it’s best to only drink small amounts, and have a plan for getting home safely if you go out.

Drinking alcohol regularly, or in large amounts, can make your symptoms worse and may mean you won’t get the maximum benefit from your medication.

Street drugs

There are many different street drugs, but we don’t know what effect taking them with valproate will have, so it’s best to be cautious. Taking them together could result in the risk of overdose as well as other dangers like blacking out and not remembering what you have done. There is no regulation of street drugs or ‘legal highs’, so even if there are no known issues with the medication you take, the supply you receive might be mixed with other substances that could be dangerous.

Get more advice on our drugs and alcohol guide.

There are multiple companies that manufacture this medicine and the non-active ingredients may vary between products and also between the different strengths of tablets that are available.

Always let your pharmacist know if you have any food allergies or intolerances, and always check with them if you’re concerned about any of the ingredients in your medication.

Liquid formulations contain sorbitol and saccharin, while the syrup additionally contains sugar and should be avoided if you have diabetes.

If you need to avoid animal products, please note that non-active ingredients used in the production of medicines may sometimes be of animal origin. Ask your pharmacist if you have any questions about the ingredients.

Further information about practical considerations for medicines if you need to avoid animal products can be found on the Vegan Society website.

You may feel sleepy, confused or dizzy when you start taking valproate, which may affect your concentration when doing things like driving a car or riding a bike.

It might be best to stop driving, riding a bike or doing anything that requires a lot of focus for the first few days or weeks until you know how it affects you.

Most people drive as normal while taking valproate. If you are worried about this or have any concerns you would like to discuss, speak to your doctor or pharmacist.

You must tell The DVLA (Driver and Vehicle Licensing Agency) if you have bipolar disorder, schizophrenia, schizoaffective disorder or other mental health conditions that could affect your driving. You can be fined if you do not tell The DVLA about a medical condition that affects your driving and may be prosecuted if you are involved in an accident as a result.

Pregnancy

It is not safe to take valproate during pregnancy. It can be harmful to developing babies during pregnancy and cause a condition called Fetal Valproate Syndrome ( FVS) which can cause physical birth defects and lifelong learning and behaviour changes.

It is recommended that if you can get pregnant and are taking valproate, you must use an effective method of contraception as part of the Valproate Pregnancy prevention Programme to reduce the risk of unplanned pregnancy.

If you are prescribed valproate, talk to your doctor if you are planning to have a family so you can discuss treatment options that are best for you and your baby. Do not stop using contraception until you and your specialist have agreed on what treatment option would be best for you. They are likely to need to change you to another medicine and carefully stop your valproate.

However, if you become pregnant while you are on valproate, you should carry on taking it and make an urgent appointment to see your doctor. They can discuss the benefits and risks of continuing valproate and help you to make a decision that is best for you and your baby.

They may refer you to a specialist perinatal mental health team to support you with this decision.

You can find out more information about taking valproate during pregnancy at Bumps (Best Use of Medicines in Pregnancy).

If you are planning to get pregnant, it is recommended that you take folic acid while you are trying for a baby and during pregnancy.

Post-natal

Some newborn babies whose mothers take valproate during pregnancy can get withdrawal symptoms at birth and soon after, like feeding difficulties or restlessness.

Tell your midwife if you are taking valproate, so that they can help if the baby has any symptoms after birth.

Breastfeeding

Valproate is passed to the baby in breastmilk in small amounts.
If your baby was born early, then breastfeeding while you are taking valproate may not be recommended. Talk to your midwife and doctor about feeding options.

Tell your midwife if you are taking valproate, so that they can help if the baby has any symptoms after birth.

It’s important to remember that breastfeeding is not a form of contraception and you can get pregnant during this time. If you are taking valproate and breastfeeding, use a form of contraception. Speak to your doctor or midwife for advice.

Sex

Valproate can have side effects that may affect your sex life. These include:

breast growth (regardless of gender)
gaining weight, temporary hair loss or acne, which may affect your confidence and therefore your desire to have sex

Talk to your doctor if you get these symptoms.

Untreated illness can have a negative effect on your sex life, so if valproate helps you to recover, positive effects can include improving your desire, experience and enjoyment of intermit relationships again.

Fertility

Valproate has been shown to reduce fertility or cause infertility in men. This can be reversed if valproate is stopped.

If you are taking valproate, or have taken it in the last few months, when you conceive there might be an increased risk of your child having a neurodevelopmental disorder like autism, ADHD or a learning disability. More research is being done to understand this better.

Valproate can cause polycystic ovary syndrome (PCOS), which can lead to future infertility.

Valproate should not be taken by anyone who can get pregnant unless they are on the Valproate Pregnancy Prevention Programme (Prevent).

If you want to start a family and are taking valproate, you must speak to your doctor about your treatment options. Do not stop taking your contraception until you have spoken with them.

Valproate is not a banned substance in sport.

Most people play sports as normal while taking valproate, but if valproate affects your concentration, eyesight or co-ordination, then you may want to wait to see if those effects go away before playing sports that need a lot of focus. If you have any concerns, discuss this with your doctor.

Valproate may affect your concentration, make you feel sleepy or make it harder to remember things.

Ideally it is best not to take valproate for the first time just before your exams.

It is not possible to predict how the medication will make you feel, and if you do get any side effects, these are more likely to occur when you first start taking valproate.

You should talk to your doctor about any future exams if you are starting valproate. You might decide together to delay starting it until you have done them. If they are more than a month away, however, you might find that it is better to start valproate to improve your motivation to study.

Most people take exams as normal while taking valproate, but if you have concerns, discuss this with your doctor.

Information and safety considerations

Your doctor will consider any other medical conditions or symptoms you have before recommending a medicine for you.

Your medicine will come with a ‘patient information leaflet’. It’s important that you read this information. Speak to your pharmacist if:

you’re not given a leaflet
you don’t understand the information
you need it in a different format or language
you’re concerned about something you’ve read

The information leaflet also includes a list of warnings and precautions to consider before you take the medicine. If you think that any of these apply to you and are concerned that your doctor is not already aware of them, check with your doctor or pharmacist before you start to take your medication (or as soon as possible if you are already taking it).

Uses, warnings, safety and side effects

Taking valproate

You will need to take valproate for at least several months after you feel better, otherwise your symptoms can come back.

Your doctor will advise you how long you'll need to stay on valproate, as it depends on what you are taking it for. If you are taking it to prevent the symptoms of mania from coming back, it might be about six months.
If you stop taking the valproate too soon, there is more chance that your symptoms will come back.

For bipolar disorder the longer-term use of medicines can reduce the chance of you becoming ill again. Valproate can be used as a long-term medicine, but there are other choices too. You should discuss your options with your doctor.

You will get the most benefit from your valproate if you take it regularly every day.

You may start with a low dose that increases slowly to your regular dose over the next few days.

Valproate semisodium is normally taken twice a day but sometimes it may be three times a day.

The starting dose is normally 750mg per day but will probably be increased to between 1000mg and 2000mg a day.

The controlled-release capsules or tablets should be swallowed whole with a glass of water and not crushed or chewed.

The controlled-release granules can either be sprinkled on a small amount of soft cold food, taken in a drink, or poured directly into the mouth and washed down with a cold drink. If the granules are added to a drink, after you’ve had the drink, the glass should be rinsed with a small amount of water and you should drink this water as well, as some granules may stick to the glass. The granules should not be crushed or chewed.

Controlled-release medicines might help you if you find it difficult to remember all the doses and would otherwise need to take doses at school, university or work.

Valproate can be taken with or after a meal. Taking it with food can help to reduce the chance of feeling sick. Not everyone feels sick with valproate, but this is one of the possible side effects.

Some of the valproate preparations have a special coating (“enteric” or “gastro-resistant” coating) to protect the tablet from stomach acid. This tablet should be swallowed whole with a glass of water – do not chew it as it tastes bitter and you will break the protective coat.

If you remember later during the day, take it as soon as you remember, unless you are less than four hours away from your next dose. If you forget to take it by then, just start again with the next dose. Do not try and catch up by taking a double dose.

If you forget to take it for a few days, you may start getting your symptoms back and should talk to your doctor about it.

Once you start taking valproate, the brain adjusts to having its calming effect. If you stop taking the valproate all at once, the chemical balance in your brain starts to change again, meaning you could get your old symptoms back.

However, you can stop taking valproate safely with your doctor’s help.
When you agree with your doctor to stop the medicine, you will carry on with a dose that gradually decreases over about a month.

Warnings and safety

If you have taken more than the dose prescribed by your doctor, contact NHS 111 immediately to ask for advice, or ask a family member or friend to do this for you. This is important even if you don’t feel any different.

NHS 111 can give you advice and direct you to the best place to get more help if you need it.

If you have taken too much medication on purpose, or if after taking this you quickly feel unwell, call 999 or get someone to take you to A&E straight away. This includes:

being sick
headache
blurred eyesight
confusion and tiredness
weak or ‘floppy’ muscles, with no reflexes
seizures or fits
loss of consciousness (blackouts)
behavioural changes
breathing difficulties such as fast breathing, shortness of breath or chest pain

If you need to go to A&E, do not travel alone or drive yourself there. Get your parent, family member or friend to go with you to support you and keep you safe on the way. If someone is not able to drive you there, call for an ambulance. Take your medication with you and tell doctors how much you have taken.

Suicidal thoughts

Changes in mood as part of bipolar disorder (and other mental illnesses) can sometimes cause you to have thoughts about hurting yourself or taking your own life. While uncommon, this could also be a side effect of your medicine. These thoughts may happen or get worse in the first few weeks of taking (or stopping) your medication. This can happen to anyone but is more likely to happen if you are under 25 years old.

If you have any thoughts like this, it is important you get urgent help. Contact your doctor immediately for advice and support. This could be your GP or specialist mental health team. If you are able, share how you are feeling with family member or friend as well so they can support you to get help.

If you discussed with your doctor what to do if you get these thoughts and created a safety plan, read this to remind you who to contact for support and what you can do to help you cope.

Read our guide to suicidal feelings

Serious side effects

Valproate can cause rare but serious side effects, including allergic reactions.

If you get or think you could be having an allergic reaction or potentially life-threatening skin reaction, get urgent medical advice from your doctor straight away, or go to hospital. This includes:

skin rash or skin lesions with a pink/red ring and a pale centre which may be itchy, scaly or filled with fluid
blistering, peeling or bleeding on any part of your skin (including your lips, eyes, mouth, nose, genitals, hands or feet) with or without rash, sometimes with flu-like symptoms such as fever, chills or aching muscles)
joint pain
fever
swallowing or breathing problems
swelling of your lips, face, throat or tongue
swelling of your hands, feet or genitals

Stop taking valproate and go to a doctor or hospital straight away if you get any of the following symptoms (which may be signs of a problem with your liver or pancreas):

feeling weak, general feeling of being unwell
loss of or decreased appetite
feeling drowsy, confused or tired
oedema (swelling of your feet and legs)
nausea (feeling sick) or vomiting (being sick)
stomach pain, which may feel very bad and reach through to your back
jaundice (eyes or skin going yellow)

Stop taking valproate and go to a doctor or hospital straight away if you get any of the following symptoms (which may be signs of a problem with your blood cells):

feeling weak, tired, faint, dizzy or having unusually pale skin
bruising more easily, or unusual bruising or bleeding
getting more infections than usual with fever, severe chills, sore throat or mouth ulcers

Contact your doctor immediately but don't stop taking valproate, if you get any of the following symptoms:

unusual behaviour, including being very alert, and sometimes also aggressive and/or hyperactive
swollen arms or legs (water retention)
bleeding a lot if you cut yourself
loss of consciousness (blackouts)
hallucinations (seeing or hearing things that are not there)
memory problems, difficulty performing mental tasks, being unable to concentrate
difficulty in speaking, or slurred speech
muscle weakness, lack of co-ordination, muscle twitching or sudden jerks and shaking
seizures or fits (for patients with epilepsy)

If you are unable to contact your doctor, contact NHS 111 for urgent advice.

Side effects and your health

Side effects are more common when you first start taking valproate. Many go away as you continue your medicine. If they don’t get better, or if you are worried by them and they are causing you distress, speak to your doctor or pharmacist about them.

Very common side effects of taking valproate (affecting more than one in ten people) include:

nausea (feeling sick)
tremor (shakes)

Common side effects (affecting up to one in ten) include:

short-term hair loss – expect regrowth within six months but likely to be more curly
painful periods
weight gain
gingival disorder
diarrhoea
tiredness
headache
blurred vision

There are other side effects that you can get when taking this medicine. We have only included the most common ones here.

This list of side effects can look scary. You may not experience any of them, but it’s important to be aware of them so you know what to do if they do happen.

Unless your side effects are very severe or distressing, try to continue taking your medication until you can talk to your doctor. Your doctor can make changes to your medication to help if needed.

Uncommon but important side effects to be aware of include thoughts of harming yourself, thinking about taking your own life or trying to take your own life. This may be a symptom of your illness, including depression, but may be a side effect of medication. If you experience these thoughts, contact your doctor to seek immediate support to keep you safe.

Your doctor will make sure you are monitored carefully for these side effects, and you should decide with your doctor what to do if you experience these feelings while taking valproate. It’s a good idea to write these plans down and keep them somewhere safe.

If you are taking valproate and have not talked about this with your doctor, go back to them and talk it through. You might also want to talk to your parents, family member or friend about it too.

Before starting valproate, your doctor will check that your blood, liver and kidneys are healthy and functioning normally. This will require a blood test.

Your doctor will recommend regular monitoring while you are taking valproate (for example after six months and then once a year).
Your doctor might also check your weight and discuss any concerns you have about weight gain if this has affected you.

It is very important to go for these checks when you are asked to do so. If you are worried or anxious about the monitoring, talk to your doctor, care team or practice nurse about this for advice and support.