This review shows that lithium and valproate have comparable anti-manic effects. However, manic patients who respond well to lithium are euphoric but manic patients who respond poorly to lithium have more than 10 past recurrences, are in a mixed state and/or have dysphoric mood and mood-incongruent psychotic features such as delusions of persecution. Valproate exhibits greater anti-manic efficacy than lithium in manic patients with a higher number of past recurrences and may be effective for patients with mixed conditions and rapid cycling. The antidepressant effects of both lithium and valproate are modest, and may necessitate concomitant lamotrigine and/or switching. Lithium may afford more prophylactic efficacy than valproate. Positive predictors for lithium prophylaxis are an episodic pattern of mania-depression-interval and a high age of illness onset, while negative predictors are a high number of previous hospitalizations, an episodic pattern of depression-mania-interval, and continuous cycling. Checking these predictors in order to determine whether lithium or valproate should be selected would appear to be useful. In addition, even very low levels of lithium in drinking water may contribute to a reduction in suicide risk in the general population. In conclusion, both lithium and valproate are useful in the treatment of bipolar disorders, and several measures exist for differentiating their clinical positioning.

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Purpose: Clozapine has been reported to be effective for refractory schizophrenic patients. However, there have been few reports investigating whether clozapine responders are likely to suffer from more or fewer extrapyramidal symptoms. The aim of the present study is to investigate the association between clinical effects of clozapine and extrapyramidal symptoms in clozapine-treated patients.
Methods: Ten patients were divided into Improvement Group with CGI-I scores ranging from 1 to 3 and Non-improvement Group with CGI-I scores ranging from 4 to 7. The Drug-Induced Extrapyramidal Symptoms Scale (DIEPSS) scores were compared between these two groups just before starting clozapine treatment and after 12 weeks of clozapine treatment.
Results: Although there was no significant difference in any DIEPSS scores between Improvement Group and Non-improvement Group just before clozapine treatment, Improvement Group had significantly fewer extrapyramidal symptoms in DIEPSS scores than Non-improvement Group after 12 weeks of clozapine treatment. Moreover, there was a significant interaction between overall severity of extrapyramidal symptoms assessed by DIEPSS and improvement measured by CGI-I across the 12 weeks of clozapine treatment.
Discussion: These findings suggest that clozapine responders are less likely to suffer from extrapyramidal symptoms.

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Aim: To investigate the metabolic effects of atypical antipsychotics with or without sodium valproate (VPA) supplementation
Methods: The anthropometrics and metabolic markers were reviewed in 132 Japanese psychotic patients treated with olanzapine, paliperidone, or aripiprazole. The outcome values and triglyceride (TG)/high-density lipoprotein cholesterol (HDL-C) ratios reflecting insulin resistance were compared at baseline and at 3 and 6 months in VPA-non-using (-VPA) patients and VPA-using (+VPA) patients for each atypical antipsychotic.
Results: There were significant increases relative to baseline in body mass index (BMI) at 6 months in olanzapine/-VPA patients, and higher TG levels at 6 months in olanzapine/-VPA patients, olanzapine/+ VPA patients, and paliperidone/-VPA patients. The TG/HDL-C ratio at 6 months was significantly higher in olanzapine/+VPA patients and olanzapine/-VPA patients. Aripiprazole had no significant effects on these markers irrespective of whether or not VPA was used.
Conclusion: Sodium valproate may produce different metabolic effects on body weight, lipid levels, and insulin resistance when combined with various atypical antipsychotics.

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We present the case of an epileptic patient who experienced risperidone-induced hyperprolactinemia with chronic renal failure under hemodialysis. Her prolactin level was 1058 ng/ml, which was unexpectedly high. Because prolactin is mainly excreted in the urine, clinicians should pay more attention to chronic renal failure as one of the risk factors of hyperprolactinemia when prescribing risperidone.

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