Comparison of tremor induced by valproate and lithium in bipolar disorder using a hand steadiness tester

Mohua Sengupta, Prathama Guha, Prithwijit Banerjee, Suhrita Paul, Ritasman Baisya, Kaveri Bhattacharya


Background: Quantitative measurement of valproate and lithium induced tremor using hand steadiness tester and their comparison in bipolar disorder.

Methods: 200 newly diagnosed patients of bipolar disorder were randomly allocated into two equal groups receiving lithium (300mg twice daily) and sodium valproate (500 mg twice daily) after they fulfilled the inclusion / exclusion criteria of the study. 87 patients from Lithium group and 93 from Valproate completed the study.  Hand Tremor was assessed quantitatively at 0, 6, 12, 18 and 24 weeks using hand steadiness tester. Anxiety level of the study subjects was assessed to be insignificant using a standardized anxiety scale.  Final data was assessed after 24 weeks by using Stat Calc and Z test. P value <0.05 was considered to be significant.

Results: No significant difference was found in terms of the development and transition of tremor induced by valproate and lithium (p=0.22).  However more men developed tremor with lithium when compared with females (p<0.05) and the mean age of patients who developed tremor appeared to be significantly higher in lithium group (54.7±3.9) than valproate (39.6±5.1).

Conclusions: Tremor of hands is a common side effect of lithium and valproate treatment. Timely, objective assessment of onset and extent of tremor has always remained a challenge to the clinicians. Hand Steadiness tester is a simple, portable, inexpensive, non-invasive instrument that can be used to ascertain the development and transition of tremor in a quantitative manner. This would guide the clinicians as when to intervene for better management of such tremors.


Tremor, Lithium, Valproate, Hand Steadiness Tester

Full Text:



Victor I Reus. Mental disorders. In Fauci, Braunwald, Kasper, Haiser, Longo, Jameson, Loscalzo. Harrison’s Principles of Internal Medicine. 17th Edition. New York: Mc Graw Hill; 2008: 2710-2723.

Poolsup N, Li Wan Po A, de Oliveira IR. Systematic overview of lithium treatment in acute mania. J Clin Pharm Ther. 2000;25 (2):139–56.

Tripathi KD. Drugs used in mental illness: Antipsychotic and antimanic drugs. In Essentials of medical pharmacology, 6th Edition. Jaypee Brothers Medical Publishers (P) Ltd.; 2008: 423-438.

N.Ferrier, S.P.Tyrer & A.J.Bell. Lithium therapy. Advances in Psychiatric Treatment. 1995;1:102-10.

Arbaizar B, Gómez-Acebo I, Llorca J. Postural induced-tremor in psychiatry. Psychiatry clin neurosci. 2008;62(6):638-45.

Canning JE, Burton S, Hall B. Lithium and Valproate-Induced Tremors. Ment Health Clin. 2012;1(7):19.

Beuter, A., Edwards, R., Degeoffroy A., Margler, D. Andhundell, K. Quantification of neuromotor function for detection of the effects of manganese. Neurotoxicity. 1999;20:355–66.

Caligiuri, M. P., Jeste, D. V., and Lacro, J. P. Drug induced movement disorders in the elderly: epidemiology and treatment recommendations. Drugs and Aging. 2000;17:363–84.

Gelenberg AJ and Jefferson JW. Lithium Tremor. Journal of Clinical Psychiatry. 1995;56:283 –7.

Gelenberg AJ, Kane JM, Keller MB et al. Comparison of standard and low serum levels of lithium for maintenance treatment of bipolar disorder. N. Engl. J. Med. 1989;321:489–93.

Carroll JA, Jeffersion JW, Greistjh. Treating tremor induced by lithium. Hospital and Community Psychiatry. 1987;38:1280-8.

Van Putten T. Lithium-induced disabling tremor. Psychosomatics Canadian Medical Association Journal. 1976;114:619-24.

Vestergaard P. Clinically important side effects of long-term lithium treatment: A review. Acta Psychiatr Scan. 1983;supp305.

Rinnerthaler M, Luef G, Mueller J, Seppi K, Wissel J, Trinka E, Bauer G, Poewe W. Computerized tremor analysis of valproate-induced tremor: a comparative study of controlled-release versus conventional valproate. Epilepsia. 2005:46(2):320-3.

Karas BJ, Wilder BJ, Hammond EJ, Bauman AW. Treatment of valproate tremors. Neurology. 1983;33(10):1380-2.

Elble RJ, Koller WC. Tremor. Baltimore: The Johns Hopkins University Press; 1990.