Mania antipsychotic drugs

SHORT-TERM TREATMENT The antipsychotic drugs are effective in acute psychoses of unknown etiology, including mania, acute idiopathic psychoses, and acute exacerbations of schizophrenia. The best studied indications are for the acute and chronic phases of schizophrenia and in acute mania. Antipsychotic drugs also are used empirically in many other neuromedical and idiopathic disorders with prominent psychotic symptoms or severe agitation. 

Divalproex sodium is comprised of sodium valproate and valproic acid. The delayed-release and extended-release formulations are converted in the small intestine into valproic add, which is the systemically absorbed form. It was developed as an antiepileptic drug, but also has efficacy for mood stabilization and migraine headaches. It is FDA-approved for the treatment of the manic phase of bipolar disorder. It is generally equal in efficacy to lithium and some other drugs for bipolar mania. It has particular utility in bipolar disorder patients with rapid cycling, mixed mood features, and substance abuse comorbidity. Although not FDA-approved for relapse prevention, studies support this use, and it is widely prescribed for maintenance therapy. Divalproex can be used as monotherapy or in combination with lithium or an antipsychotic drug.31... 

Conventional antipsychotic drugs such as chlorpromazine and haloperidol have long been used in the treatment of acute mania. More recently, atypical antipsychotic drugs including aripiprazole, olanzapine, quetiapine, risperidone, and ziprasi-done have been approved for the treatment of bipolar mania or mixed mood episodes as monotherapy or in combination with mood-stabilizing drugs.25 Aripiprazole and olanzapine are also approved for maintenance therapy. The combination of olanzapine and fluoxetine is approved for treatment of bipolar depression. Quetiapine is approved for treatment of... 

Introduced in clinical practice in the 1960s, lithium was the first mood stabilizer to be used in China. This was followed by carbamazepine and sodium valproate. For many years, these were the only treatment options available as mood stabilizers. Although lamotrigine was approved for maintenance treatment of bipolar I disorder in 2003 by FDA (Food and Drug Administration) in the USA, this indication has not yet been approved by the Chinese authorities. At present, only one atypical antipsychotic drug, risperidone, has been approved for treating acute mania (February 2005 by SFDA [State Food and Drug Administration]) in China (see Table 6.1). 

It is common for both the depressive and manic phases to occur simultaneously in what is termed a mixed state or dysphoric mania. During these mixed episodes, the patient s mood is characterized by symptoms of both a depression and mania. Mixed episodes often have a poorer outcome than classic euphoric mania and, as a rule, respond better to certain anticonvulsants and atypical antipsychotic drugs than to lithium. As many as 50% of admissions to inpatient psychiatric facilities for the treatment of manic episodes appear to be for mixed manic states. The recognition... 

Lithium remains the treatment of choice for bipolar patients who experience classic euphoric episodes of mania. Current evidence suggests that those with mixed episodes or rapid cycling episodes respond preferably to anticonvulsants or atypical antipsychotic drugs. In addition to its use as a mood stabilizer, lithium is effective in converting unipolar antidepressant nonresponders to responders. Finally, lithium may also be an effective treatment for patients with clnster headaches. 

Antipsychotic drugs, such as flupentixol and haloperidol are the mainstay of treatment for acute attacks of mania. Lithium is not indicated as it may take a few days before the drug exerts an effect. Lithium may be given concomitantly with an antipsychotic drug. 

Antipsychotic drugs are also indicated for schizoaffective disorders, which share characteristics of both schizophrenia and affective disorders. No fundamental difference between these two diagnoses has been reliably demonstrated. They are part of a continuum with bipolar psychotic disorder. The psychotic aspects of the illness require treatment with antipsychotic drugs, which may be used with other drugs such as antidepressants, lithium, or valproic acid. The manic phase in bipolar affective disorder often requires treatment with antipsychotic agents, although lithium or valproic acid supplemented with high-potency benzodiazepines (eg, lorazepam or clonazepam) may suffice in milder cases. Recent controlled trials support the efficacy of monotherapy with atypical antipsychotics in the acute phase (up to 4 weeks) of mania, and olanzapine and quetiapine has been approved for this indication. 

As mania subsides, the antipsychotic drug may be withdrawn, although maintenance treatment with atypical antipsychotic agents has become more common. Nonmanic excited states may also be managed by antipsychotics, often in combination with benzodiazepines. 

Until recently, lithium carbonate was the universally preferred treatment for bipolar disorder, especially in the manic phase. With the approval of valproate, aripiprazole, olanzapine, quetiapine, risperidone, and ziprasidone for this indication, a smaller percentage of bipolar patients now receive lithium. This trend is reinforced by the slow onset of action of lithium, which has often been supplemented with concurrent use of antipsychotic drugs or potent benzodiazepines in severely manic patients. The overall success rate for achieving remission from the manic phase of bipolar disorder can be as high as 80% but lower among patients who require hospitalization. A similar situation applies to maintenance treatment, which is about 60% effective overall but less in severely ill patients. These considerations have led to increased use of combined treatment in severe cases. After mania is controlled, the antipsychotic drug may be stopped and benzodiazepines and lithium continued as maintenance therapy. 

Bipolar affective (manic- depressive) Characterized by episodes of mania. Cyclic mania alone, rare depression alone, occasional mania-depression, usual. About 10-15% of all depressions. May be misdiagnosed as endogenous if hypomanic episodes are missed. Lithium carbonate stabilizes mood. Mania may require antipsychotic drugs as well depression managed with antidepressants. 

Pravin et al. (2004) described four patients, age 6-15, who developed mania on citalopram. One child first developed mania when exposed to fluoxetine and then again when given citalopram. Three of the children required additional treatment with lithium or antipsychotic drugs, and the fourth ended up being given ECT. 

Q5 Lithium (lithium carbonate or citrate) is administered in doses of between 0.2 and 1.5 g daily. The dose is monitored to provide a therapeutic plasma level of 0. 4-1.0 mmol l-1 12 hours after the most recent dose taken on days 4-7 of treatment. The plasma concentration is then measured every week until the dosage has been stabilized and the required concentration has remained constant for four weeks. Lithium can take several days to become effective. If a patient is suffering an acute attack of mania and is excessively disturbed, treatment with an antipsychotic drug may also be required. The antipsychotic... 

Lithium is an alkaline earth element that is used medicinally in the form of salts such as lithium chloride and lithium carbonate. Its main use is in the prevention or attenuation of recurrent episodes of mania and depression in individuals with bipolar mood disorder (manic depression). Lithium also has clearly established antima-nic activity, although its relatively slow onset of action often necessitates the use of ancillary drugs, such as antipsychotic drugs and/or benzodiazepines, at the start of therapy. If lithium alone is ineffective for recurrent bipolar mood disorder, combining it or replacing it with car-bamazepine or valproate may be of value reports with lamotrigine and olanzapine are also encouraging. 

While the efficacy of lithium alone or in combination continues to be reconfirmed, drawbacks related to adherence to therapy or genetic links to poorer outcomes have also been highlighted. For those reasons, alternatives to lithium, such as anticonvulsants and antipsychotic drugs, have often been discussed (77). However, several studies have reconfirmed the efficacy of lithium in acute mania and its equivalence to some of the newer options. 

The adverse effects of lithium in elderly patients include cognitive status worsening, tremor, and hypothyroidism. The authors suggested that divalproex is also useful in elderly patients with mania and that concentrations of divalproex in the elderly are similar to those useful for the treatment of mania in younger patients. They noted that carbamazepine should be considered a second-line treatment for mania in the elderly. A partial response would warrant the addition of an atypical antipsychotic drug. For bipolar depression, they recommended lithium in combination with an antidepressant, such as an SSRI. They also noted that lamotrigine may be useful for bipolar depression. Electroconvulsive therapy (ECT) may also be useful, but there have been no comparisons of ECT and pharmacotherapy in elderly patients with bipolar depression. 

Mania has rarely been associated with classic neuroleptic drugs, but has been described in patients treated with new antipsychotic drugs, especially risperidone (SEDA-22, 69). Several cases of mania, presumably associated with olanzapine, have been reported (99,137-144). The mechanism is not clear. It has been suggested that olanzapine could lead to manic symptoms in patients with schizophrenia because of its potent anti-5HT2A action. 

Clonazepam is a benzodiazepine that is used predominantly in epilepsy, panic disorder, and mania, and also appears to be effective in relieving antipsychotic drug-induced akathisia (1). The use of clonazepam in psychiatric disorders is complicated by significant drowsiness in a majority of patients, and additional behavioral problems in children (SEDA-19, 34). 

Antipsychotic drugs are used for the prophylaxis and acute treatment of psychotic illnesses including schizophrenia and psychoses associated with depression and mania. They also have an important role as an alternative or adjunct to benzodiazepines in the... 

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