Mania pharmacological treatment

According to the Expert Consensus Panel for Mental Retardation Rush and Frances, (2000), the mainstays of the pharmacological treatment of acute mania or bipolar disorder in adults are anticonvulsant medications (divalproex, valproic acid, or carbamazepine) or lithium. Both divalproex or valproic acid and lithium were preferred treatments for classic, euphoric manic episodes. Divalproex or valproic acid was preferred over lithium and carbamazepine for mixed or dysphoric manic episodes and rapid-cycling mania. For depressive episodes associated with bipolar disorder, the addition of an antidepressant (SSRI, bupropion, or venlafaxine) was recommended. According to the Expert Consensus Panel, the presence of MR does not affect the choice of medication for these psychiatric disorders in adults. 

From the above discussion, it appears that both lithium and valproate are equally effective pharmacological treatments for acute mania. Lithium is also established as an effective prophylactic agent, particularly for prevention of... 

Keck PE Jr, McElroy SL, Tugrul KC, et al Valproate oral loading in the treatment of acute mania. J Clin Psychiatry 54 305-308, 1993 Keck PE Jr, McElroy SL, Strakowski SM, et al Pharmacologic treatment of schizoaffective disorder. Psychopharmacology 114 529-538, 1994 Keller MB Chronic and recurrent affective disorders Incidence, course, and influencing factors, in Chronic Treatments in Neuropsychiatry. Edited by Kemah D, Recagni G. New York, Raven, 1985... 

Mania may develop as a consequence of a general medical condition (see figure 6-A) or as a result of pharmacologic treatment (see figure 6-B). 

Botteron, K. N., Geller, B. (1995). Pharmacologic treatment of childhood and adolescent mania. Child and Adolescent Psychiatric Clinics of North America Pediatric Psychopharmacology II, 283-302. 

Clinical experience with various pharmacological regimens (mainly mood stabilizers) has suggested that a drug that is efficacious in one manifestation of mania is not necessarily the treatment of choice for the overall spectrum of manic states. Much progress have been made in the treatment of acute manic states, especially since the demonstrated efficacy of the second-generation antipsychotics (e.g. olanzapine, quetiapine, and risperidone) for the treatment of acute mania. However, treatment of acute manic states remains incomplete, and new treatment strategies are in continuous development. ... 

There is, however, a unique risk in the bipolar form that antidepressant treatment may trigger a switch into mania. This may occur either as the natural outcome of recovery from depression or as a pharmacological effect of the drug. Particular antidepressants (the selective serotonin reuptake inhibitors) seem less liable to induce the switch into mania than other antidepressants or electroconvulsive therapy. Treatment for mania consists initially of antipsychotic medication, for instance the widely used haloperidol, often combined with other less specific sedative medication such as the benzodiazepines (lorazepam intramuscularly or diazepam orally). The manic state will usually begin to subside within hours and this improvement develops further over the next 2 weeks. If the patient remains disturbed with manic symptoms, additional treatment with a mood stabilizer may help. 

Treatment of depressive episodes in bipolar disorder patients presents a particular challenge because of the risk of a pharmacologic mood switch to mania, although there is not complete agreement about such risk. Treatment guidelines suggest lithium or lamotrigine as first-line therapy.17,41 Olanzapine has also demonstrated efficacy in treatment of bipolar depression, and quetiapine is under review for approval of treatment of bipolar depression.42 When these fail, efficacy data support use of antidepressants. 

Baldessarini, R., Drugs and the treatment of psychiatric disorders depression and mania, in Goodman and Gilman s The Pharmacological Basis of Therapeutics, 9th ed., Hardman, J.G. and Limbird, L.E., Eds., McGraw-Hill, New York, 1996,... 

Secunda SK, Katz MM, Koslow SH, et al Mania diagnosis, state measurement and prediction of treatment response. J Affect Disord 8 113-121, 1985 Seeman MV Neuroleptic prescription for men and women. Social Pharmacology 3[3) 219-236, 1989... 

Manji, H. K., Moore, G. J. and Chen, G. Lithium at 50 have the neuroprotective effects of this unique cation been overlooked Biol. Psychiat. 46 (1999) 929-940. McElroy, S. L. and Keck, P. E. Pharmacological agents for the treatment of acute bipolar mania. Biol. Psychiat. 48 (2000) 539-557. 

McElroy S, Keck P (2000) Pharmacological agents for the treatment of acute bipolar mania. Biol Psychiatry 48 539-557. 

Phenothiazines are tricyclic compounds tliat have chemical and pharmacological properties in common with the tricyclic antidepressant drugs (Figure 34-13 see also previous section on Tricyclic Antidepressants). They are primarily used for their neuroleptic (behavior modifying) properties in the treatment of severe psychiatric iUness (psychoses and mania). In addition, phenothiazines are administered to control nausea and vomiting, for sedation, and for potentiation of analgesia and general anesthesia. ... 

Baldessarini RJ Tarazi FI. Drugs and the treatment of psychiatric disorders. Psychosis and mania.In Hardman JG, Limbird LE, Gilman AG, eds. Goodman and Gilman s the pharmacological basis of therapeutics. 10 ed. New York McGraw-Hill, 2001 485-520. 

Pharmacology and Mechanism of Action. Typical (conventional) antipsychotic agents that block DA2 receptors and newer atypical antipsychotics that block both DA2 and 5-HT2a receptors are used to decrease DA activity in the treatment of mania and mixed states. 

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