Mania prophylactic treatment

Carbamazepine is effective in both acute and prophylactic treatment of mania (Weisler et al. 2005). An extended-release formulation of carbamazepine, available since 1997 for treatment of epilepsy, was approved in 2004 under the brand name Equetro. Extended-release preparations are preferred because simplified dosage schedules facilitate patient adherence. Other extended-release carbamazepine preparations include Tegretol XR and Carbatrol, although neither has been specifically indicated for the treatment of bipolar disorder. The longer-acting preparations are also of benefit because they tend to have fewer gastrointestinal side effects. 

Antipsychotic drugs commonly have been used empirically to manage manic and psychotic illness in bipolar disorder patients. Indeed, standard neuroleptics are a mainstay of the treatment of acute mania (only chlorpromazine is FDA-approved for this indication, although haloperidol has also been widely used) and for manic episodes that break through prophylactic treatment with LF or an anticonvulsant. However, the older antipsychotics are not used routinely for long-term prophylactic treatment in bipolar disorder because their effectiveness is untested, some may worsen depression, and the risk of tardive dyskinesia in these syndromes may be higher than in schizophrenia. 

Several modem, better-tolerated antipsychotic agents (olanzapine, quetiapine, and risperidone) have recently received FDA approval for use in acute mania. There is also evidence of antimanic efficacy for aripiprazole and ziprasidone. Olanzapine is FDA-approved for its long-term effectiveness in bipolar disorder 1. Other atypical antipsychotic drugs are under investigation for long-term prophylactic treatment of bipolar disorder. 

Lithium has been used clinically for many years in the treatment of mania (Dl, S27), and latterly as a prophylactic in recurrent depression (Bl, B2, CIO, H16). For a short while, about 1948, lithium salts were sold as a common salt substitute for patients on low sodium intake diets, but its high toxicity, culminating in a number of deaths, led to its discontinuance for this purpose. 

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... 

Bipolar patients treated under typical clinical conditions may have a more difficult posthospital course than has been generally appreciated. Mander ( 168), for example, reported on 2745 bipolar patients initially admitted because of an episode of mania or depression, and found that lithium did not reduce the readmission rate within 3 months of discharge. As a result, he proposed that its full prophylactic effect may not occur for 6 to 12 months after the start of treatment, and that it should be reserved for long-term prophylaxis in those who have had a number of severe episodes in a defined period of time. 

Clinicians rely on measurements of serum lithium concentrations for assessing both the dosage required for treatment of acute mania and for prophylactic maintenance. These measurements are customarily taken 10-12 hours after the last dose, so all data in the literature pertaining to these... 

The mood stabilizer lithium was developed as the first treatment for bipolar disorder. It has definitely modified the long-term outcome of bipolar disorder because it not only treats acute episodes of mania, but it is the first psychotropic drug proven to have a prophylactic effect in preventing future episodes of illness. Lithium even treats depression in bipolar patients, although it is not so clear that it is a powerful antidepressant for unipolar depression. Nevertheless, it is used to augment antidepressants for treating resistant cases of unipolar depression. 

Lithium was introduced into modern psychiatric practice in the 1950s and for decades it was the only drug that was thought to have a specific effect on the psychiatric condition known as manic depression. At first it was viewed as a specific treatment for an acute episode of mania and later it was proposed to have prophylactic properties against recurrence of future episodes. It continues to be recommended for the treatment of acute mania, although it is rarely used alone in such circumstances. It is most commonly prescribed for the prophylaxis, or prevention of recurrence, of manic-depressive episodes. 

Atypical antipsychotics such as aripiprazole, olanzapine, que-tiapine, risperidone, and ziprasidone are effective as monotherapy or adjunctive therapy with lithium and valproate in the treatment of acute mania. Some antipsychotics have the potential to cause adverse effects such as extrapyramidal reactions, sedation, depression, emotional blunting, sexual dysfunction, weight gain, and orthostatic hypotension. Prophylactic use of antipsychotics may be needed for some patients with recurrent mania or mixed states, but the risks versus benefits must be weighed because of long-term adverse effects (e.g., obesity, type 2 diabetes, hyperlipidemia, hyperprolactinemia, cardiac disease, and tardive dyskinesia). ... 

Similarly, the authors of a review of published randomized comparisons of lithium and carbamazepine concluded that the two drugs are equivalent in both acute and prophylactic efficacy [4 ]. Carbamazepine was associated with fewer withdrawals due to adverse effects in acute mania, while with lithium there were fewer discontinuations during maintenance treatment. 

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