Antipsychotics in acute mania

Abstract

The use of antipsychotic agents in the treatment of mania was first reported by Delay et al. (1952) almost half a century ago. In their original publication, Delay and co-workers (1952) described the benefits of chlorpromazine in five patients who were severely agitated, three of them suffering from psychotic mania. They suggested that antipsychotic agents were lifesaving, as their use prevented the exhaustion and dehydration secondary to severe agitation. Antipsychotic agents therefore represent the oldest pharmacological treatment for acute mania, not only for those suffering from schizophrenia, but also those suffering from bipolar disorder. In the 1950s and 1960s chlorpromazine was instrumental in the treatment of the severely mentally ill. Prior to 1980, when DSM-III was published, the boundaries between schizophrenia and bipolar disorder in the United States were unclear. The US/UK diagnostic study highlighted the lack of clarity in the differential diagnosis of schizophrenia and bipolar disorder (Cooper et al. 1972). It is possible that many patients treated with antipsychotics at that time would be diagnosed as bipolar using modern criteria. In the 1970s, when lithium became available in the United States, the use of antipsychotics became a second option, primarily because of their adverse effect potential. In the late 1980s and early 1990s the use of the anticonvulsant divalproex sodium further relegated the use of antipsychotic agents. More recently, with the availability of new atypical antipsychotic agents, a renewed interest in antipsychotic agents has evolved in the field. This chapter will review the use of both typical and atypical antipsychotic agents in the treatment of acute mania.