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Abstract
Until now, in various parts of the world, no consensus has been reached with regard to the treatment of acute mania. Controlled clinical trials have at last provided irrefutable evidence for the effectiveness of lithium, which had long been used alone, as well as that of divalproate or its derivatives and, to a lesser extent, carbamazepine (1). In Europe, haloperidol is still the reference compound used in clinical trials while it has never been officially approved in the treatment of mania. In the USA, lithium, divalproate, or second-generation-antipsychotics can be prescribed as first-line treatments. As dopamine was reported to be involved in the pathophysiology of mania in the 1970s and as changes in dopaminergic neurotransmission have consistently been reported in bipolar disorders (BDs), the question of the antimanic properties of antidopaminergic drugs such as antipsychotics is a fair one (2).
Highlights
Until now, in various parts of the world, no consensus has been reached with regard to the treatment of acute mania
The Europeans consider mania to be more of a mood episode and prefer lithium as first-line treatment, whereas the Americans believe that psychotic symptoms dominate and widely use antipsychotic agents
This meta-analysis is in agreement with a previous one (16) focusing mainly on second-generation antipsychotic monotherapy in acute mania but in this latter study there was no comparison with classical antipsychotics
Summary
Antipsychotic and mood stabilizer agents and/or anticonvulsants do not appear to have equivalent effects on each of these identifiable clusters of symptoms, especially on psychotic features We think that it is vitally important for future clinical trials conducted in mania treatment to focus on the treatment effects using a factorial approach and an appropriate methodological structure. The question as to whether mood stabilizer agents such as lithium or anticonvulsants (even a combination of both) or antipsychotic agents should preferably be used as first-line treatment of mania remains unanswered and neither the American nor the European guidelines provide an entirely satisfactory answer to this crucial question These two classes can have a somewhat different impact on the underlying symptoms of mania (1).
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