ACUTE MANIA - PRACTICAL THERAPEUTIC GUIDELINES

Several psychoactive drugs have been shown to be effective in the trea tment of acute manic syndromes. In clinical practice, antipsychotics a re the most commonly used medications, although they are associated wi th several adverse effects, namely extrapyramidal symptoms, which may interfere with patient compliance. Therefore, their use should be rest ricted to severe cases of mania, in which patients have a lack of insi ght and concomitant psychotic features. Alternative antimanic drugs [l ithium and anticonvulsants such as carbamazepine and, in some cases, v alproic acid (sodium valproate)] can effectively be used in compliant patients, especially at the beginning of manic episodes or in hypomani a. However, anticonvulsants lack sedative effects and lithium has a de layed onset of antimanic effects. Nevertheless, these disadvantages ca n be overcome by the short term concomitant use of low potency antipsy chotics or benzodiazepines. This provides effective sedation with mini mal unpleasant adverse effects and (with short term use of benzodiazep ines) risks for the development of dependency. Previously untreated ou tpatients in the early stage of hypomania should be treated with slowl y increased doses of lithium or carbamazepine, assisted by low potency antipsychotics or benzodiazepines to provide sedation and improve sle ep, In noncompliant patients or those with manic syndromes with pronou nced psychotic features, high potency antipsychotics (oral or depot fo rmulations) may have to be used. In outpatients who relapse into mania while receiving prophylactic lithium or carbamazepine, the dosage of either drug should be increased in parallel with the measures suggeste d for previously untreated patients. Inpatients can be effectively tre ated with rapidly increasing doses of carbamazepine suspension and the use of higher doses of sedative medication. In some patients with tre atment-resistant mania, the combination of lithium with antipsychotics may augment therapeutic efficacy, while a minority of patients may re quire electroconvulsive therapy.