DRUG-TREATMENT OF MANIA - A CRITICAL-REVIEW

While lithium is generally considered to be a first-line treatment for mania, the position of the anticonvulsants and the antipsychotics in the treatment of this disorder is currently under debate. For that rea son, this paper reviews the original literature, in particular address ing the randomized controlled trials (RCTs) on lithium, anticonvulsant s and antipsychotics, and the methodological limitations therein. As t he treatment of mania needs to anticipate the future course of the ill ness, the data on prophylaxis will also be reviewed, albeit briefly. I t is concluded that antipsychotics are powerful antimanics, which are particularly beneficial for some clinical presentations of severe mani a. However, in general their use should not be prolonged into the main tenance phase. Lithium is still to be considered the mood-stabilizing drug par excellence, although it may be insufficient in mixed states a nd severe mania. The evidence for antimanic efficacy of valproate, in particular for mixed states, seems more convincing than that for carba mazepine, while the evidence for a prophylactic action of carbamazepin e still exceeds that for valproate. Adjunctive treatment with benzodia zepines is often useful. Small sample sizes, highly selected study pop ulations and high drop-out rates seem to be the most important limitat ions of the RCTs on mania. Quasi-experimental, naturalistic studies on unselected populations are needed to investigate how the various trea tments work in clinical practice. Based on the available evidence, sum mary guidelines for treatment are proposed.