TREATMENT OF MANIA, MIXED-STATE, AND RAPID-CYCLING

Objectives: To summarize the quality of evidence for the efficacy of d ifferent biological treatments in mania, mixed state, and vapid cyclin g and to propose guidelines for treatment of these conditions. Method: Articles published on treatment of acute mania, mixed states, and vap id cycling were reviewed and rated for quality of evidence using Perio dic Health Examination guidelines. Results: Lithium and divalproex sod ium are effective in classical pure mania, whereas divalproex sodium a nd carbamazepine are likely move effective in mixed states. Divalproex sodium is likely more efficacious than carbamazepine and lithium when the mania is part of a rapid-cycling course. Typical neuroleptics are efficacious in acute mania, particularly in the presence of marked ps ychotic symptoms. Atypical neuroleptics can be useful in refractory ma nia. Some benzodiazepines do have antimanic effects, but they are incr easingly being shown to have usefulness as adjuncts to mood stabilizer s or neuroleptics rather than as primary antimanic agents. Electroconv ulsive therapy (ECT) is an efficacious and broad-spectrum treatment. C onclusions: Mania can present with or without mood-congruent or mood-i ncongruent psychotic features and as part of a rapid-cycling or nonrap id-cycling course. Mixed stare is a common presentation in an acutely manic patient. The accurate assessment of these issues can serve as a guide in determining treatment options and choices.