How to treat mania

Abstract

Objective In this paper, we aimed at reviewing evidence‐based treatment options for bipolar mania and proposed tentative evidence‐based clinical suggestions regarding the management of a manic episode, especially regarding the choice of the proper mood stabilizer and antipsychotic medication. Method A narrative review was undertaken addressing 'treatment of bipolar mania'. Findings have been synthesized and incorporated with clinical experience into a model to support different treatment choices. Results To date, there is solid evidence supporting the use of several medications, such as lithium, divalproex, and carbamazepine, and antipsychotics, such as chlorpromazine, haloperidol, risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole, inhaled loxapine, asenapine, and cariprazine in acute mania, and some evidence supporting the use of clozapine or electroconvulsive therapy in treatment‐refractory cases. However, in clinical practice, when making decisions about treatment, personalized treatment is needed, according to the different clinical presentations and more complex clinical situations within the manic episode and considering a long‐term view and with the objective of not only a symptomatic but also functional recovery. After remission from acute mania, psychoeducation strategies are useful to ensure adherence. Discussion Despite the evidence forefficacy of many currently available treatments for mania, the majority of RCTs provide little direction for the clinician as to what steps might be optimal in different presentations of mania as well as in the presence of specific patient characteristics. Manic episodes should be managed on a personalized basis considering the clinical course and patient criteria and with the expectation of maintaining that treatment in the long‐term.

Existing and emerging pharmacological approaches to the treatment of mania: A critical overview

“…The existing approaches for the treatment of MEs are summarized and categorized in Table 1 . A tentative treatment algorithm can be found in a recently published work from our same research group [ 7 ].…”

“…Another important point to consider is that a ME needs to be understood and treated not in a “cross-sectional” way, but as a phenomenon included in the complex and long-lasting course of bipolar illness. As a consequence, the treatment of the acute manic phase should already consider the maintenance treatment and course specifiers, such as the number of episodes, predominant polarity, the presence of rapid cycling, the risk of counterpolar switch [ 7 ], making the pharmacological treatment a complex choice. Predominant polarity (PP) is a course specifier concept aimed at identifying the presence of a predominant affective pole of illness within the same patient across its illness course [ 8 ].…”

“…Other clinical aspects that should be considered when treating a ME include the management of psychomotor agitation; the differences in the manic symptoms presentation in order to personalize treatment for a specific patient as much as possible (precision psychiatry); the need for using monotherapy versus combination therapy; the presence of mood incongruent psychotic symptoms which will require a more complex treatment; the importance of addressing compliance issues and the possibility of choosing long-acting formulations. Lastly, safety/tolerability issues in the short and long-term treatment, the presence of psychiatric/medical comorbidities and the need for a functional recovery complete this complex scenario [ 7 , 11 ].…”

Lithium: about discrepancies between efficacy and clinical use

“…In this issue of Acta Psychiatrica Scandinavica, two narrative reviews deal with important treatment areas of bipolar disorder. The paper by Barroilhet and Ghaemi (2) focuses exclusively on the role of lithium, while Pacchiarotti and colleagues (3) review more broader treatment concepts of mania including the position of lithium. Both reviews are timely documents by providing evidence, practical guide for clinicians, and some general clues specifically related to lithium.…”

“…As pointed out by Pacchiarotti et al 3, there is solid evidence supporting the use of several medication classes for the treatment of mania including first and second generation antipsychotics, anticonvulsantsand lithium. Given these many choices, it becomes apparent for the authors that clinicians when taking decisions about treatment, need more personalized treatment approaches according to the different clinical presentations and more complex clinical situations during the manic episode and in the long-term when functional recovery and decline in the number of mood episodes are essential treatment goals (3). With the importance of the latter long-term goals, the role of lithium comes into place again, even if it is a more 'complicated' drug to be administered during an acute manic episode.…”