Clinical Health Updates

Combination of antipsychotics and mood stabilizers best for acute mania

Clinical Question:
What is the optimal medical management for adults with acute mania?

Bottom Line:
Currently available data suggest that combining SGAs and MSs is the most efficacious treatment of acute mania.

Scherk H, Pajonk FG, Leucht S. Second-generation antipsychotic agents in the treatment of acute mania. A systematic review and meta-analysis of randomized controlled trials. Arch Gen Psychiatry 2007;64:442-455.

Study Design:
Meta-analysis (randomized controlled trials)

Recommendations of treatment guidelines concerning the use of second-generation antipsychotic (SGA) agents for acute mania vary substantially across committees or working groups. Meta-analyses addressing the use of SGAs in the treatment of acute mania are lacking. The author conduct a meta-analysis of the efficacy and safety of SGAs in the treatment of acute mania. Randomized controlled trials comparing SGAs with placebo, first-generation antipsychotic drugs, or mood stabilizers (MSs) in the treatment of acute mania were searched for in the PsiTri and MEDLINE databases (last search: May 2006). The abstracts, titles, and index terms of studies were searched using the following key words: aripiprazole, amisulpride, clozapine, olanzapine, quetiapine, risperidone, ziprasidone, and zotepine in conjunction with mania, manic, and bipolar. Data on efficacy, global dropout, dropout due to adverse events, dropout due to inefficacy, weight gain, rate of somnolence, and extrapyramidal symptoms were extracted and combined in a meta-analysis. A total of 24 studies with 6187 patients were included. The SGAs were significantly more efficacious than placebo. The analysis demonstrated that adding antipsychotic agents to MS treatment was significantly more effective than treatment with MSs alone. The SGAs displayed efficacy comparable with that of MSs. Some SGAs seemed to induce more extrapyramidal symptoms than placebo. The SGAs were also associated with higher rates of somnolence than placebo.