[Treating a manic episode: theoretical guidelines and practice]

Theoretical guidelines on the biological treatment of a manic episode differ noticeably from everyday practice, especially in Europe. International guidelines stress the importance of monotherapy, either with lithium, anticonvulsive or antipsychotic agents, depending on the authors and the clinical picture. In some situations, it is recommended to associate an antipsychoticagentanda mood-stabilizer. In the last decade, antipsychotic agents have been mentioned more and more in these guidelines, while lithium has declined in importance. Respective characteristics and specific indications of the different antipsychotic agents have not been fully elucidated yet; nevertheless, some of these have been studied more than others. In practice the situation is quite different, polytherapy is frequent, including classical neuroleptic agents, and for periods that far exceed the duration of a manic episode, despite side-effects and contra-indications particularly frequent in this population. There is no evidence supporting the use of these agents either in the treatment of a manic episode or in the subsequent prophylaxis, but theoretical recommendations do not always reflect the practical situations. Taking this into account and in particular evaluating indications and conditions of polytherapy are critical issues in future studies on the biological treatment of a manic episode; however methodological problems are complex.