Treatment approaches for acute mania

Drug treatment of mania is conceptually divided into mood stabilizers and tranquilizers. Indications for each are defined and a graphical decision tree for treatment of acute mania is presented. The anticonvulsants carbamazepine and valproic acid have an efficacy comparable to that of lithium and work in many lithium-refractory patients. They have not, however, been sufficiently studied in maintenance treatment. Guidelines are presented for the selection of a mood stabilizing agent as well as for combining two mood stabilizers. Lithium-refractoriness, a key concept in determining drug choice, is poorly defined in the literature and requires refinement. Among tranquilizers, neuroleptics are used most frequently, but their use should be minimized. Neuroleptic dosing of manic patients is probably too high and exposes patients to an unnecessary risk of side effects including tardive dyskinesia. In patients with no history of substance abuse, benzodiazepines can be used instead of neuroleptics or in augmentation of neuroleptics which can then be used at lower doses.