Antipsychotics in bipolar disorder

Antipsychotics are commonly added to lithium for relief of severe psychotic symptoms and behavioral disruption during an acute manic episode. In general, lithium is superior in stabilizing mood and ideation, whereas neuroleptics are better in controlling hyperactivity, and the course of clinical response is faster to antipsychotics than to lithium. The effects of neuroleptics on bipolar depression need further study. Traditional neuroleptics carry the risk of extrapyramidal symptoms, and concern exists over neurotoxicity from the combination of lithium and a neuroleptic. Roles for clozapine, risperidone, and newer atypical neuroleptics, which may carry a lower risk of associated extrapyramidal side effects, will become clear with additional study and clinical experience. Long-term antipsychotic therapy in the maintenance phase of bipolar disorder is common; the efficacy, however, remains unclear and the risk of tardive movement disorders is substantial. Otherwise treatment-resistant patients who receive maintenance antipsychotic therapy to prevent recurrent episodes of mania should be followed closely, with regular screening for early signs of movement disorders.