Pharmacotherapy in mania and depression

Bipolar disorders are characterised by an irregular, partially chaotic pattern of mood swings and, most difficult to treat, mixed states where both symptoms of mania and depression are concurrently present. Thus, individualised treatments, quickly adapting to the prevailing symptomatology, becomes necessary. There is a clear indication for mood stabilisers thus as lithium, valproate, carbamazepine or lamotrigine to improve the long-term course of the illness; however, short-term interventions are often necessary tailored to specific symptoms without provoking other symptoms or worsening the long-term outcome. The use and usefulness of antidepressants in bipolar disorder still remains a matter of ongoing controversy. Concerning efficacy, a metaanalysis [1] and a recent systematic review [2] supports the use of some antidepressants in treating acute bipolar depression. However, recent data of the STEP-BD program also question their true clinical effectiveness [3]. On the manic side, conventional antipsychotics are effective [4], but their tolerability is often poor. With their superior tolerability profile atypical antipsychotics appear to be useful tools in such a symptom orientated treatment. Besides antimanic properties, several atypical antipsychotics have shown efficacy in mixed mania [5], psychotic mania [6] and, especially quetiapine and olanzapine, bipolar depression [7]. In addition, they may be useful in stabilising frequently cycling patients [8, 9]. In addition, there is increasing evidence for prophylactic efficacy of atypical antipsychotics against break-through mania (aripiprazole [10], risperidone (unpublished)) and both new manic and depressed episodes (olanzapine [11], quetiapine (unpublished). Thus, atypical antipsychotics may emerge as a true alternative to standard treatment with mood stabilizers in combination with antimanic or antidepressant agents.