Antipsychotic drugs were some of the first drugs used to treat acute mania and are highly effective (Prien et al., 1973). While onset of action is often more rapid than lithium, carbamazepine, or valproic acid, antipsychotics can cause serious potential side effects.
A major concern with typical antipsychotics is the potential for tardive dyskinesia. Tardive dyskinesia may occur more frequently in patients with mood disorders than those with schizophrenia and also in those with intermittent exposure rather than continuous use, placing bipolar patients at higher risk (Casey, 1987). Because of this and the availability of safer and better tolerated drugs, antipsychotic medications should only be used in the management of acute agitation, excitement, or psychosis in manic patients or in those few patients who clearly relapse on gradual discontinuation of maintenance antipsychotics.
While only approved by the FDA for the treatment of drug-resistant schizophrenia, the atypical antipsychotic drug clozapine has been shown to be effective in the treatment of mania and dysphoric mania (McElroy et al., 1991; Alphs and Campbell, 2002). Eighty-six percent of 14 bipolar patients with psychotic features showed significant improvement, and 7 of these patients were followed for an additional 3- to 5-year period with no further hospitalizations (Suppes et al., 1992). Other studies suggest clozapine is also effective in maintenance treatment of patients with bipolar disorder (Alphs and Campbell, 2002). Because of the risk of potentially fatal agranulocytosis, clozapine should not be used unless other first-line agents or traditional antipsychotic drugs have failed.
Newer atypical antipsychotics that do not have a risk of agranulocytosis are now widely available. These drugs are being intensively studied for the treatment of bipolar and unipolar mood disorders because they appear to have a lower risk of tardive dysk-inesia and are associated with a lower overall side effect profile compared with older antipsychotics. Olanzepine, risperidone, and quetiapine are all being studied as both monotherapy and as an adjunctive therapy for treatment of acute mania. Of the three, olanzapine is the best studied, with double-blind comparator trials as well as doubleblind placebo-controlled trials showing significant efficacy (Tohen et al., 1999) in acute mania. All atypical antipsychotic drugs are being widely used in the United States for the treatment of agitation and psychosis in manic or psychotically depressed patients, in spite of the absence of controlled data. Interestingly, olanzapine and risperidone have both been reported to cause mania in some patients with schizophrenia, schizoaffective, or bipolar disorder. At this point, none of these drugs should be used for long-term monotherapy of bipolar disorder in patients who have been tried on other available agents since no long-term studies have been completed.
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Bipolar is a condition that wreaks havoc on those that it affects. If you suffer from Bipolar, chances are that your family suffers right with you. No matter if you are that family member trying to learn to cope or you are the person that has been diagnosed, there is hope out there.