ACUTE NONPSYCHOTIC MANIA: FIRST EPISODE

Acute mania has always been one of the most intense acute psychiatric syndromes. While many controlled clinical trials of acute mania treatments have been completed in the last several decades, leading to numerous Food and Drug Administration-approved treatments, most of the questions that arise clinically remain unstudied. Many of the acute mania trials studied monotherapy or a combination of two medications for a syndrome often treated with polypharmacy. Most of the subjects in acute mania trials were only moderately ill, and even efficacious treatments had only modest effects. Mania associated with substances, a common clinical condition, was essentially excluded from most trials. Mixed episode has been studied largely as an afterthought. Traditionally, a treatment became known as a mood stabilizer if it was shown to have efficacy in mania. Evolving research in acute bipolar depression and bipolar maintenance has raised many new questions regarding the effects of mania treatments during other phases of illness. Treatment of bipolar disorder has now become highly complex, and most bipolar patients are treated with more than four medications. A lack of clear acceptance or consensus on the definitions of many crucial terms related to bipolar disorder often leads to further clinical confusion. Examples of these include mood stabilizers, hypomania (versus normal), mixed episode (versus mixed states), and antidepressant-induced mania. In this supplement, three experts present case discussions and attempt to tackle some of these commonly faced clinical problems. In each case, the experts draw from their own clinical experience to try to bridge the gap between evidence-based medicine and clinical practice. Michael H. Allen, MD, presents a case of first-episode mania without psychotic features. Many issues are discussed, including recognition of psychosis, a rationale for selecting medications from the numerous approved treatments, and subsequent implications during maintenance. In the next case, James C.-Y. Chou, MD, discusses mixed episode with psychotic features, one of the most severe among bipolar states. The topics of antipsychotics as mood stabilizers, predictors of treatment resistance, and a rationale for polypharmacy are discussed. Finally, Alan C. Swann, MD, presents three complex cases: pharmacologic mania, mania with comorbid attention-deficit/hyperactivity disorder, and antidepressant-induced destabilization during maintenance treatment. He addresses the challenging questions of when to use or avoid antidepressants in bipolar disorder, who is at risk for destabilization, and the destabilizing effects of antidepressant withdrawal.