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Best treatment for acute mania
What are the best (most efficacious and well-tolerated) pharmacotherapeutic options for acute mania?
Meta analyses have found that the antipsychotics haloperidol, risperidone, and olanzapine (in that order) are more effective than mood stabilizers, and olanzapine and risperidone (in that order) are better tolerated as well.
Lithium may be the most effective mood stabilizer but may not be as well tolerated as valproate.
Quetiapine is about as effective as lithium and about as well tolerated as valproate.
For severe acute mania, the American Psychological Association guidelines recommend the combination of lithium or valproate with an antipsychotic (such as olanzapine) with consideration for benzodiazepine adjunctive therapy.
Monotherapy with a mood stabilizer may be possible following treatment of the acute episode.
Sources
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Schulz SC, Goerke D, O’Sullivan M, Jasberg S: Early-stage schizophrenia. In Gabbard GO (ed): Gabbard’s treatments of psychiatric disorders. Washington, DC: American Psychiatric Publishing, 2014, pp 134-135.
Janicak PG: Pharmacological treatment of psychosis. In Gabbard GO (ed): Gabbard’s treatments of psychiatric disorders. Washington, DC: American Psychiatric Publishing, 2014, pp 187-205.
Cipriani A, Barbui C, Salanti G, et al.: Comparative efficacy and acceptability of antimanic drugs in acute mania: a multiple-treatments meta-analysis. Lancet 378(9799):1306-1315, 2011.
American Psychiatric Association: Practice guideline for the treatment of patients with bipolar disorder, second edition. Am J Psychiatry 159(4 Suppl):1-50, 2002.
