According to an article published by The Lancet, antipsychotic drugs are much more effective than mood stabilizers in tackling acute manic episodes. Researchers categorized antipsychotic drugs according to their effectiveness and revealed that three drugs in particular outperformed other drugs. The drugs were haloperidol, risperidone and olanzapine.
Andrea Cipriani, Section of Psychiatry and Clinical Psychology at the University of Verona, Italy, and John Geddes, Professor of Epidemiological Psychiatry at the University of Oxford, UK, who led the research project commented that these findings could offer useful clinical guidance, as current guidelines do not differentiate between the drugs.
About 1% of the population is affected by Mania, which is defined as “excessively raised mood”. Mania tends to alternate with depression, and describes the diagnosis of bipolar disorder.
Between the 1 January 1980 and 25 November 2010, Cipriani together with his fellow researchers established the most commonly administered drugs for treating acute mania in adults by evaluating results from 68 randomized controlled trials involving 16,073 participants. Their findings revealed the most effective antimanic drugs to be haloperidol, olanzapine and risperidone, with haloperidol having the highest number of significant differences in head-to-head comparisons, outperforming aripiprazole, asenapine, carbamazepine, valproate, gabapentin, lamotrigine, lithium, quetiapine, topiramate, and ziprasidone. Research showed, that risperidone, olanzapine, and quetiapine were least likely to result in treatment discontinuation and proved more effective than many mood stabilizers, such as lithium, lamotrigine, topiramate, and gabapentin.
The researchers state that these results have potential clinical implications that should be considered in the development of clinical practice guidelines. Strikingly, some antipsychotic drugs were, overall, significantly more effective than mood stabilizers. However, they caution that,
“All statements comparing the merits of one medicine with another must be tempered by the potential biases and uncertainties that result from choice of dose and choice of patients.”
In a concluding statement, the authors highlight the need for new treatments to show either greater efficacy or acceptability than the existing best standard treatments and serve as a disincentive to the development of drugs that offer little to patients other than increased costs.
Michael Berk at the School of Medicine, Deakin University, Geelong, Victoria, Australia and Gin S Malhi at the CADE Clinic, Department of Psychiatry, Royal North Shore Hospital in Sydney, NSW, Australia say in a linked Comment,
“Haloperidol seems to have won the race for pole position in the treatment of acute mania. However, the management of manic episodes, or indeed acute therapy per se, is not the overriding therapeutic imperative in this polyphasic and capricious disorder. Instead, the main goals of treatment are attention to long-term mood stability and prophylaxis. The promotion of haloperidol as a first-line drug for acute mania is problematic in this context, since it lacks maintenance efficacy for depression – the predominant clinical state – and indeed carries an inherent risk of incident depression.”
Berk and Malhi conclude that these findings are likely to attract much interest and have a substantial effect both on clinical practice guidelines and real world treatment, making it all the more crucial that the true comparative effectiveness and acceptability of antimanic drugs, and their positioning in broader management is understood.
Written by Petra Rattue