Description

Antipsychotic drugs have long occupied a central place in the treatment of bipolar disorders, for both acute and maintenance phases. Recently, there have been trends, in both the UK and US, towards the use of anticonvulsant drugs as mood stabilising medications. This change has taken place despite a lack of supporting evidence.

Contemporary approaches to the treatment of bipolar disorders prove inadequate for many patients. This is reflected in the great variability in treatment practices, both between clinicians and across countries. Lithium proves ineffective or intolerable for a substantial proportion of bipolar patients and is associated, on withdrawal, with a heightened risk of relapse. With regard to the anticonvulsants, carbamazepine and valproate, neither agent is uniformly well tolerated and supporting evidence for effectiveness is less than with lithium.

Conventional antipsychotics have been shown to be highly effective in mania, however, these agents may provoke or exacerbate depressive symptoms and are associated with motor and other side effects. There are few studies that demonstrate the efficacy of conventional antipsychotics in the prophylaxis of affective disorder. In contrast to conventional antipsychotic treatment regimens, the atypical, or novel antipsychotics are characterised by a lower liability to induce acute EPS. There are now a number of studies addressing the issue of effectiveness of the atypical antipsychotics in acute mania, although the majority are case series or uncontrolled trials. There have been favourable reports of effectiveness in mania with clozapine, risperidone, quetiapine and olanzapine, but of the four agents, the evidence for olanzapine is at present the most substantial. There are now studies examining the contribution of the atypical antipsychotics to stability in the longer-term treatment of bipolar disorders, although there is a need for large scale comparative studies.

This paper reviews the evidence supporting the use of antipsychotics in bipolar disorders and, by comparison with the alternative treatments, outlines a role, in the contemporary treatment of bipolar disorders, for the newer generation of atypical antipsychotics.