EVIDENCE-BASED PHARMACOTHERAPY OF DYSPHORIC MANIA

The treatment of dysphoric mania and bipolar mixed states is complex and supported by a scant number of controlled studies. There is some evidence that it may be more responsive to anticonvulsants than to = Valproate, and to a lesser extent carhamazepine, may he used either in monotherapy or as adjuncts to lithium. Use of other anticonvulsants, such as gabapentin, lamotrigine, leviteracetam, oxcarbazepine, tiagahine or topiramate, is not supported by controlled data as yet. The use of antidepressants is largely discouraged, as they may worsen this condition. Atypical antipsychotics, on the other hand, may be effective either in monotherapy or in combination with valproate or lithium. As dysphoric mania is associated to higher risk of switching to depression, and antipsychotics are not very good for the prevention of depression, antipsychotic monotherapy is not advised. Only the trials with olanzapine in combination with valproate or lithium enrolled a substantial number of patients to allow for statistical subaualyses on this population, with positive results. Aripiprazole and ziprasidone have shown efficacy in pooled analysis from a few trials. To a lesser extent, risperidoue, quetiapine and clozapine have also been studied in randomized clinical trials but the number of patients enrolled was quite small. Both evidence and clinical experience point at combination therapy of an atypical antipsychotic and an anticonvulsaut, preferably valproate, or lithium as first-line therapy for severe mixed states. Mild cases could he treated with valproate monotherapy. A good alternative is electroconvulsive therapy. More research is needed in this area, and particularly in mixed states other than dysphoric mania.