Acute bipolar mania: A systematic review and meta-analysis of co-therapy vs. monotherapy

South London and Maudsley NHS Foundation Trust, Londinium, England, United Kingdom
Acta Psychiatrica Scandinavica (Impact Factor: 5.61). 02/2007; 115(1):12-20. DOI: 10.1111/j.1600-0447.2006.00912.x
Source: PubMed


The aim of this meta-analysis was to systematically review the effectiveness of co-therapy compared with monotherapy for people with bipolar mania.
MEDLINE, Embase, Psychinfo, The Cochrane Library and reference lists of retrieved studies were searched without language restrictions for randomized controlled trials evaluating co-therapy compared with monotherapy for acute bipolar mania. Each trial was assessed for susceptibility to bias. Data on mania outcomes, withdrawals, extrapyramidal symptoms and weight were extracted and pooled effect estimates summarized as relative risks (RR) or differences in mean values (MD) where appropriate.
Eight eligible studies were included (1124 participants). Significant reductions in mania (Young Mania Rating Scale, YMRS) scores were shown for haloperidol, olanzapine, risperidone and quetiapine as co-therapy compared with monotherapy with a mood stabilizer. For atypical antipsychotics combined, the pooled difference in mean scores was 4.41 (95% CI: 2.74, 6.07). Significantly more participants on co-therapy met the response criterion (at least 50% reduction in YMRS score), RR 1.53 (1.31, 1.80). With some drugs, co-therapy decreased tolerability compared with monotherapy, and resulted in greater weight gain. There were insufficient data to compare one co-therapy regimen with another.
The addition of antipsychotic treatment to established mood-stabilizer treatment is more effective than mood-stabilizer treatment alone.

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Available from: Victoria R Cornelius, Jan 02, 2014
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    • "Sometimes a triple combination (Lithium, an anticonvulsant and an atypical antipsychotic) may be needed in treatment resistant mania. Combinations of Olanzapine, Quetiapine, Risperidone and Aripiprazole with a mood stabiliser are more effective than therapy with a single mood stabiliser (Yatham 2005; Smith et al. 2007; Ketter 2008). Combinations are also useful in long term maintenance treatment. "

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    • "In this study, the ziprasidone and divalproex combination was not associated with weight gain. Because weight gain is greater with other atypical anti-psychotic and mood stabilizer combinations than monotherapy,24 the favorable effect of ziprasidone on weight is an advantage to treating with this medication. "
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    ABSTRACT: We investigated the efficacy and tolerability of ziprasidone combined with divalproex to determine the relationship between the initial dose of ziprasidone and the treatment effect among Korean patients with acute bipolar manic or mixed disorders. This study was a 6-week, open-label, prospective investigation of Korean patients with an acute manic or mixed episode of bipolar disorder. Sixty-five patients were recruited. The patients were categorized based on the initial dose of ziprasidone as follows: low (20-79 mg/day) and standard (80 mg/day). Ziprasidone was given in combination with divalproex in flexible doses, according to the clinical response and tolerability. The response and remission rates were significantly higher in the standard-dose group than the low-dose group. The combination of ziprasidone and divalproex was well-tolerated and adverse events were mostly mild with no statistically significant increase in body weight. The results of this study showed that a standard starting dose of ziprasidone in combination with divalproex for bipolar disorder is more effective than a low starting dose.
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    • "En effet, seulement 50 % des patients maniaques répondent à une monothérapie et 75 % à une bithérapie [32]. La littérature scientifique recommande les associations telles que le lithium ou le divalproate avec un antipsychotique atypique [37] [38]. Si un antipsychotique n'est pas déjà utilisé, les guidelines recommandent l'adjonction d'un antipsychotique quand la symptomatologie du patient comprend des signes psychotiques [39]. "
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    ABSTRACT: Management of bipolar disorder has undergone many revisions in recent years as new agents and treatments have been developed and studied with variable success. In conjunction with the advent of novel therapies and indications, there has been an increase in the understanding of the phenomenology and neurobiology of bipolar disorder that has made the classification and management of the illness necessarily more sophisticated. However, there remains a significant delay of 8 years in detecting and diagnosing bipolar disorder, and a further need to improve treatments. However, this paper has emphasized the need to be aware of recent advances and the emerging uses of new pharmacological treatments in the management of bipolar disorder. It has also highlighted the need for tailoring management to the individual. In particular, the successful treatment of bipolar disorder requires achieving prophylaxis and preventing relapse. In this regard, maintenance therapy is of paramount importance, and thus the tolerability of agents needs to be considered throughout treatment and should be factored into all management decisions. At the centre is the individual with bipolar disorder and the need to maintain a healthy therapeutic relationship. However, it is important to note that the evidence synthesized in this paper serves only as a guide to the management of bipolar disorder and that, in clinical practice, all treatment recommendations require contextual interpretation, the consideration of local factors and the consultation of additional resources.
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