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28 April 2006

The newer atypical antipsychotics appear to be effective for the treatment of acute bipolar mania, with only modest differences in acute efficacy seen among the drugs, study findings show.

Roy Perlis, from Massachusetts General Hospital in Boston, USA, and colleagues therefore suggest that "efficacy alone may not be a useful factor in selecting among the various acute treatment options available."

The researchers conducted a review of placebo-controlled studies of atypical antipsychotics, both as monotherapy and adjunctive therapy, for acute bipolar mania.

Data from 12 monotherapy and six adjunctive therapy trials involving a total of 4304 patients, including 1750 individuals taking placebo, were identified.

The effects of five atypical antipsychotics – aripiprazole, olanzapine, quetiapine, risperidone, and ziprasidone – were compared with that for placebo based on Young Mania Rating Scale (YMRS) scores.

All five antipsychotics proved to be superior to placebo as monotherapies. Overall, rates of response, defined as a 50% reduction in YMRS scores, were 53% for atypical antipsychotics and 30% for placebo.

The findings for the six add-on trials also indicated that atypical antipsychotics conferred an additional benefit over monotherapy with a traditional mood stabilizer.

"It therefore appears that recommendations for the use of combination therapy with a traditional mood stabilizer and an atypical antipsychotic in manic patients are warranted," say Perlis and team.

They add that there were only modest differences in efficacy across the five drugs, and acknowledge that comparisons were based upon their difference from placebo, rather than absolute change in mania rating scale score, in order to control for study differences.

"While studies are often compared in terms of effect size, this measure is somewhat more difficult to interpret in clinical terms," the investigators note.

They conclude: "Our results suggest broad similarity across the atypical antipsychotics in efficacy for treatment of bipolar mania, whether used in monotherapy or add-on therapy.

"In the face of substantial study heterogeneity, we cannot exclude modest differences. However, treatment selection among these agents may be better governed by factors other than short-term efficacy, such as maintenance efficacy, tolerability, safety, and cost."



Source: J Clin Psychiatry 2006; 67: 509–516
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