ABSTRACT

With the emergence of the atypical antipsychotics and the subsequent broadening of the treatment portfolio for acute mania, recent treatment guidelines seem to neglect typical neuroleptics as a treatment option or even discourage their use. Nevertheless, there is still a widespread clinical use, as demonstrated by several observational studies (1-4), which may well exceed the time frame of acute antimanic treatment (5). For example, a Medline-based review using publications between 1980 and 1999 on the naturalistic use of typical antipsychotics in bipolar disorder by Tohen et al. (3) showed that on average 90.7% of manic inpatients and 65.3% of outpatients received typical antipsychotics. At least in an outpatient population, a lower degree of severity of mania may be expected, which makes the extensive use of typical antipsychotics somewhat surprising. The reasons behind the use of typical antipsychotics may be plentiful: it may just be sticking to tradition, as especially older clinicians are more familiar with their use or it may be due to the fact that psychosis, including hallucinations, is part of severe stages of mania (6) and may occur in up to 40% of patients (7). Many clinicians may also associate typical antipsychotics not only with stronger antipsychotic effects, but also see them as more powerful against other symptoms of acute mania (irritability, agitation, impulsiveness, and aggression) than other treatment modalities. However, all these potential advantages of typical antipsychotics are based on clinical experience. Thus, it is important to review the existing data to elucidate whether this impression is also backed up by controlled studies.