Lithium and divalproex sodium are effective in classical pure mania, whereas divalproex sodium and carbamazepine are likely more effective in mixed states. Divalproex sodium is likely more efficacious than carbamazepine and lithium when the mania is part of a rapid-cycling course. Typical neuroleptics are efficacious in acute mania, particularly in the presence of marked psychotic symptoms. Atypical neuroleptics can be useful in refractory mania. Some benzodiazepines do have antimanic effects, but they are increasingly being shown to have usefulness as adjuncts to mood stabilizers or neuroleptics rather than as primary antimanic agents.
Mixed state is a common presentation in an acutely manic patient.
The accurate assessment of these issues can serve as a guide in determining treatment options and choices. Studies that examined various treatments for bipolar depression were evaluated and rated for evidence of efficacy using Periodic Health Examination criteria. The rating for classification of recommendation for an intervention was made taking both the efficacy and the side effects into consideration. Almost all antidepressant treatments with the exception of mood stabilizers have been reported to induce a manic-hypomanic switch and rapid cycling. Mood stabilizers, lithium in particular, are recommended as the first-line treatment.