title: Comparative efficacy and acceptability of mood stabilizer and second generation antipsychotic monotherapy for acute mania--a systematic review and meta-analysis.
abstract: BACKGROUND
  All treatment guidelines for acute mania recommend monotherapy with either mood stabilizers (MS) or antipsychotics. The objective of this analysis was to compare the efficacy and acceptability of both drug classes in an expanded set of clinical trials in acute mania.
  
  
  METHODS
  Randomized double-blind trials comparing MS vs second generation antipsychotics (SGA) in acute mania were identified in a systematic literature search. Change in mania rating scale, responder rates and dropout rates were compared by treatment assignment using Review Manager version 5.0.
  
  
  RESULTS
  Nine studies totaling 1631 patients that compared the MS lithium or valproate against a number of SGAs, and which reported one or more analysis endpoints were identified. Statistically significant advantages were noted in favour of SGA over MS for standardized mean difference (SMD) for change in mania scores (-0.22 [95% CI -0.33 to -0.11]; p < 0.0001), responder rate risk difference (7% [95% CI 1% to 13%]; p = 0.02), and dropout risk difference (-5% [95% CI -10% to -1%]; p = 0.02). This change in SMD for mania scores is equivalent to a 2.5-3 point difference in Young Mania Rating Scale score. Similar trends for SMD were noted when comparing subgroups of lithium and valproate studies against SGAs.
  
  
  CONCLUSIONS
  Over half the included studies included olanzapine, and the applicability of these findings, especially to first generation antipsychotic drugs, requires confirmation. This analysis could not assess the relative efficacy of combined MS/SGA vs individual monotherapies.
  
  
  CONCLUSIONS
  In acute mania, monotherapy with SGAs demonstrates statistically significant advantages over MS in terms of both efficacy and acceptability, and may be preferable for initial choice of treatment.
authors.affiliation: Departments of Psychological Medicine and Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand.
authors.forename: Greg P
authors.initials: GP
authors.lastname: Tarr
authors.forename: Paul
authors.initials: P
authors.lastname: Glue
authors.forename: Peter
authors.initials: P
authors.lastname: Herbison
mesh_terms: D000339:Affect; D000928:Antidepressive Agents / Q000627:therapeutic use; D018692:Antimanic Agents / Q000627:therapeutic use*; D014150:Antipsychotic Agents / Q000627:therapeutic use*; D001569:Benzodiazepines; D001714:Bipolar Disorder / Q000188:drug therapy*; D004311:Double-Blind Method; D006801:Humans; D008094:Lithium / Q000627:therapeutic use; D016651:Lithium Carbonate / Q000627:therapeutic use; D018020:Lithium Compounds / Q000627:therapeutic use; D019964:Mood Disorders / Q000188:drug therapy; D000077152:Olanzapine; D016032:Randomized Controlled Trials as Topic; D014635:Valproic Acid / Q000627:therapeutic use
chemical_list: D000928:Antidepressive Agents; D018692:Antimanic Agents; D014150:Antipsychotic Agents; D018020:Lithium Compounds; D001569:Benzodiazepines; D016651:Lithium Carbonate; D014635:Valproic Acid; D008094:Lithium; D000077152:Olanzapine