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Mania: The other pole

Vol. 8, No. 6 / June 2009

Most of the research and diagnostic and treatment guidance regarding bipolar disorder focuses on depression (“Controversies in bipolar disorder: Trust evidence or experience?” Current Psychiatry). Why is there not more focus on the mania, which can be as debilitating and lethal as depression? What therapeutic guidance is there for bipolar patients in whom mania is the predominant state and who no longer want to live with minds that are bombarded day and night with inescapable, racing thoughts?

Jeannette Smith
Canadian Agency for Drugs and Technologies in Health
Ottawa, Ontario, Canada

Drs. Miller and Noel respond

We agree that manic episodes can be debilitating for the patient. Marital strife, job loss, legal problems, financial extravagance, sexual indiscretion, and embarrassment are some potential adverse consequences of untreated mania.

However, it is uncommon to see patients in whom mania is the predominant state. While classical elated mania rarely is seen in clinical practice, patients with bipolar depression often describe concurrent manic symptoms such as racing thoughts without fully meeting DSMIV-TR criteria for a mixed state. The therapeutic guidance we offer for such patients is to begin with a mood stabilizer (eg, divalproex) and an atypical antipsychotic (eg, aripiprazole), to assess thyroid status and supplement if necessary, and—as a last resort if these measures fail to achieve stability for the patient—to start an anti-depressant (eg, sertraline) at a low dose.

Unlike bipolar depression with or without manic features, mania is relatively easy to treat and responds to virtually every antipsychotic—both old and new—most mood stabilizers, benzodiazepines and, in olden days, barbiturates.

In their prospective natural history studies of bipolar I and II patients, Judd et al1,2 found that depression—not mania or hypomania—is the predominant feature of bipolar disorder. Treatment of bipolar depression presents the greatest challenge to clinicians and is the subject of the controversy about use of antidepressants discussed in our article.

Gary E. Miller, MD
Clinical professor of psychiatry

Richard L. Noel, MD
Assistant clinical professor of psychiatry
University of Texas Health Science Center
Houston, TX


1. Judd LL, Akiskal HS, Schettler PJ. The long-term natural history of the weekly symptomatic status of bipolar I disorder. Arch Gen Psychiatry. 2002;59(6):530-537.

2. Judd LL, Akiskal HS, Schettler PJ. A prospective investigation of the natural history of the long-term weekly symptomatic status of bipolar II disorder. Arch Gen Psychiatry. 2003;60(3):261-269.

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