Antipsychotics have been utilized in thetreatment of bipolar disorder for many decades and were the mainstay oftreatment before lithium was reintroduced in the late 1960s.Today, many bipolar patients who present with psychotic features aremisdiagnosed and prescribed an antipsychotic for another disorder.Estimates of psychotic symptoms in bipolar disorder, particularly duringa manic episode, are ≥50% by clinical assessment and even higher byindividual reports. Thus, antipsychotics are frequently used: as firsttreatment for psychosis not recognized as bipolar disorder, and as anadjunct to a mood-stabilizing agent in bipolars with psychotic symptoms.

Most recently, antipsychotics have beenexamined for their mood-stabilizing properties as well (Slide 9). Onemay conceptualize using a selective serotonin reuptake inhibitor (SSRI)antidepressant for disorders such as panic disorder orobsessive-compulsive disorder, and using an antiepileptic as amood-stabilizing agent; however, it is more difficult to accept that anagent approved for treatment of psychosis can be a primary therapy forbipolar disorder. Data from the monotherapy trials suggest thatsecond-generation antipsychotics (SGAs) are at least as effective aslithium and valproic acid for acute mania. There is a very largedatabase indicating that SGAs can be utilized as monotherapy for acutemania. However, there is limited data on the role of theseagents in prevention of relapse and recurrence and in their efficacy fordepression in the context of bipolar disorder. More studies will beneeded to clarify whether SGAs should be used as monotherapy or whetherthey would be best used as augmenting agents in severe and psychoticallymanic or depressed patients.