Numerous studies on the treatment of acute mania in bipolar patients have demonstrated the efficacy of atypical neuroleptics versus placebo or active comparator. However, there is a lack of direct comparative studies between atypicals. We present an overview on the efficacy (response and remission rates) of atypicals.

Using MEDLINE-analysis, all prospective double-blind studies of atypical neuroleptics in acute mania published until November 2006 were identified. Response was defined as 50% improvement and remission as an endpoint ? 12 in YMRS. The following parameters were calculated: response rates, remission rates, odds ratios, adjusted odds ratios.

Response rates in placebo controlled studies (duration 3-4 weeks) ranged from 18.9% to 42.9% (placebo) and from 39.8% (aripiprazol) to 72.9% (risperidone) for comparators. The adjusted odds ratios ranged from 1.946 (ziprasidone) to 2.727 (risperidone), all differences versus placebo were statistically significant in favor of the atypical. Remission rates ranged between 22.1% and 35.7% (placebo) and for comparators between 27.7% (quetiapine) and 61.1% (olanzapine). In comparator controlled studies (duration 3-12 weeks) response rates ranged between 42.3% and 74.2%. With odds ratios between 0.580 and 1.629, differences versus comparator were not statistically significant. Remission rates in these studies varied from 27,7% (quetiapine) to 49% (lithium). The observed trends for treatment effect differences between the atypicals are confounded by different study designs and patient characteristics. Thus, direct comparative studies between atypicals in acute mania are required to detect potential treatment effect differences, e.g. in special patient subgroups.