Magazine article Clinical Psychiatry News

Risperidone and Acute Mania

Magazine article Clinical Psychiatry News

Risperidone and Acute Mania

Article excerpt

The Problem

You have an adult patient who is clearly suffering with mania. He is already taking a low dose of risperidone (Risperdal). After you review the various treatment options with him, he will consent only to an increase in the dose of his risperidone.

The Question

How effective is risperidone monotherapy in treating acute mania?

The Analysis

We did a search of the Cochrane Database of Systematic Reviews that combined "risperidone" and "mania" and discovered a review updated Feb. 21, 2006.

The Evidence

For this Cochrane review, randomized controlled trials comparing risperidone with placebo or other active treatments were included. Patients of both sexes and all ages with a diagnosis of bipolar disorder, with or without psychotic symptoms or schizoaffective disorder (manic or mixed), were included. In all but one trial, the inclusion criteria included a minimum Young Mania Rating Scale (YMRS) score of 20. (The YMRS is an 11-item instrument used to assess the severity of mania in patients with a diagnosis of bipolar disorder. The total score ranges between 0 and 60.) Trials lasted 3-4 weeks.

The Cochrane authors reviewed 610 studies, from which 5 (plus one conference poster) were identified as randomized controlled trials that examined the efficacy of risperidone for treatment of acute mania. These six trials yielded a total of 1,343 participants. Rates of treatment withdrawal for the six trials ranged between 12% and 62%. For all trials, the measure of efficacy was change in YMRS score. No differences in the use of rescue medication (lorazepam, diazepam, or chloral hydrate) were found between the risperidone and placebo group.

Two trials examined the efficacy of risperidone monotherapy. Risperidone was more effective than placebo, reducing the YMRS score by a weighted mean difference of 5.75. A third study included a graph (but no data) that showed an approximate difference of 11 points on the YMRS.

The proportion of study participants treated with risperidone who failed to have a response (defined as a greater than 50% reduction in the YMRS score) was less than that of the placebo group (relative risk, 0.64). Even fewer study participants treated with risperidone failed to meet criteria for remission (RR 0.78), which was defined as a YMRS score of 12 or less, or to achieve a YMRS score of 8 or less (RR 0.68).

Two trials examined the efficacy of risperidone vs. placebo plus lithium or an anticonvulsant. As adjunctive treatment to lithium or an anticonvulsant, risperidone was more effective than placebo, as measured by a change on the YMRS (weighted mean difference, 5. …

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