Treatment for mixed states overall appears to be about as effective with the atypical antipsychotic medications as for manic episodes, she said. Adding an antidepressant to a mood stabilizing medication does not make depression better in these patients and actually makes the mania worse, she added.
"The therapeutic challenges are many," Dr. Suppes said, but she presented an evidence-based algorithm that she helped develop. It was published in the Journal of Clinical Psychiatry in 2005.
For bipolar disorder type I patients who are in a mixed manic or hypomanic state, she recommended valproate(Drug information on valproate), aripiprazole(Drug information on aripiprazole) (Abilify), risperidone(Drug information on risperidone) (Risperdal) or ziprasidone(Drug information on ziprasidone) (Geodon) as initial treatment with olanzapine(Drug information on olanzapine) (Zyprexa) and clozapine(Drug information on clozapine) (Clozaril) as alternate choices. Nonresponders should be put on an alternate monotherapy.
Stage two, for patients who get only partial response is to try a two-drug combination of lithium(Drug information on lithium) and valproate or an atypical antipsychotic. They should not be put on two atypical antipsychotics or given aripiprazole or clozapine.