Au cours de l'épisode maniaque, le recours aux agents thymorégulateurs en monothérapie ne concerne qu'une minorité de patients présentant le plus souvent une manie modérée ou une hypomanie. Les neuroleptiques, les benzodiazépines et plus récemment les nouveaux antipsychotiques sont largement utilisés en traitements adjuvants au thymorégulateur, bien au-delà des indications retenues par les différentes recommandations. Notre objectif consiste à exposer les situations cliniques justifiant l'association d'un traitement adjuvant dans l'épisode maniaque (l'agitation, les troubles du sommeil, les symptômes psychotiques, les comorbidités) et d'éclaircir, à partir des données de la littérature, les avantages et les inconvénients des associations thymorégulateur et antipsychotique et/ou benzodiazépine de façon à dégager des indications différenciées. Les neuroleptiques restent largement utilisés en première intention avec un thymorégulateur, souvent après avoir été proposés seuls dans les premières semaines. Pourtant les données de la littérature ne confirment pas leur efficacité et leur rapidité d'action par rapport aux thymorégulateurs ou aux benzodiazépines. Lorsque le neuroleptique fait partie du traitement initial, il continue à faire partie du traitement à distance dans plus de la moitié des cas sans justification. Or, les effets indésirables des neuroleptiques sont suffisamment nombreux et sévères dans l'épisode maniaque pour inciter à ne les utiliser qu'avec parcimonie en première intention. Si la tolérance de l'association des nouveaux antipsychotiques avec les thymorégulateurs semble jusqu'à présent acceptable, son indication devrait être limitée aux manies psychotiques. L'association benzodiazépine-thymorégulateur mériterait d'être évaluée dans les différentes formes de manie et présente un intérêt pour le traitement des agitations anxieuses, des symptômes catatoniques, d'une insomnie ou encore dans les situations de comorbidité fréquemment rencontrées en psychiatrie de liaison.

When treating patients with manic states, the physician has to deal with at least two main issues. First, the therapeutic decision has to be rapid because of the unpredictability of its immediate course. This concerns often results in polypharmacy with adjunct treatments. However, the therapeutic choice has to be cautious since part of the treatment will be maintained for prophylaxis. According to recent guidelines, the use of monotherapy with mood stabilisers during acute manic states concerns only few patients with mostly hypomania to moderate mania. Up to date, antipsychotics and benzodiazepines are considered as adjunct treatment in mania with psychotic symptoms or hostility. However, survey studies show that antipsychotics are widely used as adjunct treatments to mood stabilisers, indeed beyond the indications held by the guidelines. Our objective was to describe the clinical situations justifying the addition of an adjunct treatment during acute mania and to clear up from published data, the advantages and the inconveniences of combining antipsychotics and/or benzodiazepines with a mood stabilisers in order to define differentiated indications. Mania associated with either agitation, sleep disturbances or psychotic symptoms requires most of the time to combine mood stabiliser and respectively, sedative and/or anxiolytic, hypnotic or antipsychotic treatments. Patients suffering from mania associated with other disorders need specific treatment adjustment and combination related to their medical condition. Adjunctive conventional antipsychotic remains widely used in first intention treatment. The conventional antipsychotic is often prescribed alone in the first weeks prior to the association with a mood stabiliser. Nevertheless there are controversies in the literature about their efficiency and their delay of action with regard to other treatments. When the conventional antipsychotic is a part of their initial treatment, manic patients remain taking them when discharged from hospital and are still taking them after 6 months in a great percentage of the cases. The adverse events with conventional antipsychotic are numerous and severe enough in bipolar patients to restrict their use in first intention mainly to psychotic mania. Moreover, there are evidences for higher sensitivity to adverse effects of the conventional antipsychotics in manic patients. When agitation in acute mania requires an adjunct to mood stabiliser, the conventional antipsychotic treatment could be use for over-excitation without catatonic features and with particular care with the risk of akathisia. Long term effects of conventional antipsychotics, especially on depressive recurrences, should argue to stop them as soon as possible. Since the safety of adjunctive new antipsychotics with mood stabilisers seems until now acceptable, its indication should be limited to acute psychotic manias. Adjunctive benzodiazepine, should be evaluated in the various types of mania with specific concerns with comorbidity frequently met in consultation-liaison psychiatry. Benzodiazepines plus mood stabilisers may be the treatment of choice for the manias in which anxious state, catatonic symptoms or sleeplessness.