Mania in the Nordic countries: Patients and treatment in the acute phase of the EMBLEM study JENS KNUD LARSEN, VIBEKE PORSDAL, TROND F. AARRE, HANNU J. KOPONEN, JORMA AARNIO, OLE KRISTIAN KLEIVENES, THE EMBLEM ADVISORY BOARD Larsen JK, Porsdal V, Aarre TF, Koponen H, Aarnio J, Kleivenes OK, and the EMBLEM Advisory Board. Mania in the Nordic countries: Patients and treatment in the acute phase of the EMBLEM study. Nord J Psychiatry 2009;63:285291. In bipolar disorder, mood stabilizers and second-generation antipsychotics have a central role in pharmacotherapy. Thereare, however, substantial differences in how the treatment is realized in different countries. The aim of this paper was to compare the treatment of acute mania in the Nordic countries with other European countries during the first 12 weeks of the EMBLEM (European Mania in Bipolar Longitudinal Evaluation of Medication) study. Adult patientswith bipolar disorder were enrolled within standard course of care as in/outpatients if they initiated/ changed oral medication with antipsychotics, anticonvulsants or lithium for treatment of acute mania. Five hundred and thirty European psychiatrists including 23 Nordic psychiatrists enrolled 3459 patients including 79 Nordic patients eligible for analysis using the same study methods assessing demographics, psychiatric history, clinical status, functional status and pharmacological treatment. Psychiatric status at inclusion measured by the Young Mania Rating Scale (YMRS) and the Clinical Global Impression*Bipolar Disorder (CGI-BP) were similar in the Nordic and European patient groups, which is surprising as 73% of the Nordic patients compared with 38% of the European patients were inpatients. In the Nordic group of patients, more patientswere living independently. Before inclusion in the study more patients in the Nordic group had combination therapy, but after inclusion in the study the prescription pattern of psychopharmacy was similar in the Nordic and the European patient groups. This study indicated differences in admission patterns, patient social functioning and medical treatment in the Nordic patients compared with the European patients.  Bipolar disorder, mood stabilizers, observational study, psychoactive medication, social functioning. Jens Knud Larsen, M.D., Gentofte Psychiatric Centre, Niels Andersensvej 65, DK-2900 Hellerup, Denmark, E-mail: jela@geh.regionh.dk; Accepted 4 December 2008. B ipolar disorder has a lifetime prevalence of 12% (1, 2) and is a major cause of lost disability-adjusted life years (DALY’s) in industrialized societies (3). In most individuals the disorder runs a chronic course with multiple relapses. Patients are symptomatic for more than 40% of the time, mostly with depressive symptoms (4, 5). Although bipolar disorder is among the most heritable of mental disorders (6), social and psychologi- cal factors are nonetheless of great importance for determining the onset and course of the disorder (7). While medication is the cornerstone of therapy, social factors such as availability of social support and access to adequate housing, work opportunities, and specia- lized care will truly influence the course of the illness. In recent years there has been an outstanding increase in our knowledge on the treatment of mania on the basis of randomized clinical trials (8). Many of these studies investigated combination therapy with mood stabilizers and second-generation antipsychotics in the treatment of mania in bipolar disorder (9). There is, however, quite limited knowledge on the actual use of antimanic agents in routine clinical conditions, and large observational studies are rare. Observational studies are more likely to be challenged for their internal validity than randomized clinical trials, but they provide relevant data about the actual use of therapies either as monotherapy or combination therapy in ‘‘real world’’ patients, that is, without excluding comorbidities, suicide risk, with flexible and broader dose ranges, and across all ranges of illness severity (10, 11). EMBLEM (European Mania in Bipolar Longitudinal Evaluation of Medication) is a large-scale observational # 2009 Informa UK Ltd. (Informa Healthcare, Taylor & Francis As) DOI: 10.1080/08039480802663890