OBJECTIVES:  Update a previously published systematic review1 of pharmacological treatments for acute mania in bipolar I disorder, to include recent publications, including new formulation quetiapine extended release (XR), and remission rates. METHODS: Systematic review of CENTRAL, EMBASE, MEDLINE, for randomised, controlled trials comparing placebo to: aripiprazole, carbamazepine, divalproex, haloperidol, lithium, olanzapine, quetiapine XR, and risperidone as monotherapy, in the treatment of acute mania in bipolar I disorder, published before March 2009. Trials of combination therapy and patients non-responsive to previous therapy were excluded. Data were combined through random effects meta-analyses using Comprehensive Meta Analysis. Summary effect estimates were presented as Relative Risk (RR) versus placebo and 95% Confidence Interval (95%CI). RESULTS: 408 publications were identified and overall 19 trials from 18 papers were included in the analysis. The results for remission reported that risperidone followed by quetiapine XR were the most effective antipsychotics: risperidone (RR:1.87, 95%CI:1.22-2.85), quetiapine XR (RR:1.46, 95%CI:1.07-2.01), olanzapine (RR:1.39, 95%CI:1.08-1.79), aripiprazole (RR:1.29, 95%CI:1.05-1.58), haloperidol (RR:1.29, 95%CI:1.03-1.62). Lithium followed by divalproex ER were the most effective mood stabilisers: lithium (RR:1.73, 95%CI:1.08-2.79), divalproex ER (RR:1.40, 95%CI:1.09-1.80), divalproex (1.12, 95%CI:0.81-1.55), carbamazepine ER (not available). The results for response reported that risperidone and quetiapine XR were the most effective antipsychotics: risperidone (RR:1.77, 95%CI:1.50-2.09), quetiapine XR (RR:1.61, 95%CI:1.23-2.10), olanzapine (RR:1.54, 95%CI:1.23-1.92), aripiprazole (RR:1.46, 95%CI:1.26-1.70), haloperidol (RR:1.41, 95%CI:1.19-1.66). Carbamazepine ER followed by lithium were the most effective mood stabilisers: carbamazepine ER (RR:2.01, 95%CI:1.55-2.61), lithium (RR:1.57, 95%CI:1.28-1.92), divalproex (RR:1.46, 95%CI:1.10-1.93), divalproex ER (RR:1.45, 95%CI:1.12-1.87). Due to incomplete reporting, the pooled mean difference in YMRS was considered unreliable. CONCLUSIONS: Selecting the right pharmacological treatment strategy which optimises remission is key to maximising patient outcomes and efficient use of healthcare resources. This analysis suggests that risperidone, quetiapine XR and lithium are promising treatment options for bipolar I mania. 1. Smith, Bipolar Disord. 2007;9:551-560.