Principles of managing acute mania in adults and young people
For multifaceted management of bipolar disorder that is not restricted to an episode of acute mania, see Principles of managing bipolar disorder in adults and young people.
Before comprehensively assessing a person with manic symptoms, determine if they pose a threat to themselves or others. If there is a risk of harm, see Approach to managing acute behavioural disturbance.
Assessment of a patient with acute mania is best undertaken by a specialist—urgently refer people with manic symptoms to a psychiatrist or mental health service. Young people should ideally be referred to a youth mental health service such as Headspace, if available. For a first presentation of acute mania, psychiatrist review is particularly important to confirm the diagnosis; psychoeducation about bipolar disorder is also required.
Start treatment in liaison with a psychiatrist but do not delay treatment if prompt psychiatrist review is not available.
Determine the severity of mania symptoms. Patients with severe symptoms of mania usually have impaired insight and judgement, and risk causing significant harm to themselves or others (eg engaging in behaviour that damages their reputation, relationships or finances; aggression or physical harm to others). Determine whether the patient has engaged in uncharacteristic behaviour and help them to address any consequences of this behaviour.
Patients with severe symptoms of mania who are a danger to themselves or others require urgent treatment in hospital1. The primary aim of treatment is to curb disturbed behaviour (eg aggression, violence, agitation, overactivity, disinhibition)—an antipsychotic is used to rapidly achieve this. Additional intervention may be required to calm patients who are severely agitated, or are behaving in a threatening or aggressive manner. Start lithium, sodium valproate or carbamazepine simultaneously with the antipsychotic. See Overview of pharmacotherapy for acute mania in adults and young people for more detail and drug regimens. Electroconvulsive therapy (ECT) may be considered for severe acute mania.
Patients with less severe symptoms of mania also require prompt treatment but may not need to be hospitalised. Treatment in the community is preferred and may be delivered by a community mental health team, a shared-care program with the treating psychiatrist and general practitioner, or an outpatient program. Link patients to an acute specialist treatment team (eg crisis assessment and treatment team). Start combination therapy with an antipsychotic (to rapidly reduce the symptoms of mania), and lithium, sodium valproate or carbamazepine (for maintenance therapy). See Overview of pharmacotherapy for acute mania in adutls and young people for more detail and drug regimens.
In addition to starting pharmacological treatment, immediately stop or rapidly reduce any drug the patient is currently taking that has mood-elevating properties (eg antidepressant, stimulant).
Once acute mania has stabilised, offer relevant psychosocial interventions. Optimised multimodal therapy and an adequate duration of drug therapy can prevent recurrent episodes, which are associated with worse long-term outcomes. Poor treatment adherence can lead to relapse or recurrent episodes; check blood drug concentrations where relevant23. Other common causes of recurrence or relapse include substance abuse, antidepressant use, stressful life events and sleep deprivation. Some patients will relapse in the absence of any of these factors. If relapse occurs, treat according to the mood episode and consider the need for prophylaxis of bipolar disorder, in consultation with the patient’s psychiatrist.
See also the additional considerations: