Overview of pharmacotherapy for acute mania in adults and young people
See Principles of managing acute mania in adults and young people for advice on the setting in which initial treatment should be delivered, the requirement for psychiatrist oversight and an overview of management. Involuntary treatment is often necessary1.
An antipsychotic is the most effective drug for rapidly reducing symptoms of acute mania but is usually stopped once acute mania remits because lithium, sodium valproate or carbamazepine are preferred for maintenance therapy. Lithium, sodium valproate or carbamazepine is started in parallel with an antipsychotic, which may enhance resolution of the acute mania. Additional short-term pharmacotherapy may be needed for patients with severe agitation or threatening and aggressive behaviour.
The pharmacological treatment of acute mania is summarised in Pharmacological treatment of acute mania in bipolar disorder in adults and young people.
Review response to treatment every 2 to 3 days. Agitation, difficulty sleeping and aggressive behaviour often start to settle within a few days, while the underlying elevated or irritable mood and any associated psychotic features may take up to a month to resolve. If there is no response to initial treatment, or the treatment response is inadequate, seek expert advice (see also Nonresponse to treatment for acute mania).
Simultaneously monitor the tolerability of treatment—tolerability is an important consideration because drug therapy is usually prolonged.
Consider contraindications, precautions, adverse effects, dosage adjustments, clinical monitoring requirements before and during therapy, and therapeutic drug monitoring23. For the principles of antipsychotic use, see here. Consult a drug information source for other drugs.
After acute mania has resolved and the patient is euthymic (ie has a stable mental state that is neither manic nor depressed), monotherapy with lithium, sodium valproate or carbamazepine for maintenance therapy is preferred—follow the psychiatrist’s treatment plan for stopping the antipsychotic and any adjunctive pharmacotherapy for agitation.
Use maintenance therapy for at least 6 months after a first manic episode, then assess whether prophylaxis of bipolar disorder is required. If stopping a drug, liaise with a psychiatrist about how to do so.
See also the additional considerations:
- in young people
- in females of childbearing potential
- during pregnancy
- during the postpartum
- for sodium valproate use in males of reproductive potential.
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Drug |
Comments |
|---|---|
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start immediately to rapidly reduce symptoms of mania [NB1] use short term—stop once acute mania symptoms remit and the patient is euthymic [NB2] | |
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PLUS | |
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start concurrently with the antipsychotic continue for 6 to 12 months to prevent relapse, then consider if prophylaxis is needed | |
Note:
NB1: Additional short-term pharmacotherapy may be needed for patients with severe agitation or threatening and aggressive behaviour. NB2: Some patients relapse when the antipsychotic is stopped and may require ongoing treatment with an antipsychotic (in combination with lithium, sodium valproate or carbamazepine). Alternatively, 2 of the 3 drugs used for maintenance therapy—lithium, sodium valproate and carbamazepine—can be combined. | |