Principles of treatment for agitation in adults and young people with acute mania

Agitation is a common symptom of acute mania that varies in duration and severity, ranging from mild (eg pacing, fidgeting) to severe (eg uncooperative, threatening or aggressive behaviours). If initial treatment with an antipsychotic plus lithium, sodium valproate or carbamazepine is not effective in managing agitation, further intervention may be required.

If a patient with mania is acutely agitated, only provide treatment if it is safe and appropriate to do so. If possible, use nonpharmacological measures, including verbal de-escalation and psychological intervention, to reduce the risk of harm.

If a patient with acute mania remains agitated but is willing to accept an oral drug, consider using a suitable dose of the patient’s antipsychotic or adding a benzodiazepine. Drug choice is influenced by current treatment, previous response, severity of agitation and patient factors. Additionally, consider the following:

• An antipsychotic is preferred for more severe agitation; however, there are few data to support ‘as needed’ (prn) administration of antipsychotics, and it can worsen agitation and increase the risk of adverse effects (eg akathisia).
• A benzodiazepine is preferred for a first episode of mania, to minimise exposure to antipsychotics; however, high doses of benzodiazepines can cause delirium, which can cause or worsen agitation.

Zuclopenthixol may be considered by a psychiatrist for some patients—see Zuclopenthixol for agitation in adults and young people with acute mania.

See the additional considerations in drug choice:

• in young people
• during pregnancy—see Benzodiazepine use during pregnancy and Antipsychotic use during pregnancy
• while breastfeeding—see Benzodiazepine use while breastfeeding and Antipsychotic use while breastfeeding.

If the patient will not accept an oral drug, see Pharmacological management for acute behavioural disturbance in adults or Pharmacological management for acute behavioural disturbance in older people for further advice.