Acute mania or mixed episode (Bipolar I)

As with any medical disorder, proper treatment of bipolar disorder is reliant upon correct diagnosis. Due to the nature of acute mania the management of severe symptoms often has to go hand in hand with the information gathering of the complete assessment process.

Treatment of Acute Mania, or of Mixed Episodes with acute manic symptoms involves first and foremost:

Consideration of the safety and wellbeing

of self  and of others

In acute mania, judgement can be significantly impaired and overactivity and irritablity highly problematic. The individual is at risk of behaviour which they may significantly regret later on such as spending or sexual indiscretions that they would never normally consider. In some people, there may even be uncharacteristic and unpredictable violent behaviour.

Also some individuals with mania will have psychotic symptoms such as hallucinations or delusions which may put them or others at risk.  For all of these reasons, one of the first decisions to be made is about whether hospitalisation is required. Many individuals with anything more than mild mania may require hospitalisation for at least a short period of time until treatment is established and symptoms are brought under control.

In severe mania where the individual has lost insight into the situation involuntary admission to hospital (“detention“/”sectioning“) may be neccessary.

In mild mania – where the individual remains cooperative or hypomania and where there is good insight into what is going on, managing things on an outpatient or day patient basis may be perfectly possible if suitable support and monitoring can be put in place.

Acute Stabilisation of the Manic Episode

The goals during the acute stabilsation phase should be:

  • to nurse/support the patients in a safe and suitable environment appropriate to the level of symptomatology
  • to commence and adjust the dose of medication to rapidly bring acute agitation, sleep disturbance and any psychotic symptoms under control with minimal degree of side effects
  • to complete the information gathering and workup to clarify any uncertainties remaining around issues of diagnosis
  • to provide information and support to family/carers

Once the decision has been made about where the individual is to be treated, a plan needs to be made about “anti-manic” medication.  Medications currently used for the treatment of acute mania can be divided into:

  • Antipsychotic Antimanic Agents including:  Aripiprazole, Asenapine, Olanzapine, Risperidone, Paliperidone and Quetiapine
  • Lithium: taken as Lithium Carbonate or Lithium Citrate
  • Anticonvulsant Anitmanic Agents: usually Sodium Valproate or Semisodium Valproate, or Carbamazepine
  • Benzodiazepines: (diazepam related drugs) such as Lorazepam are also used to manage arousal and agitation in some settings

Treatment summaries of the evidence base and reference lists for most of these individual agents are available by following the links of the left-hand side.