Treatment of mania

4 Treatment of mania




4.1 What is the best treatment for mania? 82

4.2 How are antipsychotics used in mania? 82

4.3 How quickly does antipsychotic treatment work? 83

4.4 What other treatments are effective in mania apart from antipsychotics? 83

4.5 What if the mania is not improving on antimanic treatment? 85

4.6 What are the next lines of treatment in mania that has not responded to the first antimanic treatment? 86

4.7 How long should antimanic drugs be taken? 86

4.8 How are psychotic symptoms in mania treated? 86

4.9 What treatment is useful in an emergency? 87

4.10 Do antipsychotics increase the risk of switching into depression? 87

4.11 What treatment is effective for hypomania? 88

4.12 Is ECT an effective treatment for mania? 88

4.13 What investigations are needed? 88

4.14 How should I talk to a manic patient? 89

4.15 How is the need for hospitalisation judged? 90

4.16 How is the need for compulsory detention for treatment in hospital judged? 91

4.17 Can other specialist staff help in coping with a manic patient? 92

4.18 How often do patients commit serious crimes when they are manic? 93

4.19 Is violence a problem in mania? 93

4.20 What is the best way to deal with violent behaviour in a bipolar patient? 94

4.21 How do I resolve potentially violent situations involving bipolar patients? 94

4.22 What can family and friends do to help a manic patient? 95

4.23 Is an advance directive helpful when you are managing mania? 96

PQ Patient questions
4.24 How can I recognise that I am going manic? 97

4.25 What can I do to help myself if I think that I am becoming manic? 97



4.1 What is the best treatment for mania?




imageThe first step in the treatment of mania is to stop the antidepressants. There are then two main lines of treatment in acute manic relapses. The first is to increase the long-term treatment–for example if the patient is already taking lithium then the levels should be checked and, providing it is being tolerated reasonably well, to increase the dose, aiming for a level of up to 1.0 mmol/l (occasionally up to 1.2 mmol/l). A similar approach can be adopted with valproate and carbamazepine. The alternative line is to give a specific antimanic treatment, usually an antipsychotic, either on its own or in combination with a long-term treatment (Fig. 4.1).


image

Fig. 4.1 Acute treatment of mania.



4.2 How are antipsychotics used in mania?


The most commonly used medicines for the acute treatment of mania are the antipsychotic drugs (neuroleptics).


imageUntil the introduction of the newer (atypical) neuroleptics the standard treatment was with haloperidol or chlorpromazine. These older treatments are effective but tend to cause a lot of side-effects, particularly parkinsonian symptoms such as tremor, shuffling and abnormal movements. They often cause akinesia and lack of facial expression but can also precipitate restlessness or akathisia where the patient has trouble sitting or standing still–a very distressing state. Akathisia can also be mistaken for the overactivity of mania. The main difference is that the manic patient likes being active but hates feeling restless, usually locating the restlessness of akathisia directly in their limbs rather than in their mind.


Traditional antipsychotics also have the advantage of being both sedative and calming which can be a considerable benefit in the early stages of treatment of mania. They still have a place in the emergency treatment of manic excitement and haloperidol (5 or 10 mg IM) is a safe drug to inject in these circumstances, usually in combination with procyclidine 10 mg to prevent dystonic reactions.


Olanzapine, quetiapine and risperidone are the atypical antipsychotics that are licensed for the treatment of mania but it is probably true that all antipsychotic drugs, including the newest one, aripiprazole, improve manic symptoms. These drugs are relatively free of parkinsonian side-effects, and are generally well tolerated (Table 4.1). They are available in either rapidly dispersing tablets or liquid which can be helpful when compliance is in doubt. Olanzapine is now also available as an injection.



TABLE 4.1 Drugs used in the acute treatment of mania

image

The reason that antipsychotics are preferred to other medicines such as lithium and carbamazepine is that they are easy to use so an effective dose can be quickly reached. Additionally, most GPs are familiar with their use.



4.3 How quickly does antipsychotic treatment work?


Some improvement in manic symptoms should be seen within a few days of starting the treatment (often due to a sedative effect), with a more substantial recovery over 6 weeks. It is worth continuing one treatment line for 6 weeks to assess response rather than changing or adding another treatment after a couple of weeks. (This can require steady nerves since if there is no improvement in the first 2 weeks everyone starts to wonder if you know what you are doing!) If the level of activity or disturbance is high and sleeplessness is a problem, prescribing benzodiazepines (diazepam or lorazepam) in combination with the antipsychotics can be a useful short-term measure.



4.4 What other treatments are effective in mania apart from antipsychotics?




VALPROATE


Valproate is the main alternative acute treatment and has the advantage of being effective, well tolerated and easy to use. Depakote is the formulation that is licensed for the treatment of mania as the studies have been done using this form (Bowden et al 2000, NICE Technology Appraisal 66). This particular formulation provides higher blood levels for the same apparent dose compared to other forms of valproate. The usual starting dose is 750 mg daily (250 mg tablets spread over two doses). It can then be increased gradually over a week up to 1500 mg or further to 2 g if necessary. It would seem likely that the other forms of valproate are also effective but licensed preparations are generally preferred (see National Institute for Clinical Excellence guidelines, www.nice.org.uk).



LITHIUM


Lithium is also an effective antimanic treatment and is used in similar doses and with similar blood levels to those used in preventive treatment (see Chapter 5). Higher doses with levels up to 1.0 mmol/l or even slightly higher than this are sometimes used. There are several difficulties in using lithium in mania:


image Patients who are severely ill may be drinking little and are therefore liable to dehydration; this makes treatment with lithium more difficult and potentially dangerous.

image It is difficult to find the effective dose rapidly as increases are usually done gradually: it can take a couple of weeks to reach a therapeutic dose and manic symptoms often need more urgent treatment than this.

image Another reason relates to starting a long-term preventive treatment when a patient is manic and is not capable of making longer term decisions. Stopping lithium suddenly can cause a rebound manic effect (see Chapter 5). If lithium is started when patients are acutely manic and not committed to long-term treatment, they are likely to stop when they have recovered and this will risk precipitating a further episode of mania. This effect is not so apparent with antipsychotics and valproate.

For all these reasons antipsychotics or valproate are usually used first line; lithium is then added if the first line of treatment is not proving effective. In practice most patients are given a combination of treatment, with antipsychotics being added as an acute treatment to the longer term treatment, usually lithium.



CARBAMAZEPINE


Carbamazepine is also effective in the treatment of mania and it is useful to bear this in mind either as a primary treatment or increasing the dose if the patient is already on carbamazepine.



BENZODIAZEPINES


Benzodiazepines are also commonly used in mania. They are used generally for their sedative effect and particularly in cases where urgent calming and sleep induction are necessary. Lorazepam (0.5-1 mg) as an intramuscular injection is an effective emergency treatment for acute psychosis including mania (see Q 4.9). In the early days of treating excited manic patients many doctors give diazepam which has a long half-life, helps to improve sleep and has a calming effect during the day. Clonazepam is also used and there have been some studies to show this is effective in mania on its own, though it is unusual to treat mania only with benzodiazepines.



4.5 What if the mania is not improving on antimanic treatment?


This is a similar answer to that of treating depression that does not improve (see Q 3.9). The following questions should be considered before contemplating a change in medication:


image Have you given the treatment long enough?: For example, at least 4 weeks with no or only minor response. It can be difficult to stick with the treatment when there is little improvement, but if the treatment is changed too early the benefits of the medication may be missed.

image Have you tried a higher dose?: If the patient is not getting better, doses should be increased to the maximum dose that is recommended, provided that the treatment is reasonably tolerated before turning to an alternative antimanic.

image Have you assessed concordance/compliance?: This is usually a problem in the treatment of mania as most patients have limited insight into their condition and so are unlikely to be taking the treatment correctly. There is also a fair chance that they are deliberately concealing their non-compliance rather than refusing. It is not uncommon to find a stack of tablets hidden away in a patient’s room when they have appeared entirely willing to take the treatment (see also Q 5.43). Can you arrange some supervision of the treatment and give it in a formulation that is harder to evade–a liquid or dispersible tablet?

image Are they physically ill? (see Q 4.13): Specifically, is their thyroid function normal?

image Have you got the diagnosis right?: For example, is this really an episode of mania or is this a drug or alcohol problem?

image Is there another medication that they are taking that might be affecting their mania (e.g. steroids)?


4.6 What are the next lines of treatment in mania that has not responded to the first antimanic treatment?


If the first line being followed is with a single medication then try a combination of treatments: an antipsychotic should be one medication together with another antimanic, usually lithium or valproate.


Although there are some reservations on using lithium in acute mania, if there is little improvement lithium must be considered and at a sufficient dose to give a level of about 1.0 mmol/l.


There are other options available but these would usually be restricted to specialist use. These include carbamazepine, lamotrigine (see Q 3.4), benzodiazepines (including clonazepam) or ECT (see Q 3.22).



4.7 How long should antimanic drugs be taken?




imageThe symptoms of mania need to have completely abated before considering slowly tapering off the antimanic medication.


As soon as the symptoms have begun to settle it is reasonable to start reducing the additional sedatives if these have been prescribed. If the patient is sedated by the antimanic treatment then this should also be cautiously reduced. These changes should be made slowly and on an experimental basis so that if symptoms re-emerge then the dose can be increased again.


Most doctors would wait 2-3 months after the manic symptoms have remitted to start slowly tapering the antimanic treatment, again watching for signs of relapse. This is the stage at which to have a discussion with the patient about longer term treatment.

< div class='tao-gold-member'>

Related posts:

Causes and course of the illness Lithium and long-term prophylactic treatment Special circumstances and considerations What is manic depression (bipolar disorder)? Treatment of bipolar depression Psychosexual Development and Sexual Dysfunctions

Stay updated, free articles. Join our Telegram channel
Tags:
Jul 12, 2016 | Posted by in PSYCHOLOGY | Comments Off on Treatment of mania

Full access? Get Clinical Tree
Get Clinical Tree app for offline access