ACUTE MANIA AND MIXED STATES (see algorithm)

In acute mania it is recommended to begin treatment with a mood stabilizer, either Lithium or Divalproex. In mixed mania, Divalproex (DVPX) and Carbamazepine are the drugs of choice. The principle is to use the medication that has both antimanic efficacy and is likely to be used to prophylaxis. In moderate to severe mania there is often a need to achieve rapid stabilization. This can be achieved by using a loading dose of 20 mg/kg/day of DVPX, the use of Lorazepam or Clonazepam in doses from 2 mg to 12 mg per day, and or, where there is severe behavioural disturbance and marked psychosis, the use of a neuroleptic or ECT. Both typical and atypical neuroleptics have specific anti-manic effects. Neuroleptics should be discontinued after the patient has been stabilized usually about two weeks into treatment unless there are persistent and or mood incongruent psychotic symptoms. Behaviour suppressers, like Lorazepam and Clonazepam have been used successfully as adjuncts instead of neuroleptics. Neuroleptic use is indicated in the long term if there is persistent or mood incongruent psychosis. It is important to taper down and stop antidepressants or other manicogenic agents and stabilize sleep patterns. Substance and alcohol use should be discontinued.

If the mania or mixed state is refractory to treatment, there should be a reassessment of the possibility of an underlying treatable medical cause. Any medical condition or substance abuse should be treated. If this is not present, the addition of a second mood stabilizer is acceptable practice while concurrently evaluating the need for ECT depending on the clinical situation. In partial or non-responders, the combination of three mood stabilizers (Lithium, DVPX and CBZ), or the addition of an atypical neuroleptic, Risperidone, in doses below 4 mg per day or substitution with Clozapine may be tried. The addition of a calcium channel blocker or a novel agent, like Lomatrigine or Gabapentin may also be considered.

It is usually sufficient to do serum medication levels no more frequently than once a week in the acute phase. Serum medication levels should be repeated until two consecutive levels have been obtained in the therapeutic range. After baseline investigations, the monitoring/investigations of bodily systems should be conducted as clinically indicated.