What is the recommended treatment for acute mania in adults?

Treatment for Acute Mania in Adults

First-line treatment for acute mania in adults should include a mood stabilizer such as lithium or valproate, or an atypical antipsychotic such as risperidone, with combination therapy reserved for severe cases or inadequate response to monotherapy. 1

First-Line Treatment Options

Mood Stabilizers

• Lithium

  • Established efficacy in acute mania
  • Requires baseline and periodic monitoring of:
    • Serum levels
    • Thyroid function
    • Renal function
  • May cause bradycardia and T-wave changes 1

• Valproate

  • Effective for mixed mania and rapid cycling
  • Monitoring requirements:
    • Liver function tests
    • Complete blood counts
    • Pregnancy tests in females of childbearing potential
    • Serum drug levels every 3-6 months 1
  • Risks include gastrointestinal disorders, rare hepatitis and pancreatitis 1

Atypical Antipsychotics

• Risperidone

  • FDA-approved for acute manic or mixed episodes in Bipolar I Disorder
  • Effective as monotherapy in doses of 1-6 mg/day (mean modal dose: 4.1-5.6 mg/day)
  • Can be used as adjunctive therapy with lithium or valproate 2

• Aripiprazole

  • Preferred due to efficacy and lower risk of weight gain
  • Effective for acute manic symptoms at 3-4 weeks 1, 3

Treatment Algorithm

1. Initial Assessment

   • Determine severity of mania (mild, moderate, severe)
   • Assess for psychotic features
   • Check for rapid cycling pattern

2. Monotherapy (First Choice)

   • For mild to moderate mania without psychotic features:
     • Lithium OR
     • Valproate OR
     • Atypical antipsychotic (risperidone, aripiprazole)

3. Combination Therapy (For Severe Cases)

   • For severe mania, psychotic features, or rapid cycling:
     • Mood stabilizer + atypical antipsychotic
     • Common combination: Risperidone (1-6 mg/day) + lithium or valproate 2

4. Special Considerations

   • For psychotic mania: Prioritize antipsychotics
   • For mixed episodes or rapid cycling: Valproate may be preferred over lithium 1
   • For severe, treatment-resistant mania: Consider intravenous valproate loading 4

Monitoring and Follow-up

• Assess response within 1-2 weeks
• Monitor for side effects:
  • Movement disorders (especially with antipsychotics)
  • Gastrointestinal disturbances
  • Metabolic changes (weight, glucose, lipids)
• Regular laboratory monitoring as indicated for specific medications 1

Common Pitfalls to Avoid

1. Inadequate dosing: Ensure therapeutic doses are reached quickly but safely
2. Premature discontinuation: Maintain treatment for at least 2 years after the last episode 1
3. Inappropriate use of antidepressants: Avoid in acute mania as they may worsen symptoms
4. Neglecting physical health monitoring: Regular monitoring of metabolic parameters is essential
5. Abrupt discontinuation: Can lead to withdrawal symptoms and rapid relapse 1

While benzodiazepines may be used for short-term management of agitation, they should not be the primary treatment for mania 5. Psychotherapy, including psychoeducational therapy, family-focused therapy, and cognitive-behavioral therapy, should be considered as adjunctive treatments once the acute phase has stabilized 1.