A number of mood stabilizers are reported to have an acute antimanic effect, but the Expert Consensus Guideline on the Treatment of Bipolar Disorder (1°3) advocated either lithium or valproate as the drugs of first choice. Valproate is often preferred for patients with mixed states or rapid cycling disorder. Response to lithium or valproate is usually delayed by 7 to 14 days, so most clinicians also use other drugs such as neuroleptics or atypical antipsychotics. These are effective within a matter of days in controlling the acute symptoms of mania, particularly delusions, hallucinations, thought disorder, or severe agitation. The main problem with the classic combination of haloperidol and lithium is the need for close monitoring, as manic patients are at greater risk of neuroleptic malignant syndrome and a combined lithium-neuroleptic neurotoxicity syndrome has also been reported. Benzodiazepines such as lorazepam and clonazepam are frequently used to treat hyperactivity, insomnia, and agitation. (103)
The loss of insight, impaired judgement, and disinhibited behaviour of manic patients or the level of agitation and hyperactivity often mean that hospitalization is required to ensure the patient's safety and commence an appropriate treatment regimen. For severe cases of mania, ECT may occasionally be used as a first-line treatment.
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