Management of acute mania

Treatment is best carried out in hospital; if the patient is already in a neurology ward, transfer to a psychiatric ward is desirable. Because of the lack of insight which is characteristic of mania, compulsory admission may have to be arranged. The two groups of drugs which are regularly used in acute mania are: (i) antipsychotics (such as chlorpromazine or haloperidol and the newer so-called atypical antipsychotics olanzapine and risperidone) and (ii) benzodiazepines (such as diazepam). Chlorpromazine can be given orally starting at a dose of 25-50 mg eight hourly, increasing to a maximum daily dose of 1500 mg according to the clinical response. When oral treatment is not accepted, an intramuscular injection of up to 150 mg can be given but this should not be repeated because of its irritant effect on muscle tissue. Haloperidol can be started at an oral dose of 5 mg eight hourly increasing to a maximum daily dose of 40 mg. When speedier control of symptoms is required, an intramuscular injection of 10-20 mg can be given.

The older antipsychotic drugs are likely to produce a variety of extrapyramidal side effects, especially in patients with existing brain damage. Akathisia, Parkinsonism, acute dystonia, and tardive dyskinesia are well established complications. Akathisia, a subjective sense of motor restlessness, leads to hyperactivity and an inability to relax. It can be wrongly attributed to a worsening of the manic condition, so an inexperienced clinician may increase the dose of antipsychotic rather than reduce it and consequently the akathisia symptoms worsen. A beta-adrenergic blocking drug such as propranolol is an effective remedy once the condition is diagnosed. Acute dystonias can also give rise to diagnostic confusion. They can present with tongue protrusion, torticollis, oculogyric crisis, or opisthotonus, and these are often wrongly diagnosed as dissociative (hysterical) reactions. Rapid relief of symptoms can be achieved by an intravenous dose of 5-10 mg of procyclidine. Sudden cardiorespiratory collapse is a potentially fatal complication of antipsychotic treatment, especially when the patient shows evidence of extreme physiological arousal and overactivity. Drug doses should be kept as low as possible and the treatment regimen monitored regularly. Pulse and blood pressure should be checked before each intramuscular injection and at regular intervals during oral treatment. In the light of these problems attention is turning to the newer antipsychotics. Olanzapine appears effective in the treatment of acute mania, with a low incidence of side effects,35 so it may replace the more established drugs.

If manic symptoms do not respond to medication, ECT can prove to be a quick and effective treatment.

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