Treatment of Acute Mania or Hypomania.

Treatment of Acute Mania or Hypomania. - Flowchart Treatment of acute mania or hypomania Treatment of acute mania or hypomania

«Flowchart»

Stop antidepressant treatment

If taking an antipsychotic, check compliance and dose. Increase if necessary. Consider adding lithium or valproate

If taking lithium, check plasma levels, consider increasing the dose to give levels 1.0-1.2 mmol/L (to treat the acute episode - not for long-term maintenance), and/or adding an antipsychotic

If taking valproate, check plasma levels,⁴,⁵,²²,²³ increase dose to give levels up to 125mg/L if tolerated. Consider adding an antipsychotic

If taking lithium or valproate and mania is severe, check level, add an antipsychotic²

If taking carbamazepine, consider adding antipsychotic (higher doses may be needed as antipsychotic levels reduced)

All patients - consider adding short-term benzodiazepine¹⁹,²⁰,²¹ (lorazepam or clonazepam)

If taking an antipsychotic, check compliance and dose. Increase if necessary. Consider adding lithium or valproate

If taking lithium, check plasma levels, consider increasing the dose to give levels 1.0-1.2 mmol/L (to treat the acute episode - not for long-term maintenance), and/or adding an antipsychotic

If taking valproate, check plasma levels,⁴,⁵,²²,²³ increase dose to give levels up to 125mg/L if tolerated. Consider adding an antipsychotic

If taking lithium or valproate and mania is severe, check level, add an antipsychotic²

If taking carbamazepine, consider adding antipsychotic (higher doses may be needed as antipsychotic levels reduced)

All patients - consider adding short-term benzodiazepine¹⁹,²⁰,²¹ (lorazepam or clonazepam)

If taking an antipsychotic, check compliance and dose. Increase if necessary. Consider adding lithium or valproate

If taking an antipsychotic,

If taking lithium, check plasma levels, consider increasing the dose to give levels 1.0-1.2 mmol/L (to treat the acute episode - not for long-term maintenance), and/or adding an antipsychotic

If taking lithium,

If taking valproate, check plasma levels,⁴,⁵,²²,²³ increase dose to give levels up to 125mg/L if tolerated. Consider adding an antipsychotic

If taking valproate, ⁴ ⁴ ⁵ ⁵ ²² ²² ²³ ²³

If taking lithium or valproate and mania is severe, check level, add an antipsychotic²

If taking lithium or valproate ² ²

If taking carbamazepine, consider adding antipsychotic (higher doses may be needed as antipsychotic levels reduced)

If taking carbamazepine,

All patients - consider adding short-term benzodiazepine¹⁹,²⁰,²¹ (lorazepam or clonazepam)

All patients - consider adding short-term benzodiazepine¹⁹,²⁰,²¹ ¹⁹ ¹⁹ ²⁰ ²⁰ ²¹ ²¹

End

Note that lithium may be somewhat less effective in mixed states²⁴ or substance misuse²⁵.

²⁴ ²⁴ ²⁵ ²⁵

Is the patient taking antimanic medication?

Yes

Yes Yes

No No

Consider:
An antipsychotic (if symptoms severe or behaviour disturbed)

Valproate (avoid in women of child-bearing potential)

Lithium (if future adherence likely)

If response is inadequate
Combine antipsychotic and valproate or lithium

All patients - consider adding short-term benzodiazepine¹⁹,²⁰,²¹ (lorazepam or clonazepam)

Consider:
An antipsychotic (if symptoms severe or behaviour disturbed)

Valproate (avoid in women of child-bearing potential)

Lithium (if future adherence likely)

If response is inadequate
Combine antipsychotic and valproate or lithium

All patients - consider adding short-term benzodiazepine¹⁹,²⁰,²¹ (lorazepam or clonazepam)

Consider:
An antipsychotic (if symptoms severe or behaviour disturbed)

Consider:

Valproate (avoid in women of child-bearing potential)

Lithium (if future adherence likely)

If response is inadequate
Combine antipsychotic and valproate or lithium

If response is inadequate

All patients - consider adding short-term benzodiazepine¹⁹,²⁰,²¹ (lorazepam or clonazepam)

All patients - consider adding short-term benzodiazepine¹⁹,²⁰,²¹ ¹⁹ ¹⁹ ²⁰ ²⁰ ²¹ ²¹