Mania is a clearly denned condition that can present in different levels of severity varying from the mild (hypomanic) to the florid, raging, and psychotic. Only the mildest forms can be left untreated without risking harm to either the patient’s welfare, relationships, and job, or to the well-being of those who are close to them (relatives, care givers, or staff). Severe forms constitute a psychiatric emergency, demanding immediate control including rapid tranquillization with medication. Treatment lessens the severity and shortens the duration of manic episodes, which in the pretreatment era was usually 3 to 12 months with a mean of 26 weeks. In one modern series, remission from mania occurred in 50% of manic episodes by 12 weeks. After the first episode of mania, the mean latency to recovery was 13.7 weeks and the median 5.4 weeks in terms of the DSM-defmed syndrome of mania; 97% had recovered within two years, but only 35% had recovered in terms of personal and occupational functioning. The mean duration of hospitalization was 28 days.
Mania may immediately be followed by a phase of “post-manic” depression, which may be regarded as part of the same “cycle” of affective illness. Major depression ensued in 16% in one series treated with fluphenazine. Cognitive impairment particularly in attention and concentration may persist in some patients even when their mood has apparently recovered.
The Need For Admission
While milder cases may be treated in outpatients or at home, mania requires admission most obviously when associated with aggressive behavior, but also when overspending, grandiosity, sexual indiscretion or substance abuse threatens health or safety.
The loss of insight, grandiosity, and hyperactivity often preclude voluntary admission. Compulsory admission should be considered before the situation deteriorates. When assessing the needs of the patient with mania, it is helpful to remember that the severity of their condition is often greater than it appears at interview with a doctor. Whatever the means of admission, the patient should always be reassured that admission will enable them to rest and have relief, for instance, from their excessive activities and personal conflicts, and from their “overexcitement.”
The patient should be addressed tactfully, avoiding provocation or pressure. There should be stable external control, and administrative issues should be handled in a firm and nonnegotiable manner. Consistent limits should be set in order to prevent behavior that is dangerous or disruptive to the patient or others. All the staff should be consistent in this. The patient will often require either individual attention or nursing in a (locked) psychiatric intensive care setting to prevent them leaving the ward. The emphasis should be on calming the patient. Restrictions on visiting and time spent alone can help to reduce stimulation. When speaking with the patient, the voice should be lowered with slightly slower cadence than usual. Argument about the content of delusions should be avoided, although once responding to drug treatment, cognitive therapy challenging abnormal ideas may assist recovery.
A structured timetable may be helpful, and writing or coloring materials should be available if the patient can concentrate sufficiently to use them. Other reality-based diversionary activities should be provided.
Specific issues to be addressed are the alienation of family members, the progressive testing of limits by the patient, the overinvolvement with other patients and the tendency to dominate the ward. In 1974, Janowsky et al. described these tendencies as “the manic game” and implied that the manic patient demands care without having to admit their need for it. Staff need to understand these maneuvers in order to avoid becoming too personally involved, for instance, in angry exchanges. Community meetings are helpful as they allow the responses of other patients to the manic person’s behavior to be recognized and guided.
As the patient’s condition improves, individual work should be aimed at identifying factors that may have contributed to the present episode, and helping the patient to tolerate feelings of depression or distress that may emerge. They may need help to reestablish personal and occupational relationships. Empathic meetings between a member of the ward team and relatives can prepare them to understand explanations that the patient’s condition is a treatable illness that, in the longer term, needs their support and may benefit from prophylactic medication.
Treating Subtypes Of Mania
Mania with Psychotic Features
Earlier guidelines regard psychotic features as being an indication for us of “neuroleptic” or antipsychotic drugs. However, psychosis has not been identified as a predictor of differential response to any of the treatments. Rather, psychosis is often an indicator of severity of mania, and antipsychotics are recommended particularly for their ability to control severe mania rapidly.
Treatment of Mixed Mania
The description “mixed state” has been used in more than a dozen ways, each of which carries different implications about treatment.
Lithium is less favored than valproate, and atypical antipsychotic drugs are recommended in preference to older drugs. Some guidelines caution that typical antipsychotics may worsen depression, although evidence for this is rarely cited. Carbamazepine has been recommended for dysphoric mania, a form of mixed state. ECT is recommended in some, as is clozapine for refractory patients.
Treatment of Mania with Rapid Cycling
Most authorities emphasize the importance of discontinuing antidepressants particularly tricyclic drugs and drugs of abuse, and of checking thyroid function. There is agreement that such patients can be refractory to treatment, particularly with lithium. Depot formulations of classical antipsychotics have been used and recently atypical antipsychotics are suggested, although some believe that combinations of “mood stabilizers” may also be required.
In studies of olanzapine mania improved to a similar extent in those with rapid cycling. There is no mention of rapid cycling in any of the placebo-controlled studies of risperidone. However, open studies suggest risperidone may be of benefit, usually as augmentation to lithium or valproate.
Management on Recovery from Mania
Although lack of insight is characteristic of mania and is often the last symptom to improve, on recovery from an episode of mania, most people will have begun to acknowledge that they have been ill. A therapeutic alliance between the patient and the treatment team should be developing. At this time, efforts should be made to improve their understanding of their condition, by means of psychoeducation about bipolar illness and about treatments available. They should be encouraged to recognize the early features of mania (such as racing thoughts, insomnia, irritability, or comments from others about their mood). They should have a plan of what steps to take in the event of a recurrence of such symptoms. In particular, they should have access to antipsychotic medication, which they might usefully take in order to avert the development of another manic episode. The possibility of prophylactic treatment should also be discussed, including lithium. This approach can increased the time to first manic recurrence and improve social functioning and employment.
Treatment of Mania: Conclusion
Mania can affect people of all social and occupational groups and is usually a phase in a recurring bipolar illness. Manic episodes are very disruptive to family life and employment, and there is a high rate of divorce and successful suicide in bipolar patients. Treatment will often minimize or allow such disruptions to be avoided, and reduce the suicide risk. There is overwhelming evidence for the value of antipsy-chotic medication in mania. Lithium and valproate are also useful. “NNT” analysis shows that only a minority of episodes of mania, severe enough to enter clinical trials, respond to monotherapy; but combinations of an antipsychotic with another antimanic drug (lithium or valproate) provide additional efficacy, and for some patients, carbamazepine is a useful alternative. Sufferers from these conditions are now able to choose from a range of treatments. Doctors and relatives should encourage patients with bipolar disorder to make these choices, and doctors should advise them on how, by providing them with sufficient information. Treatment of a manic episode is often the opportunity to begin the process of forging a therapeutic alliance, to commence psychoeducation with the patient and care givers, and to start further treatment with the aim of averting future episodes.
Selections from the book: “Handbook of Bipolar Disorder: Diagnosis and Therapeutic Approaches”, 2005.