(Mania)
A disorder of mood control characterized by episodes in which the person’s mood and activity level are significantly
disturbed: in some occasions, there is an elevation of mood and increased energy and activity (mania) and in other
occasions, there is a lowering of mood and decreased energy and activity (depression). Characteristically, recovery is
complete in between the episodes.
Causes
- Biological, genetic, environmental factors
Clinical features
Patient can present in an acute manic episode, in a depressive episode or in between the episodes.
Mania
- Elevated, expansive or irritable moods
- Speech is increased with flight of ideas (increased talkativeness)
- Increased self image, restlessness, over-activity
- Decreased need for sleep
- Delusions of grandeur, increased libido
- Increased appetite but weight loss occurs due to overactivity
- Auditory and visual hallucinations may be present
Depression
- As for depression described above, but with a history of manic episode
Differential diagnosis
- Organic mental states e.g. drug or alcohol intoxication, delirium
- Chronic Psychosis
Investigations
- Good medical, social and personal history
- Assess for acute state of mania
- If depressive symptoms, investigate for previous manic episodes
- Assess for other medical or mental conditions (alcohol or subtance abuse, dementia, suicide/self harm)
Management
Patients with suspected bipolar disorder should be referred for specialist assessment.
Manic episode
Multiple symptoms as above for > 1 week and severe enough to interfere with work/social
activities and/or requiring hospitalization
- Discontinue antidepressant if any
- Provide counseling and education
- Chlorpromazine initially 100-200 mg every 8 hours, then adjust according to response
- Daily doses of up to 300 mg may be given as a single dose at night
- Gradually reduce the dose when symptoms of mania resolve and maintain on doses as indicated
in section on Chronic psychosis
- Or haloperidol initially 5-10 mg every 12 hours then adjust according to response
- Up to 30-40 mg daily may be required in severe or resistant cases
- Or trifluoperazine initially 5-10 mg every 12hours then adjust according to response
- Up to 40 mg or more daily may be required in severe or resistant cases
If under specialist supervision: initiate a mood stabilizer
- Carbamazepine initial dose 200 mg at night, increase slowly to 600-1000 mg/day in divided
doses - Or Valproate initial dose of 500 mg/day. Usual maintenance dose 1000-2000 mg
If agitation/restlessness, add a benzodiazepine for short period (until symptoms improve)
- Diazepam 5-10 mg evey 12 hours
Note
- If extrapyramidal side-effects (muscle rigidity, dripping of saliva, tongue protrusion, tremors) are
present while on antipsychotic drugs- Add an anticholinergic: Benzhexol initially 2 mg every 12 hours then reduce gradually to once daily
and eventually give 2 mg only when required
- Add an anticholinergic: Benzhexol initially 2 mg every 12 hours then reduce gradually to once daily
Bipolar depression
Depressive symptoms but with history of manic episode/diagnosis of bipolar disorder
- Counsel about bipolar disorder
- Begin treatment with a mood stabilizer (carbamazepine or valproate, see above)
- Psychoeducation and psychotherapy if available
- If moderate/severe depression, consider treatment with antidepressant in addition to
mood stabilizer BUT under specialist supervision (there is risk of triggering a manic episode)
In between episodes
Indication for use of mood stabilizers to prevent both manic and depressive episodes
-
- 2 or more episodes (2 manic or 1 manic and 1 depressive)
- 1 severe manic episode involving significant risk and consequences
- Valproate (or carbamazepine) as above
Caution
- Avoid mood stabilizers in pregnant women. Use low dose haloperidol if necessary
- Use lower doses in elderly
- Refer adolescents for specialist management
Prevention
- Good psychosocial support