01Purpose and principlesWhat the treatment does and how it fits into care.
Acute mania treatment combines environment, engagement, risk management and medication. Provide reduced stimulation and advise against important financial, occupational or relationship decisions until recovery. Clarify the target symptoms: sleep, motor activation, psychosis, irritability, aggression and disorganisation. Reconcile current prescriptions, adherence, last doses, as-needed exposure, substances, previous benefit and adverse effects before selecting or escalating a medicine.
For a person not taking an antipsychotic or mood stabiliser, NICE offers haloperidol, olanzapine, quetiapine or risperidone. These are parallel first choices rather than a universal single drug. Selection should incorporate any advance statement, the person's preference and clinical context: metabolic risk, cardiac disease, extrapyramidal vulnerability, sedation need, pregnancy, older age, previous response and interaction burden. Discuss the adverse effects the person is most willing to tolerate and record the intended therapeutic trial.
Sequence matters. Start within the product-authorised range for phase and severity and titrate after clinical reassessment. If the initial choice is ineffective at the maximum licensed dose or poorly tolerated, offer a different recommended antipsychotic. If that alternative is also ineffective at its maximum licensed dose, consider lithium augmentation. If lithium is ineffective or unsuitable, valproate may be considered only after applying the current MHRA age, sex and reproductive restrictions and its formulation-specific licensing.
Current treatment changes the route. During antidepressant monotherapy, consider stopping the antidepressant and offer an antipsychotic. During combined antidepressant and mood-stabiliser treatment, consider stopping the antidepressant. If lithium is prescribed, check the plasma concentration and optimise treatment and add a recommended antipsychotic when needed. If valproate is prescribed, verify adherence, consider tolerated dose optimisation or change treatment, with full reproductive and physical safety review. Mixed affective presentations follow the mania sequence with close depression monitoring.
Treatment remains an explicit, monitored trial. Record baseline metabolic and cardiovascular measurements, target symptoms, expected time to change and stopping or switching criteria. Avoid routine regular antipsychotic combinations except briefly during a switch. ECT is a specialist option for rapid short-term treatment of prolonged or severe mania after other treatments fail or when the condition is life-threatening. Review continuation and long-term prevention soon after resolution instead of allowing an acute prescription to renew indefinitely.
Key points
- Begin with a calming low-stimulation environment, direct risk and physical assessment, medication reconciliation and a collaborative explanation whenever the person can participate.
- If mania or hypomania develops during antidepressant monotherapy, NICE says consider stopping the antidepressant and offer an antipsychotic whether or not it is stopped.
- First offered acute antipsychotic choices are haloperidol, olanzapine, quetiapine or risperidone, selected from previous response, preference, advance statements, comorbidity and adverse effects.
- If the first antipsychotic is poorly tolerated or ineffective at the maximum licensed dose, offer another agent from that recommended group before augmentation.
- If an alternative antipsychotic is still ineffective at its maximum licensed dose, consider adding lithium; if lithium is unsuitable or ineffective, consider valproate only within current MHRA restrictions.
- When mania occurs on lithium, check the plasma level and optimise an inadequate exposure, then consider adding a recommended antipsychotic according to response and preference.
- Treat a mixed affective state using the mania sequence while monitoring closely for emerging or worsening depression; do not offer lamotrigine for acute mania.
- Before an antipsychotic, record weight or BMI, pulse, blood pressure, glucose or HbA1c and lipids, and offer ECG when product, cardiac risk or inpatient status indicates.
- Within four weeks of symptom resolution discuss long-term treatment; if acute mania treatment continues, NICE advises a further three to six months followed by review.
02Indications, selection and cautionsWho may benefit, who needs urgent treatment and important alternatives.
Marked activation occurs without an antipsychotic or mood stabiliser, leading directly to selection among the four NICE-offered antipsychotics.
Mania during lithium treatment requires adherence, timing and plasma-level assessment before assuming pharmacological failure.
New mania or hypomania during antidepressant exposure prompts review and usually consideration of stopping that medicine while antimanic treatment begins.
Manic and depressive symptoms coexist, requiring antimanic management plus close observation for worsening despair or suicidality.
Life-threatening exhaustion, psychosis, catatonia, uncontrolled danger or severe adverse effects exceeds a routine oral outpatient medication trial.
03Assessment before treatmentTests and checks that guide safe selection.
Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.
- 01
Medication and exposure reconciliationFirst step - Why
- Establish regular, missed, as-needed and recent doses, antidepressants, interactions, substances and previous response.
- Interpretation and limitations
- Correct non-adherence, cumulative dosing or a precipitating exposure before labelling resistance; document exact formulation and last administration.
- 02
Antipsychotic physical baseline - Why
- Record weight or BMI, pulse, blood pressure, fasting glucose or HbA1c and lipid profile.
- Interpretation and limitations
- Results guide agent selection and create a comparison for treatment-emergent metabolic harm; urgent treatment may start while time-critical abnormalities are managed.
- 03
Indicated electrocardiogram - Why
- Assess rhythm and QT risk when the SmPC requires it, cardiovascular risk exists or inpatient admission occurs.
- Interpretation and limitations
- QT interval, arrhythmia, syncope history, electrolytes and interacting drugs affect antipsychotic choice; a normal tracing does not remove future dose-related risk.
- 04
Plasma lithium level - Why
- Assess exposure when mania emerges during prescribed lithium and after any supervised dose change.
- Interpretation and limitations
- Interpret a correctly timed concentration with adherence, renal function, fluid balance and symptoms; do not increase automatically when toxicity or poor sampling is possible.
- 05
Response and adverse-effect examination - Why
- Measure sleep, activity, psychosis, behaviour, movement effects, akathisia, sedation and autonomic stability.
- Interpretation and limitations
- Partial improvement must be weighed against harms and actual dose duration before switching; severe toxicity requires immediate medical action rather than routine review.
04Treatment approachPreparation, options, escalation and aftercare.
01First offered medicationChoose one recommended antipsychoticFirst stepAcute mania or hypomania occurs without an antipsychotic or mood stabiliser already prescribed.+
- 1Assess immediate risk, physical state, pregnancy, previous response, advance preferences, metabolic, cardiac and movement-disorder vulnerability.
- 2Offer haloperidol, olanzapine, quetiapine or risperidone and record target symptoms, expected benefit, dose plan and tolerability priorities.
- 3Monitor response and adverse effects during titration and offer another recommended antipsychotic if the first is ineffective at its licensed maximum or poorly tolerated.
02Escalation after two trialsAugment only after adequate sequenceAlternativeEscalationTwo appropriately selected antipsychotic trials have not controlled mania and the alternative reached its maximum licensed dose.+
- 1Recheck diagnosis, adherence, dose, duration, substances, physical causes and whether ongoing environmental stimulation is maintaining the crisis.
- 2Consider lithium augmentation with baseline testing, plasma-level monitoring and specialist oversight when the person can use it safely.
- 3If lithium is unsuitable or ineffective, consider valproate only after current MHRA restrictions, reproductive counselling and product-specific licensing are satisfied.
03Resolution reviewMove from acute control to preventionManic symptoms have resolved enough for collaborative longer-term decisions and risk learning.+
- 1Within four weeks, review the episode, consequences, medicine benefit and harm, adherence barriers and the person's prevention goals.
- 2Discuss switching to or continuing long-term treatment, including lithium's evidence, metabolic and reproductive risks and psychological relapse prevention.
- 3If continuing the acute mania regimen, plan three to six further months and a named review rather than automatic indefinite continuation.
05Regimens, contraindications and interactionsTreatment details and the circumstances that modify them.
Olanzapine oral
For a manic episode, start 15 mg by mouth once daily as monotherapy or 10 mg once daily in combination; adjust after reassessment within 5 to 20 mg daily.Substantial appetite, weight, glucose and lipid effects require baseline and follow-up monitoring; also assess sedation, orthostasis, anticholinergic effects, hepatic impairment, smoking change and pregnancy.
Quetiapine immediate-release oral
Give 100 mg total on day one, 200 mg on day two, 300 mg on day three and 400 mg on day four in two divided doses; increase by no more than 200 mg daily to a maximum 800 mg daily.Monitor somnolence, orthostatic hypotension, falls, weight, glucose, lipids and cardiac risk; slower titration or lower exposure may be necessary with frailty, hepatic impairment or interacting medicines.
Risperidone oral
Start 2 mg by mouth once daily for bipolar mania; if indicated adjust by 1 mg at intervals of at least 24 hours within the licensed range of 1 to 6 mg daily.Assess prolactin effects, sexual dysfunction, extrapyramidal symptoms, akathisia, orthostasis, QT and metabolic risk; use additional caution and lower dosing in older adults or renal impairment.
06Complications, monitoring and follow-upAdverse effects, response and longer-term review.
- During titration, record sleep, activity, psychosis, irritability, risk, pulse and blood pressure after each dose change and any emerging movement or autonomic effects.
- Measure weight or BMI weekly for the first six weeks and again at twelve weeks, with fasting glucose or HbA1c and lipids at twelve weeks.
- Review total regular and as-needed antipsychotic exposure so combination or emergency doses do not inadvertently exceed the BNF or SmPC maximum.
- Check adherence, swallowing, substance use, smoking change and practical barriers before interpreting continuing activation as pharmacological resistance.
- Within four weeks of resolution discuss long-term strategy, and if acute treatment continues, schedule the NICE three-to-six-month review and taper rather than stop antipsychotics abruptly.
07Special situationsVariants, exceptions and circumstances that change the usual approach.
Four parallel first choices
NICE does not name one universal best antipsychotic; previous response, preference and adverse-effect vulnerability determine the initial selection.
Sequence before augmentation
An alternative recommended antipsychotic should be tried before lithium is added after an ineffective initial antipsychotic.
Lamotrigine is not antimanic
Its role in bipolar depression or prevention must not be confused with treatment of an acute manic episode.
Smoking changes exposure
Starting or stopping smoking can alter olanzapine metabolism, so clinical response and adverse effects need reassessment during a change.
Acute control needs an exit plan
The regimen that settles mania may not be the preferred long-term choice, making early continuation review a separate decision.
08Common pitfallsFrequent interpretation and management errors.
- 01
Starting medication without documenting target symptoms, previous response, patient preferences and major physical risk factors.
- 02
Adding lithium after one incomplete antipsychotic trial instead of offering an alternative recommended antipsychotic first.
- 03
Escalating a breakthrough episode on lithium without checking a correctly timed level, adherence and renal or fluid changes.
- 04
Offering lamotrigine to control acute mania despite the explicit NICE recommendation against it.
- 05
Using valproate without applying the current under-55, pregnancy-prevention and male reproductive safety measures.
- 06
Combining regular antipsychotics indefinitely when short cross-titration is the only planned rationale.
- 07
Continuing an acute antipsychotic automatically after recovery without the four-week and three-to-six-month reviews.