Synopsis
Select and sequence acute antimanic treatment from current NICE guidance, prescribe licensed oral antipsychotic regimens safely, optimise existing therapy before augmentation, and review efficacy, physical harm and continuation explicitly.
- 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.
Key red flags
Hyperthermia, rigidity, autonomic instability or altered consciousness after antipsychotic exposure suggests neuroleptic malignant syndrome and needs immediate medical treatment.
Syncope, palpitations, marked QT prolongation, severe hypotension or cumulative interacting antipsychotic doses requires urgent cardiovascular and prescription review.
New severe restlessness, dystonia, parkinsonism or oculogyric crisis requires prompt assessment of an extrapyramidal adverse effect and appropriate treatment.
Several nights without sleep, poor intake, escalating psychosis or mixed suicidal thinking signals inadequate control and need for urgent higher-intensity care.
Pregnancy, possible pregnancy or reproductive potential materially changes lithium and valproate decisions and requires specialist risk-benefit review.
Investigation priorities
Establish regular, missed, as-needed and recent doses, antidepressants, interactions, substances and previous response.
Management branches
Acute mania or hypomania occurs without an antipsychotic or mood stabiliser already prescribed.
- Assess immediate risk, physical state, pregnancy, previous response, advance preferences, metabolic, cardiac and movement-disorder vulnerability.
- Offer haloperidol, olanzapine, quetiapine or risperidone and record target symptoms, expected benefit, dose plan and tolerability priorities.
- Monitor response and adverse effects during titration and offer another recommended antipsychotic if the first is ineffective at its licensed maximum or poorly tolerated.