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.
Key red flags
Hyperthermia, rigidity, autonomic instability or altered consciousness after antipsychotic exposure suggests neuroleptic malignant syndrome and needs immediate medical treatment.
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.
Key medicines
Olanzapine oralFor 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.
Quetiapine immediate-release oralGive 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.