Seek specialist advice
- management is often complex and requires an individual management plan under the supervision of a specialist-led mental healthcare team
Managing mania or hypomania in adults in secondary care
Pharmacological interventions
If a person develops mania or hypomania and is taking an antidepressant as monotherapy:
- consider stopping the antidepressant and
- an antipsychotic should be offered, regardless of whether the antidepressant is stopped
- if a person develops mania or hypomania and is not taking an antipsychotic or mood stabiliser
- offer haloperidol, olanzapine, quetiapine or risperidone, taking into account any advance statements, the person's preference and clinical context (including physical comorbidity, previous response to treatment and side effects)
- if the first antipsychotic is poorly tolerated at any dose (including rapid weight gain) or ineffective at the maximum licensed dose, offer an alternative antipsychotic
- if an alternative antipsychotic is not sufficiently effective at the maximum licensed dose, consider adding lithium
- if adding lithium is ineffective, or if lithium is not suitable (for example, because the person does not agree to routine blood monitoring), consider adding valproate instead
If the person is already taking lithium
- check plasma lithium levels to optimise treatment
- consider adding haloperidol, olanzapine, quetiapine or risperidone, depending on the person's preference and previous response to treatment.
If the person is already taking valproate or another mood stabiliser as prophylactic treatment,
- consider increasing the dose, up to the maximum level in the BNF if necessary, depending on clinical response. If there is no improvement, consider adding haloperidol, olanzapine, quetiapine or risperidone, depending on the person's preference and previous response to treatment.
If a person develops mania or hypomania and is taking an antidepressant (as defined by the BNF) in combination with a mood stabiliser, consider stopping the antidepressant.
Do not offer lamotrigine to treat mania.
In acute bipolar depression:
- short-term of of antidepressant drugs is supported by the current evidence base (3)
- note though that there is a risk of triggering a 'manic switch' and therefore the antidepressant must be given with anti-manic drug therapy, and tricyclic antidepressants are best avoided
- in context of acute bipolar depression then effective drugs also include lithium, olanzapine and lamotrigine (an unlicensed use)
Notes (2):
- valproate in women of childbearing potential
- do not offer valproate to women of childbearing potential for long-term treatment or to treat an acute episode
- if a woman of childbearing potential is already taking valproate, advise her to gradually stop the drug because of the risk of fetal malformations and adverse neurodevelopmental outcomes after any exposure in pregnancy
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