Author: Daniel Carlat M.D.
Last Updated: 4/1/20
Medicating Manic Episodes
My Usual Approach
The three key medications we use to treat mania in the inpatient setting are antipsychotics, mood stabilizers, and benzodiazepines. For patients who are very ill (meaning agitated, very psychotic, and very dysfunctional), you might start with all three. For others you might start more gingerly and monitor response.
Generally the most effective drugs for rapid control of acute mania are antipsychotics, and combining them with mood stabilizers enhances their effectiveness.
Which antipsychotic should you start with? There are no clear head to head trials showing that any particular antipsychotic is superior for mania. However, clinical lore has it that olanzapine, quetiapine, and haloperidol are the “bigger guns” and more effective in highly agitated and psychotic patients. Unfortunately, all three of these are highly likely to cause side effects.
My philosophy is that I prefer to start with an anti-manic drug that will be most tolerable for long term treatment. Given that philosophy, my first choice is generally aripiprazole, and my second choice is usually risperidone. However, if the patient is off-the-charts agitated and may become violent, I will start with Zyprexa or Seroquel.
I will also give an initial dose of a benzodiazepine, because they work well and quickly and have few side effects.
If you start with aripiprazole or risperidone, both of which are higher potency antipsychotics, you might worry about causing akathisia, which is a reasonable concern. But since I’m prescribing Ativan as needed for anxiety, any really uncomfortable akathisia will likely to be treated, at least initially, by the benzo. Later, if I assess that akathisia is an ongoing problem, I’ll prescribe a standing dose of propranolol and may discontinue the benzo altogether.
Should you avoid using benzo for mania in a substance user? While this is a matter of judgment, in general I find the benefits for the short term treatment of mania outweigh any risk of worsening substance use issues. I won’t plan on continuing the benzo for more than a week, not long enough to cause tolerance.
After a day or two of an antipsychotic plus a benzodiazepine, I’ll re-evaluate, and if they are not responding as well as I’d like, I’ll start a mood stabilizer, and my first choice is lithium followed by depakote. What about carbamazepine (CBZ)? Theoretically, it has the advantages over lithium and Depakote of causing less weight gain. However, studies show that in the acute treatment of mania, combining antipsychotics with CBZ doesn’t add any benefit, possibly because CBZ revs up metabolic enzymes that may decrease serum levels of adjunct antipsychotics. Using CBZ alone is fine, but you will usually reserve that for treatment of less severe mania, or for maintenance treatment once the mania subsides.
Example of a common medication sequence for mania:
Step One:
Initial dose of an antipsychotic and a benzodiazepine, followed by a standing daily dose plus a prn dose of the benzo.
Eg:
Abilify 10 mg twice a day, first dose now.
Ativan 1 mg now, and thereafter 1 mg every 6 hours as needed for agitation.
Step Two (if no good response to above within two days):
Lithobid 300 BID or Eskalith CR 450 HS, increasing quickly to 900 HS. Prolonged release (PR) versions of lithium are more tolerable, with less tremor, upper gastrointestinal cramping, nausea, rash, cognitive dulling, urinary frequency. However, sometimes people get more diarrhea with PR and switching from PR to immediate release (IR) almost always improves it.
Medications Helpful for Acute Mania
| Medication | Dosing Guidance |
| Aripiprazole | Start 5 mg BID, increase in 5 mg increments up to 30 mg daily as needed |
| Risperidone | Start 1 mg HS day one, 1 mg BID day two, 1 mg AM and 2 mg HS day 3, then pause. |
| Zyprexa | Start 5 mg BID day one, 5/10 day 2, 10 BID day 3, then pause. |
| Seroquel | Start 50 mg BID day one, 100 BID day two |
| Lithium | Draw blood for TSH, BUN/Cr, then start 300 mg QHS, or BID, depending on clinical need. Increase quickly (by day 2 or 3) to 900 mg daily and watch for response/SE/level. |
| Depakote | Draw blood for CBC, LFTs, then start at 250-500 mg QHS, increase rapidly to 1000 mg daily, then pause for response/SE/level. |
| Tegretol | Draw blood for CBC, Na, LFTs, HLA-B1502 in Asians, then start at 200 mg QHS, increase rapidly to 200 BID then pause for response/SE/level. |
| Lamictal | Start 25 mg |
Published on 4/13/2020. Copyright 2020 Inpatient Psychiatry Today.