Mania

Clinical Description

Presence of elated or irritable mood, associated increase in energy / activity, possible aggression and/or psychotic symptoms for at least a week or less if resulting in complete disruption of usual functioning.

Signs and Symptoms

• Elevated or irritable mood
• Reduced need for sleep
• Increased energy and activity
• Grandiosity
• Talkativeness and rapid loud speech
• Overspending
• Increased libido
• Agitation and over activity
• Possible aggression
• Reduced attention and concentration
• Possible psychotic symptoms (hallucinations and delusions Investigations
• Full assessment including physical examination to exclude underlying organic causes (delirium, syphilis, mania)or medications (steroids, some antiretrovirals))
• Vital signs: If severely unwell, dehydration/ exhaustion can be potentially fatal

Investigations

• FBC, U&E, glucose
• If evidence of hyperthyroidism on examination
• (Weight loss, tremor, exophthalmos, goiter) consider TFTs if available
• VDRL
• PITC

Treatment

• The aim of management is to reduce / alleviate symptoms, to allow the person to return to their previous daily activities and occupation if employed and to prevent any further relapses in the future. It is continued for at least 2 years.
• If marked agitation / aggression follow the Violence and Aggression Treatment

Guideline.

• Always assess risk - of suicide, harm to others and of self-neglect

Primary treatment

• Commence either a mood stabilizer or an anti-psychotic
• Give Sodium Valproate 200mg AM / 200mg PM. Increase by 200mg weekly depending on response. Usual effective dose 400 – 1000mg in a day.
• Caution: Sodium Valproate should be avoided in women of child-bearing age due to teratogenicity and risk of polycystic ovarian syndrome. If no available alternative advice about contraception.
• Side effects: sedation, tremor, weight gain, liver impairment
• Alternative treatment:
• Give Carbamazepine 200mg BD increasing by 200mg weekly depending on response and side effects to a maximum of 1200mg in a day. Usual dose 400- 600mg BD.
• Caution: Carbamazepine should be avoided in women of childbearing age due to teratogenicity. If no available alternative advice about contraception.
• Carbamazepine should not be prescribed in patients receiving antiretroviral treatment
• Side effects: sedation, rash, incoordination, RARELY Steven Johnsons syndrome
• If prominent psychotic symptoms present also give an anti-psychotic medication
• Give haloperidol 2.5mg nocte, Risperdal 1mg nocte for 2 days then 2mg or Chlorpromazine 100-200mg nocte

Alternative treatment

• Give Haloperidol 2.5mg nocte increasing by 1.25mg every week until symptoms resolve. Usual dose 1.25- 5mg daily
• Risperidone 1 mg nocte for 2 days then 2 mg nocte. Usual dose 2 to 6 mg daily. This should be considered instead of sodium valproate or carbamazepine in females of reproductive age group.

Duration of treatment

• First episode treatment should be continued for 1 year from complete resolution of

Signs and Symptoms

• Multiple episodes: treatment should be for at least 5 years from complete resolution of symptoms, and some may need lifelong medication.
• When considering stopping medication, discuss carefully with the patient and guardian. There is significantly increased risk of relapse if medication is stopped abruptly. Start to reduce slowly over 2-3 months.
• Advise about symptoms that would indicate relapse (difficulty sleeping, low/elevated mood, reduced or increased energy, increased worries) and inform to return to the clinic promptly. Continue to monitor until medication free for 1-2 months before discharging

Red Flags

For referral

• Ongoing or worsening symptoms despite adequate treatment for 2-4 weeks

For Admission

• Evidence of exhaustion, dehydration due to over-activity. IV fluid may be necessary
• Evidence that the patient is a risk to themselves (self-harm/ neglect/ vulnerable to exploitation) or a risk to others (agitation/ aggression)
• No guardian available to monitor adherence to medication

Follow-up

• At every review, ask about symptoms, suicidal ideation and medication adherence and side effects.
• Provide education about illness to patient and guardians. Give supportive counselling and encourage return to previous activities and occupation as soon as able.