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Treating a Manic, Hypomanic or Mixed Episode

The following treatment guidelines are meant as a reference tool, but are not intended as treatment advice or to replace the clinical decision-making process of psychiatrists or other health professionals who administer these treatments. In clinical practice there are often good reasons why treatment approaches differ from what is described here.

 

Step 1:  Getting started:

Step 2:  Start one of the following medications:

  • These medications usually give some effect within a week of use. So long as the manic or mixed symptoms continue to show improvement at a given dose of the medication, it need not be increased. However, if in any given week the symptoms show no more improvement, the dose should then be increased.
  • If with this approach the episode resolves fully, go to Step 6.
  • On the other hand, if after a week or two at the maximum tolerated dose the episode has improved but has not resolved fully, go to Step 3.
  • Or, if after 2-3 weeks of starting the medication there is no adequate effect, including at least one week where the dose was increased, then discontinue the medication and repeat Step 2, or, if the episode is severe, go directly to Step 3.

Step 3:  Combine an Atypical Antipsychotic with either Lithium or Valproic Acid.

    • As described in Step 2, dose adjustments can be made every week depending on the rate of symptom improvement.
    • If with this approach the episode resolves fully, go to Step 6.
    • If after a week or two of this second medication being at the maximum tolerated dose the episode improves but does not resolve fully, go to Step 4.
    • If after 2-3 weeks of starting this second medication there is no adequate effect, including at least one week where the dose was increased, then consider discontinuing this second medication and either repeating Step 3 or going to Step 4.

Step 4:  Try one of the following options:

    • As described in Step 2, dose adjustments can be made every week or two depending on the rate of symptom improvement. In the case of ECT, a full course should be given.
    • If with this approach the episode resolves fully, go to Step 6.
    • On the other hand, if after a full course of ECT, or after a week or two of the added medication being at the maximum tolerated dose, the episode does not resolve fully, repeat Step 4 or, if all options in Step 4 have been exhausted, go to Step 5.
      • At this point, the added medication can either be stopped or continued depending on how effective it has been.

Step 5:  Add one of the following treatments:

    • Dose adjustments can be made every week or two depending on the rate of symptom improvement.
    • If with this approach the episode resolves fully, go to Step 6.
    • On the other hand, if after two weeks of the added medication being at the maximum tolerated dose the episode does not resolve fully, repeat Step 5.
      • At this point, the added medication can either be stopped or continued depending on how effective it has been.

Step 6:  Maintenance treatment:

    • Continue to focus on Lifestyle Managements skills.
    • Consider starting psychotherapy, especially if
    • Continue the current medications for at least a year so as to prevent further episodes.  However, for individuals who have experienced multiple previous Bipolar mood episodes (Hypomania, Mania, Depressive or Mixed), or even just one severe episode, it is recommended that they remain on medications indefinitely.
    • If a decision is taken to stop medications, this should be done very gradually, one medication at a time, over a period of at least a couple of months for each medication, and with close monitoring by a physician. Monitoring and follow-ups should continue even after the medications have been stopped.
    • If the goal is to reduce the number of medications being used, Olanzapine, Lithium and Valproic Acid have all been shown to be effective in preventing relapses to Mania or Mixed Episodes and are thus the first choice in maintenance treatment. Lithium also has the added advantage of being the only agent with proven effect in reducing the risk of suicide when taken over a long term.
    • If the successful treatment that was used was ECT, then once the course of ECT is completed, any medications that were partially effective should be continued.
    • Long-term use of omega-3 fatty acids can also be considered.

 

Unless otherwise indicated, the above treatments strategies are based on the CANMAT Guidelines for the Management of Patients with Bipolar Disorder [ref, ref, ref, ref] and the Texas Medical Algorithm Project.

 

Medications

Bipolar I Depression