Chapter 12
Management of Acute Mania and
Bipolar Affective Disorder
69
, Chapter 12: Management of Acute Mania and Bipolar
Affective Disorder
1. Biological management.
2. Psychological management.
3. Social management.
1. Biological management
Reference: NICE Guideline (CG185). Bipolar disorder: the assessment and management of bipolar disorder in
adults, children and young people in primary and secondary care. Published September 2014 (last updated
February 2020).
A. Management of mania or hypomania
Ensure that people with mania or hypomania have access to calming environments and reduced stimulation.
Advise them not to make important decisions until they have recovered from mania or hypomania and encourage
them to maintain their relationships with their carers if possible.
If a person develops mania or hypomania and is taking an antidepressant:
o Consider stopping the antidepressant and
o Offer an antipsychotic, regardless of whether the antidepressant is stopped.
If a person develops mania or hypomania and is not taking an antipsychotic or mood stabiliser:
o 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).
o 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, taking into account any advance
statements, the person's preference and clinical context (including physical comorbidity, previous response to
treatment and side effects).
o 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 (e.g. because the person
does not agree to routine blood monitoring), consider adding valproate instead. Do not offer valproate to
women or girls of childbearing potential (including young girls who are likely to need treatment into their
childbearing years) for long-term treatment or to treat an acute episode, unless other options are ineffective or
not tolerated and the pregnancy prevention programme is in place.
If a person develops mania or hypomania and is taking an antidepressant in combination with a mood
stabiliser:
o Consider stopping the antidepressant.
o 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.
o 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 woman or girl 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.
o Do not offer lamotrigine to treat mania.
Reviewing treatment:
o Within 4 weeks of resolution of symptoms, discuss with the person, and their carers if appropriate,
whether to continue treatment for mania or start long-term treatment. Explain the potential benefits of long-
term treatment and the risks, including side effects of medication used for long term treatment.
o If the person decides to continue treatment for mania, offer it for a further 3-6 months, and then review.
70
Management of Acute Mania and
Bipolar Affective Disorder
69
, Chapter 12: Management of Acute Mania and Bipolar
Affective Disorder
1. Biological management.
2. Psychological management.
3. Social management.
1. Biological management
Reference: NICE Guideline (CG185). Bipolar disorder: the assessment and management of bipolar disorder in
adults, children and young people in primary and secondary care. Published September 2014 (last updated
February 2020).
A. Management of mania or hypomania
Ensure that people with mania or hypomania have access to calming environments and reduced stimulation.
Advise them not to make important decisions until they have recovered from mania or hypomania and encourage
them to maintain their relationships with their carers if possible.
If a person develops mania or hypomania and is taking an antidepressant:
o Consider stopping the antidepressant and
o Offer an antipsychotic, regardless of whether the antidepressant is stopped.
If a person develops mania or hypomania and is not taking an antipsychotic or mood stabiliser:
o 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).
o 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, taking into account any advance
statements, the person's preference and clinical context (including physical comorbidity, previous response to
treatment and side effects).
o 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 (e.g. because the person
does not agree to routine blood monitoring), consider adding valproate instead. Do not offer valproate to
women or girls of childbearing potential (including young girls who are likely to need treatment into their
childbearing years) for long-term treatment or to treat an acute episode, unless other options are ineffective or
not tolerated and the pregnancy prevention programme is in place.
If a person develops mania or hypomania and is taking an antidepressant in combination with a mood
stabiliser:
o Consider stopping the antidepressant.
o 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.
o 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 woman or girl 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.
o Do not offer lamotrigine to treat mania.
Reviewing treatment:
o Within 4 weeks of resolution of symptoms, discuss with the person, and their carers if appropriate,
whether to continue treatment for mania or start long-term treatment. Explain the potential benefits of long-
term treatment and the risks, including side effects of medication used for long term treatment.
o If the person decides to continue treatment for mania, offer it for a further 3-6 months, and then review.
70
