If you are in an emergency, in crisis or need someone to talk to, there is help.

View Crisis Resouces
Skip to content
  • Contact Us
  • No One Left Behind
  • Join our team
  • Referral Form
  • Virtual Urgent Care
  • Accessibility
CAMH logo
  • Patients and Families
    • Main Page
    • Access CAMH & Referral Form
      • Access CAMH

        Centralized information, intake and scheduling. Access CAMH makes it easy to find support – simply call 416-535-8501, option 2.

      • Referral Form

        For mental health services, a referral form needs to be completed by a healthcare provider. For addictions services, patient can self-refer.

    • Programs & Services
      • Addictions/Substance Use
      • Alzheimer’s & Dementia
      • Anxiety & Depression
      • Concurrent Disorders
      • Developmental Disabilities
      • Mood & Personality Disorders
      • Problem Gambling
      • Schizophrenia & Psychosis
      • Trauma & Stress Disorders
      • Virtual Mental Health and Outreach
      • Other
    • Information for Patients
      • Patient Wellness and Patient Engagement at CAMH
      • What to expect
      • Your Rights
      • Patient and Family Feedback
      • Visiting CAMH

        Planning on visiting CAMH? Find contact information, directions and accessibility for each of our three main sites.

    • Information for Families
      • Family Resource Centre
      • Patient and Family Feedback
      • Visiting CAMH

        Planning on visiting CAMH? Find contact information, directions and accessibility for each of our three main sites.

    • Patient and Family Engagement
      • Patient and Family Partners Program
      • Information and resources
      • Get Involved in Research
      • Volunteer at CAMH
    • Visiting CAMH
      • Visiting CAMH

        Planning on visiting CAMH? Find contact information, directions and accessibility for each of our three main sites.

        Read More
    • MyCAMH
  • Health Info
    • Main Page
    • Mental Illness & Addiction Index
      • Conditions & Disorders
      • Medication Therapies
      • Substance Use
      • Types of Treatment
      • Information in Other Languages
    • Mental Health 101
      • Mental Health 101

        Use this series of free online tutorials as the starting point to learn about and understand a wide range of mental health topics.

        Read More
    • Guides & Publications
      • Guides & Publications

        Accessible, reliable, professionally produced resources on an array of mental health topics for patients, families, students and professionals.

        Read More
    • Crisis Resources
      • Crisis Resources

        If you are in an emergency, in crisis or need someone to talk to, there is a list of resources available for areas in and around Toronto.

        Read More
    • CAMH Store
      • CAMH Store

        The CAMH Store offers a wide array of mental illness and addiction resources for patients, families, students and professionals. Search or browse our catalogue of brochures and booklets, textbooks, manuals and assessment tools.

        Read More
    • CAMH Library
      • CAMH Library

        Open to professionals and the general public, our comprehensive resources and services support and enhance CAMH's research and clinical programs, and they facilitate learning, dynamic knowledge exchange and health promotion initiatives.

        Read More
    • Workplace Mental Health Playbook
    • Mental Health and the COVID-19 Pandemic
      • Coping with stress & anxiety
      • Quarantine & isolation
      • Stigma and prejudice
      • Loss, grief and healing
      • Resources for Health Care Workers
  • Research
    • Main Page
    • Research Areas at CAMH
      • Brain Science

        CAMH is revolutionizing our understanding of the brain and the causes, biomarkers and treatments of mental illness.

      • Personalized Care

        By understanding diverse groups, we prevent, diagnose and care for each one with greater precision and personalization.

      • Prevention and Policy

        Using evidence, we drive system and social change to optimize care and reduce the burden of mental illness, including addictions, across populations.

    • The Discovery Fund
      • The Discovery Fund

        Fuelling the next generation of groundbreaking research and innovation dedicated to finding the causes of and cures for mental illness.

        Read More
    • Institutes & Centres
      • Azrieli Adult Neurodevelopmental Centre
      • Azrieli Centre for Neuro-Radiochemistry
      • Brain Health Imaging Centre
      • Campbell Family Mental Health Research Institute
      • Centre for Youth Bipolar Disorder
      • Cundill Centre for Child and Youth Depression
      • Institute for Mental Health Policy Research
      • Krembil Centre for Neuroinformatics
      • Slaight Family Centre for Youth in Transition
      • Tanenbaum Centre for Pharmacogenetics
      • Temerty Centre for Therapeutic Brain Intervention
      • The Margaret and Wallace McCain Centre for Child Youth & Family Mental Health
    • Clinical Divisions
      • Addictions Division
      • Adult Neurodevelopmental and Geriatric Psychiatry Division
      • Child and Youth Psychiatry Division
      • Forensic Psychiatry Division
      • General and Health Systems Psychiatry Division
      • Psychology Division
      • Schizophrenia Division
    • Research Discoveries
      • Research Discoveries

        At the leading edge of breakthrough mental health and addiction research for over 50 years.

      • BrainBuzz Newsletter

        The latest news, groundbreaking discoveries and special features about CAMH research, studies, and the people behind the work.

      • Research Strategic Plan

        Learn what drives our research agenda and priorities in the CAMH Research Plan for 2018-2023

    • Research Connect
      • Research Connect FAQs
      • Research Ethics
    • Koerner Centre for Research Training
      • Koerner Centre for Research Training

        Each year CAMH provides opportunities to the next generation of scientists: today’s undergraduate students, graduate students and postdoctoral researchers. Train in a unique learning environment and help contribute to the breakthrough mental health research and treatments of tomorrow

        Read More
    • Science & Research Staff Directory
      • Our Scientific Staff
      • Research Chairs at CAMH
    • Industry Partnerships & Technology Transfer Office (IPTTO)
  • Education
    • Main Page
    • Continuing Education Programs and Courses
      • Find the Course That's Right for You

        Browse our entire selection of certificate programs, webinars and workshops.

      • Workplace Education and Consulting Services

        View our full list of workplace mental health workshops and consulting services

    • Collaborative Learning College
    • Simulation Centre
    • TIDES
    • Student Centre
    • Clinical & Research Opportunities for Professionals in Training
      • Clinical Psychology Training Programs
      • Community-Based Research Fellowship
      • Graduate & Post-Doctoral Fellowships in Public Health Policy
      • Clinical & Research Opportunities for Professionals in Training

        Study in a world-class setting to become a leader in the field of mental health.

    • Research in Education
      • Academic & Education Research Excellence
      • Health Equity and Inclusion Framework for Education and Training
    • Evaluation
    • Workplace Mental Health Workshops and Consulting
    • CAMH Education Contacts
  • Professionals
    • Main Page
    • Treating Conditions & Disorders
      • NAVIGATE - Treating Psychosis in Youth
      • CARIBOU - Treating depression in youth
      • Virtual Mental Health
      • Alcohol Use
      • Anxiety Disorders
      • Dementia
      • Depression
      • Suicide Risk
      • Fundamentals of Addiction
      • Intellectual & Developmental Disabilities
      • Mania
      • OCD
      • Opioid use and opioid use disorder
      • Perinatal Mood & Anxiety Disorders
      • Personality Disorders
      • Psychosis
      • Posttraumatic Stress Disorder
      • Smoking Cessation
    • Professionals Projects
      • Climate Change and Mental Health
      • Health Care Access Research and Developmental Disabilities
      • Immigrant and Refugee Mental Health Project
      • Opioid Use in Primary Care Conference 2024
    • Networks
      • Psychiatry Partnerships with Northern Communities
    • Videos
    • Podcasts
  • Get Involved
    • Main Page
    • Ways to Donate
      • Give Monthly
      • Give In Memory or In Honour
      • Start a Fundraiser
      • Gifts of Celebration
      • Leave a Gift in Your Will
      • Employee Giving
      • Donate Goods & Services
      • Gifts of Securities
      • Canvassers & Callers
      • Make a one-time donation

        With your support, CAMH researchers are revolutionizing the ways we diagnose, treat, and prevent mental illness. Donate today.

    • Join the Cause
      • Corporate Partnerships
      • Business Leaders for Mental Health
      • CAMH Engage
      • womenmind
      • Visionary Society
      • Michael Wilson Society
      • Volunteer at CAMH
    • Making a Real Impact
      • Making a Real Impact

        Real stories of courage, hope and discovery. Made possible through your continued support of CAMH.

        Read More
  • Driving Change
    • Main Page
    • About CAMH
      • Leadership Team Directory
      • Performance & Accountability
      • The Role of CAMH Foundation
      • For Reporters
      • Events Calendar
      • For Our Neighbours
      • Contact CAMH
      • Careers at CAMH

        By working at CAMH, you can help people affected by mental illness and support their recovery. Join the team. Everyone who works at CAMH becomes an advocate for mental health.

    • The Crisis is Real
      • The Crisis is Real

        We are in the grips of a crisis that ruins health, threatens lives and hurts economies. Knowing the facts is the first step in creating hope.

      • Mental Health Statistics

        The latest facts and statistics on mental illness and addiction, who's affected and their impact on Canadians.

    • Addressing Stigma
      • Addressing Stigma

        Challenging the stigma associated with mental illness takes understanding, education and a closer look at our own attitudes toward health.

        Read More
    • The Mental Health Facility of the Future
      • The Mental Health Facility of the Future

        Turning what was once a walled institution into a symbol of hope for the future of mental health care.

      • Vision & Guiding Principles

        How do you replace an institution with an urban village? Lots of planning, imagination and a long-term commitment to serving patients, staff and the community.

      • History of Queen Street Site

        Our history—evolving from an asylum into a modern health facility with patients at the centre of care—is the history of mental health care in Canada.

    • Influencing Public Policy
      • Influencing Public Policy

        CAMH advocates for policies that are responsive to the needs of people with mental illness and addictions.

        Read More
    • Health Equity
      • Health Equity

        CAMH believes in the principle of equity. We respect the diversity of the individuals and communities we serve.

        Read More
    • Shkaabe Makwa
    • CAMH News & Stories
    • Strategic Plan
    • Contact Us
    • No One Left Behind
    • Join our team
    • Referral Form
    • Virtual Urgent Care
    • Accessibility

Mania - Pharmacotherapy

CAMH Logo
  • Mania - Pharmacotherapy
Back to top
  • Home
  • Professionals
  • Treating Conditions & Disorders
  • Mania
  • Treatment
CAMH logo
  • Mania
  • Screening & Assessment
  • Diagnosis
  • Treatment
  • Resources & References
Back to top

Text below adapted from The patient who has mania in Psychiatry in primary care by Roger S McIntyre,  (CAMH, 2019).

Pharmacological treatment of an acute manic episode includes lithium, divalproex sodium and atypical antipsychotics, alone or in combination (Table 1). Choosing between monotherapy and combination treatment depends on prior medication use and patient factors that may influence progress or safety. For untreated patients with mania, consider monotherapy with a first-line medication such as lithium, divalproex or an atypical antipsychotic. For patients who are insufficiently managed with monotherapy, switching to a separate antimanic monotherapy or combining antimanic treatments is recommended. Table 2 summarizes dosing, monitoring and side-effects for different medications.

Lithium

Lithium remains a highly effective pharmacological treatment for acute mania. For patients with classic mania, which refers to the presence of euphoria, grandiosity and hyperactivity in a person with a stable episodic course, many experts prefer lithium as a first-line medication.

However, most people seen in clinical practice have more complex presentations that include, but are not limited to, dysphoric/mixed states, comorbidity, psychotic features and rapid cycling (i.e., four or more affective episodes during the previous 12 months). In such complex presentations, lithium may be less efficacious and divalproex and atypical antipsychotics are preferred. (Note that the DSM-5 has eliminated mixed states, which refers to co-occurring mania and depression, and has replaced it with “mania with mixed features specifier.”)

Figure 1 Treatment algorithm for acute mania
Treatment Algorithm for Acute Mania
Please note: this treatment algorithm was developed for psychiatrists treating bipolar mania, and its later steps are beyond the clinical practice of most primary care practitioners.

 

Treatment Algorithm for Acute Mania

Related

  • Psychiatry in Primary Care: A Concise Canadian Pocket Guide 2019

    Read More

  • Bipolar Disorder: Health Information for your Patient

    Read More

  • Bipolar Disorder: An Information Guide

    Read More

Table 1: Pharmacotherapy for Acute Mania
First-Line Medication

Monotherapy: lithium, divalproex, asenapine, risperidone, quetiapine, quetiapine XR, aripiprazole, paliperidone (> 6 mg), cariprazine


Combination therapy: quetiapine + lithium or divalproex; aripiprazole + lithium or divalproex; risperidone + lithium or divalproex; asenapine +lithium or divalproex


Second-Line Medication

Monotherapy: olanzapine, carbamazepine, ziprasidone, haloperidol, electroconvulsive therapy


Combination therapy: olanzapine + lithium or divalproex; lithium + divalproex


Not Recommended

Monotherapy with gabapentin, topiramate, lamotrigine, verapamil, tiagabine, risperidone + carbamazepine, olanzapine + carbamazepine



Sources: Ostacher et al. (2016); Yatham et al. (2018). 

Divalproex and Atypical Antipsychotics

Divalproex and atypical antipsychotics are highly effective in both classic and complex bipolar presentations. Since the early 2000s, atypical anti- psychotics have been the most thoroughly studied drugs for bipolar mania, showing efficacy in treating not only psychotic features, but also non-psychotic mania. Several atypical antipsychotics have also been found to be more effective than mood stabilizers in treating acute bipolar depression and preventing recurrence (Perlis et al., 2006).

A significant liability of most atypical antipsychotics is that they often cause significant weight gain and associated metabolic disruption. The probability of significant weight gain is even higher when these medications are prescribed with other weight-gain-promoting medications, such as lithium and some antidepressants. When deciding whether to use a weight-gain- promoting atypical antipsychotic, consider the benefits and risks for that particular patient.

Conventional Antipsychotics

Although conventional antipsychotics such as haloperidol and perphenazine have been used often to treat bipolar disorder, they carry a risk of both acute side-effects (e.g., akathisia, drug-induced Parkinsonism) and tardive (e.g., tardive dyskinesia) extrapyramidal side-effects. Clinical experience also suggests that conventional antipsychotics may be associated with worsening depressive symptoms in patients with bipolar disorder. Given these issues, use of conventional antipsychotics to treat manic episodes is discouraged (Zarate & Tohen, 2004).

Benzodiazepines

Benzodiazepines are frequently prescribed to patients with bipolar disorder. They are highly effective in reducing agitation, irritability and anxiety, and normalizing sleep. Their use as an adjunctive medication is warranted in carefully selected acute cases. Because non-therapeutic use and paradoxical reactions in the form of worsening agitation are a concern, benzodiazepines are recommended only for short-term use and should be carefully monitored.


In Mania
  • Introduction
  • The Primary Care Practitioner Role
  • Screening & Assessment
  • Diagnosis
  • Treatment
    • Pharmacotherapy
      • Initiating Pharmacotherapy and Providing Management
  • Clinical Tools
  • Resources & References 

Treatment
Initiating & Managing

Follow us
  • Patient and Family Care
  • Health Info
  • Science and Research
  • Education
  • Professionals
  • Get Involved
  • Driving Change
  • About CAMH
  • Job Openings
  • Purchase Publications
  • Referral Form
  • For Reporters
  • Donor Services
  • Events

CAMH Switchboard

From the GTA: 416 535-8501


Toll-free: 1 800 463-2338

To Access CAMH Clinical Services

416 535-8501, press 2

We have multiple locations. Find directions.

Map of CAMH's Queen Street Site
  • Staff Tools

Copyright 2025 CAMH

  • Terms of Use
  • Accessibility
  • Site Map

Keep in touch with CAMH

Keep your finger on our pulse – latest CAMH news, discoveries and ways to get involved delivered to your inbox.

Please select a newsletter

Please complete the following:

    Required Fields

    Please select a newsletter option

    Please input a first name

    Please input a last name

    Please input an email address

    By clicking Sign Up below, I consent to receive electronic communications (as selected above) from CAMH and CAMH Foundation. To unsubscribe at any time click the link in our mailing or email: unsubscribe@camh.ca

    Please agree to the Terms of Use

     

    Thanks for Subscribing.

    We look forward to keeping you informed, inspired and involved in all things CAMH.

    Double your impact this Mental Health Week

    Your gift to CAMH will now go twice as far to help change mental health care forever.

    $
    Other Ways to Give