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 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.”)