If patients with mania (hypomania) pose an immediate risk to their own health (e.g. extreme agitation, severe sleep deprivation, not attending to personal hygiene, use of illicit drugs or harmful use of alcohol), risk to their own safety (e.g. accidents and reckless behaviour, provoking others, inappropriate financial decisions, being vulnerable to sexual exploitation) or risk to others (e.g. aggression, sexually inappropriate behaviour), they should be in a place of safety (psychiatric hospital) and they should be monitored and treated by professionals. Sometimes the risk can be managed while patients stay at home and reviewed frequently by mental health professionals (e.g. Home Treatment Team).
The valid approach in the management of mania (hypomania), and all other mental health problems, is the one known as Bio-Psycho-Social:
Biological: considering the high risk that patients with mania/hypomania may post to themselves or to others, it is imperative that these patients are treated with suitable medication(s) in order to reduce length and severity of their symptoms; and the consequent risk caused.
Lithium and Sodium Valproate (and other antiepileptics): Lithium and Sodium Valproate are first-line and most commonly used mood stabilisers. They are equally effective in preventing severe fluctuations in mood and other associated symptoms in bipolar disorder; both in manic and depressive episodes. Common side effects of Lithium are sedation, dry mouth, polyuria, tremor, gait and balance problem, kidney and thyroid impairment (hence need for regular blood tests) and abnormal heart rhythm. Lithium should not be taken during pregnancy, as it can cause congenital heart disease in the foetus. Sodium Valproate can cause sedation, lethargy, increased appetite and weight gain, and anaemia as a side effect. It causes severe neurological damage in the foetus as early as the first week of conception. Hence Sodium Valproate should NOT be prescribed in women of childbearing age unless any chance of pregnancy is eliminated (e.g. tubal ligation). Like Sodium Valproate, there are other antiepileptics (Carbamazepine, Lamotrigine) which are licenced as mood stabilisers. They are not as widely prescribed as Sodium Valproate and Lithium.
Antipsychotics: Older antipsychotics (e.g. Haloperidol, Zuclopenthixol), as well as newer generation (e.g. Olanzapine, Risperidone), are licenced as mood stabilisers. They can be prescribed with strict monitoring during pregnancy. They are also available in injectable form for managing severely agitated and aggressive patients. Furthermore, they can be given as long-acting injections (administered every few weeks) to ensure compliance. Antipsychotics have their own side effects.
Benzodiazepines and Hypnotics: Benzodiazepines (Lorazepam, Clonazepam) and Hypnotics (Zopiclone) are usually used in the acute management of mania to manage severe agitation and to help with sleep.
Psychological: Patients with a manic episode are unlikely able to engage with therapy. These patients (and their families) benefit significantly from therapy in the form of psychoeducation (increase awareness of early signs of relapse) and coping with consequences of an episode (feelings of shame and guilt).
Social: like depression, it is crucial that patients receive appropriate social support following a manic episode to ensure and expedite their re-integration in different aspects of life.