Bipolar Disorder — First-Line Treatment of Acute Mania
A 26-year-old woman with bipolar I disorder, off all medication for a year, is brought by her family after 10 days of elevated mood, two hours of sleep nightly, pressured speech and reckless spending. Today she is agitated, shouting at staff, and believes she has divine powers. Urine drug screen and thyroid function are normal, and pregnancy test is negative. Which medication is most appropriate to start now?
- A.Lithium with serum level monitoring
- B.Oral olanzapineCorrect
- C.Sodium valproate
- D.Sertraline
Explanation
This woman has a manic episode with psychotic features and marked agitation, and she is taking no antimanic drug. NICE guidance for an adult who develops mania while not on an antipsychotic or mood stabiliser is to start an antipsychotic such as olanzapine, haloperidol, quetiapine or risperidone. These act within days, control agitation and treat psychotic symptoms, which matters when behaviour is already putting her and others at risk. Lithium is an effective antimanic agent and the best long-term prophylactic choice, but it takes one to two weeks to work, needs titration against serum levels and renal and thyroid checks, and is considered as an add-on if a second antipsychotic is not sufficiently effective or once she is settled for maintenance. Valproate is a second-line add-on and should be avoided in women who could become pregnant because of its teratogenicity and neurodevelopmental harm. An antidepressant alone would worsen mania and is not indicated. The exception often missed: if a patient is already taking an antidepressant when mania starts, it should be tapered and stopped as well as starting the antipsychotic.
Why each option
- A.
- Lithium is slow in onset and needs level titration, so NICE reserves it as an add-on when an alternative antipsychotic has not been sufficiently effective.
- B.
- Correct. An antipsychotic such as olanzapine is first-line for acute mania off treatment and rapidly controls agitation and psychotic features.
- C.
- Valproate is a second-line add-on and should be avoided in women of childbearing potential because of major teratogenic risk.
- D.
- An antidepressant can precipitate or worsen mania and has no role in treating a current manic episode.
Reference: NICE CG185 Bipolar disorder: assessment and management (updated 2023); UpToDate — Bipolar disorder in adults: choosing pharmacotherapy for acute mania and hypomania
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