Treatment of Mania

First-Line Medication Options

The American Academy of Child and Adolescent Psychiatry recommends lithium, valproate, or an atypical antipsychotic (such as risperidone, olanzapine, quetiapine, or aripiprazole) as the treatment of choice for a first episode of mania, with the specific choice based on patient factors and side effect profiles 1, 2
Lithium is FDA-approved down to age 12 years for acute mania and maintenance therapy 1, 2
Ziprasidone is approved for acute mania in adults 2, 3

When selecting the initial medication, consider evidence of efficacy, phase of illness, presence of confounding presentations, side effect profile and safety, patient's history of medication response, and patient/family preferences 1, 2

For children/adolescents with bipolar mania, the initial dose of risperidone is 0.5 mg/day 4
The target blood level for lithium is 0.6-1.2 mEq/L, and serum levels should be monitored regularly 2, 3

Begin with monotherapy when possible to avoid unnecessary polypharmacy 2, 3
Allow an adequate trial period of at least 4 weeks at therapeutic dose 4
If there is an inadequate response, consider switching to a different agent with a different pharmacodynamic profile 4
For severe or psychotic mania, consider combination therapy from the start (e.g., lithium plus an atypical antipsychotic) 3, 5

Assess treatment effectiveness early and use a proactive approach when switching or augmenting treatment 4
Monitor for common side effects of valproate, including gastrointestinal distress, sedation, hepatic effects, and weight gain 2, 5

For patients with psychotic features, consider atypical antipsychotics as first-line treatment 2, 4
Valproate is contraindicated in women of childbearing potential due to teratogenicity 2
Lithium may have additional benefits in patients with comorbid substance abuse 5

Ensure therapeutic doses are reached before concluding treatment failure 4
Maintain treatment for an adequate duration to prevent relapse 5
Avoid antidepressants during acute mania as they may worsen symptoms or trigger cycling 2, 3
Consider medical conditions that may affect medication choice or dosing 2