Makindo Medical Notes

Related Subjects: |Psychiatric Emergencies |Depression |Mania |Schizophrenia |Suicide |Acute Psychosis |Delusions |General Anxiety Disorder |Obsessive-Compulsive disorder |Wernicke Korsakoff Syndrome |Medically Unexplained symptoms |Postpartum/Postnatal Depression |Postpartum / Postnatal Psychosis |Eating disorders in Children

🧠 About

• Hypomania = a milder, less severe form of mania, without marked social/occupational impairment or psychosis.
• Mania = more severe, often with psychotic features, dangerous impulsivity, and loss of function.

🔎 Clinical Features

• Persistently elated or irritable mood.
• Disinhibition → impulsive spending, substance misuse, risky behaviours.
• Hypersexuality and socially inappropriate behaviour.
• Motor overactivity, pressured speech, “flight of ideas.”
• Reduced need for sleep without fatigue.
• Grandiose ideas or delusions (common in mania, not typical in hypomania).
• Poor insight, loss of contact with reality (manic state).

🚨 Management of Acute Episode

• Risk assessment is essential (suicide, violence, finances, sexual risk).
• Hospital admission often required; may involve detention under the Mental Health Act 1983.
• Rapid tranquilisation: Haloperidol, Chlorpromazine, or Olanzapine. Benzodiazepines (Lorazepam) may be added for acute agitation.
• Always check for medical triggers (thyroid disease, steroids, substance misuse).

📅 Chronic / Maintenance Management

• Lithium → gold standard mood stabiliser for prophylaxis.
  • Monitor U&E, TFTs, calcium, and serum lithium every 3–6 months.
  • Maintain levels 0.6–1.0 mmol/L (higher end for mania prevention).
• Valproate → effective but contraindicated in women of childbearing potential due to teratogenicity.
• Carbamazepine → alternative, esp. with rapid cycling or mixed states.
• Lamotrigine → more effective in bipolar depression than mania.

⚡ Management of Acute Mania

• First-line antipsychotics: Olanzapine, Haloperidol, or Risperidone.
• Mood stabilisers: Sodium Valproate, Lithium (slower onset).
• Combination therapy may be needed for severe or resistant cases.

🛡️ Mania Prophylaxis

• Lithium Carbonate (best evidence, suicide risk reduction).
• Sodium Valproate (if lithium unsuitable, avoid in women of childbearing age).
• Carbamazepine for some patients.
• Other agents (Lamotrigine, Gabapentin, Topiramate) → limited evidence, under investigation.
• ECT may be used for severe, treatment-resistant mania.

Cases — Mania

• Case 1 — Classic acute mania 🔥: A 26-year-old man presents with 1 week of decreased need for sleep, pressured speech, flight of ideas, and grandiose plans to “start a global company overnight.” He is distractible and spending large amounts of money online. Diagnosis: manic episode (bipolar I disorder). Managed with hospital admission, antipsychotics (e.g. olanzapine), and mood stabiliser initiation.
• Case 2 — Mania with psychosis 🧠: A 34-year-old woman presents with elevated mood, irritability, and increased energy. She reports hearing voices telling her she is chosen to be “queen of the world.” Exam: disinhibited behaviour and persecutory delusions. Diagnosis: mania with psychotic features. Managed with antipsychotics, mood stabilisers, and inpatient psychiatric care.
• Case 3 — Secondary mania ⚕️: A 58-year-old man with no psychiatric history develops new hyperactivity, pressured speech, and irritability after starting high-dose prednisolone for temporal arteritis. Diagnosis: steroid-induced mania. Managed by reducing steroids if possible and using antipsychotics for behavioural control.

Teaching Point 🩺: Mania is defined as ≥1 week of abnormally elevated or irritable mood with increased energy, reduced sleep, pressured speech, and impaired functioning. Always distinguish primary bipolar mania from secondary causes (drugs, steroids, neurological disease).