Therapy of a mania

Synonyms

Bipolar affective disorder, manic-depressive disorder, cyclothymia, depression

Definition

Mania is a mood disorder, similar to depression. It is usually very elevated (“sky-high exultation”) or in rare cases angry (dysphoric). A distinction is made between hypomanic episodes, psychotic mania and mixed manic-depressive episodes.

Diagnosis

The diagnosis of a mania, similar to depression, is usually made by a psychiatrist or psychotherapist experienced in the matter. Depending on the severity of the symptoms, the need for treatment can often be seen by people close to the patient. The most important instruments for making a diagnosis are the diagnostic interview with the therapist and the so-called foreign anamnestic interview.

This means that close persons communicate their perception of the development of the disease to the therapist. (Beginning of symptoms, etc.) The special necessity of such a foreign anamnesis lies in the unreliability of the patient’s description due to a changed self-perception.

Basically, it must be noted that the therapy of a mania usually proves to be very difficult. Since the patients in many cases experience a real increase in their drive, their cheerfulness and their self-assessment, they themselves see no need to undergo therapy. In the course of the disease, even the close relatives are usually unable to maintain the relationship to the patient. In the worst case it can also come to extrinsically aggressive behavior

Therapy

There are three forms of therapy: drug therapy inpatient therapy electroconvulsive therapy

  • Drug therapy
  • Inpatient therapy
  • Electroconvulsive therapy

Drug therapy

The drug treatment of the manic episode has made progress in recent years to the extent that there have been new approvals here in Germany as well. In previous years, it was mainly the so-called mood stabilizers (carbamazepine – e.g., Tegretal®; valproic acid – e.g., Ergenyl; lithium – e.g., Hypnorex ®) and the classic antipsychotics (haloperidol – e.g., Haldol ®) that were used for therapy. The main problem here, however, were the sometimes immense side effects of the above mentioned drugs.

Only with the approval of olanzapine (Zyprexa®, Zyprexa® Velotab) did the therapy options begin to move. Olanzapine (Zyprexa ®) is an “atypical”, i.e. new neuroleptic, which is characterized by its significantly weaker side effects. This can lead to an improved readiness for therapy.

The most frequently reported side effect of olanzapine Zyprexa should not be concealed here. OlanzapineZyprexa makes you hungry. In most cases, patients get really hungry for sugar and fat.

As a result, in many cases weight gain occurs. In contrast to the normal starting dose for a psychotic episode (approx. 10-20 mg), one should start with a much higher dose in mania (approx.

40 mg) and reduce the dose very slowly as the patient improves. Since December 2003 Risperidone (Risperdal ®) has also been an officially approved drug for the treatment of acute mania. First results with Risperdal are very promising.

Quetiapine (Seroquel ®) was also approved in early 2004. Lithium is still used in clinical practice today. If both therapist and patient are equally informed about the possible risks of lithium therapy, this drug has the advantage that it has been proven in various studies to provide protection against relapse.

It is therefore used in prophylaxis, i.e. the prevention of a new phase of illness. The above mentioned risks of a therapy with lithium lie in the “danger of intoxication”, i.e. the danger of poisoning the patient. To a certain degree, the body can absorb lithium.

If, however, there is too much lithium in the body, i.e. the so-called blood level rises above a certain level (for those interested: > 1.2 mmol/l), the body reacts with symptoms of intoxication, which can become life-threatening in an emergency. In order to avoid exactly this, however, the drug content in the blood must be determined regularly at the beginning of the therapy, during the therapy and also when the dose is increased.Valproic acid and carbamazepine are drugs that are actually borrowed from the therapy of epilepsy (so-called anticonvulsants). In recent years, they have often been used when lithium therapy has not been successful.

The problem was that in many cases they did not have a real license for the treatment of mania and were therefore “off-label”, exposing prescribing outpatient doctors to the risk of having to pay a fine if the health insurance companies noticed that the drug helps the patient but does not give a documented permission to treat him. Since summer last year, however, valproic acid has also been approved in Germany, which is a good thing in that it is considered by experts to be the first choice for certain subtypes of mania (mania with psychotic characteristics, or rapid cycling). Low-potency neuroleptics (promethazine – e.g.

Atosil ®, levomepromazine – e.g. Neurocil ®) but also benzodiazepines (e.g. diazepam, oxazepam) have an extremely important role to play in the treatment of mania. It is known that restoring regular sleep is extremely helpful in the treatment of a manic episode.

Since both of the above-mentioned groups of drugs have a sedative effect, i.e. a dampening and sleep-inducing effect, they are frequently used (usually in combination with other drugs). In contrast to the normal initial dosage for a psychotic episode (approx. 10-20 mg), one should start with a significantly higher dosage in mania (approx.

40 mg) and reduce the dose very slowly as the condition improves. Since December 2003 Risperidone (Risperdal ®) has also been an officially approved drug for the treatment of acute mania. First results with Risperdal are very promising.

Quetiapine (Seroquel ®) was also approved in early 2004. Lithium is still used in clinical practice today. If both therapist and patient are equally informed about the possible risks of lithium therapy, this drug has the advantage that it has been proven in various studies to provide protection against relapse.

It is therefore used in prophylaxis, i.e. the prevention of a new phase of illness. The above mentioned risks of a therapy with lithium lie in the “danger of intoxication”, i.e. the danger of poisoning the patient. To a certain degree, the body can absorb lithium.

If, however, there is too much lithium in the body, i.e. the so-called blood level rises above a certain level (for those interested: > 1.2 mmol/l), the body reacts with symptoms of intoxication, which can become life-threatening in an emergency. In order to avoid exactly this, however, the drug content in the blood must be determined regularly at the beginning of the therapy, during the therapy and also when the dose is increased. Valproic acid and carbamazepine are drugs that are actually borrowed from the therapy of epilepsy (so-called anticonvulsants).

In recent years, they have often been used when lithium therapy has not been successful. The problem was that in many cases they did not have a real license for the treatment of mania and were therefore “off-label”, exposing prescribing outpatient doctors to the risk of having to pay a fine if the health insurance companies noticed that the drug helps the patient but does not give a documented permission to treat him. Since summer last year, however, valproic acid has also been approved in Germany, which is a good thing in that it is considered by experts to be the first choice for certain subtypes of mania (mania with psychotic characteristics, or rapid cycling).

Low-potency neuroleptics (promethazine – e.g. Atosil ®, levomepromazine – e.g. Neurocil ®) but also benzodiazepines (e.g. diazepam, oxazepam) have an extremely important role to play in the treatment of mania. It is known that restoring regular sleep is extremely helpful in the treatment of a manic episode. Since both of the above-mentioned groups of drugs have a sedative effect, i.e. a dampening and sleep-inducing effect, they are frequently used (usually in combination with other drugs).