Introduction

Mania refers to a phase or period of one week or more when a person displays alterations in their normal behaviour, characterised by abnormally excessive mood, emotions, energy levels, and brain and physical activity, which can significantly impair daily functioning. Specifically, a person in a manic episode can experience a euphoric mood, irritability, extreme and rapid speech (logorrhoea), racing thoughts, impulsive decisions, distractibility, hyperactivity, restlessness, and a decreased need for sleep.¹ These symptoms change an individual’s usual behaviour and are noticeable to others. People going through a manic phase, continuing even over a short period, may require medical care and hospitalisation to cope with their symptoms during their episodes.²

Manic events are usually part of a broader mental health disorder, most frequently associated with bipolar I disorder. Mania is a multifaceted and complex condition where, in some cases, severe psychotic symptoms like hallucinations and delusions may also occur.¹ Contrarily, hypomania is a less severe form of mania, which does not profoundly alter the social and working capacities of individuals. It usually lasts less than a week -approximately 4 days- and does not typically require hospitalisation. However, if the defined symptoms of mania are severe enough to require hospitalisation, true mania is diagnosed even if the symptoms do not persist for a full week.²

There are numerous strategies for the management of mania and the mitigation of acute manic episodes. Pharmacological agents, psychotherapy, lifestyle modifications, and other emerging techniques are some of the interventions proposed to individuals with mania, which effectively address their condition and reduce its impact on their lives.²

Pharmacological treatment

Many different medications have been used over the years in people with mania, seeking to address acute episodes but also maintaining a stable mood to avoid potential future relapses.²

Mood Stabilisers

The standard medications that have been used for several years to alleviate symptoms of acute manic episodes include lithium and some anticonvulsant agents such as valproate and carbamazepine. Depending on the severity of the symptoms and the willingness of individuals to collaborate, these agents are preferably administered orally, primarily aiming to resolve the agitation and aggression feelings observed in manic episodes.³

Particularly, lithium is a medication used in acute mania of bipolar disorder for more than fifty years. Despite being associated with several side effects and a potential risk of relapsing mania, lithium is considered the first choice of treatment, when it comes to mitigating euphoric symptoms and mood, but not motor symptoms. Combination therapy of lithium with other anticonvulsant or antipsychotic agents is also used in cases.³

Anticonvulsant agents, including valproate and carbamazepine, have been analysed for their mood stabilising abilities and were shown effective in the treatment of bipolar disorder, and acute manic episodes in particular.³

Antipsychotic medication

Both old and new generation antipsychotic medications have been found effective in managing manic episodes. For example, chlorpromazine has been used in mania since its introduction to the market decades ago, although its treatment efficacy may be limited compared to other agents with antimanic effects. Haloperidol, another first-generation antipsychotic agent, has also been proven effective in the treatment of mania, showing significantly positive results in improving manic symptoms without causing sedation. Notably, when compared to other mood stabilising-agents, including lithium, and other antipsychotic drugs, haloperidol remains among the treatments of choice for mania.⁴

Moreover, second-generation antipsychotic agents, such as clozapine, olanzapine, risperidone, quetiapine, and asenapine have all been evaluated for their antimanic properties. In detail, olanzapine administered intravenously in small doses during a manic episode has been found rapidly effective. This medication is also considered effective in preventing the relapse of manic episodes in people with bipolar disorder. Quetiapine, particularly when used in combination with other mood stabilisers, has also been proven effective in the treatment of acute mania and the prophylaxis of manic episodes. Risperidone and asenapine have demonstrated effective benefits in mania in bipolar I disorder, while also offering augmented prophylaxis from recurrent manic episodes in combination therapies.⁴

Finally, aripiprazole is a third-generation antipsychotic medication significantly effective for acute mania. Its therapeutic effects when combined with lithium or valproate are also noteworthy.⁴

Benzodiazepines

Benzodiazepines, although not the first-choice agents for mania, are still widely used both in acute episodes and in the long term. Their rapid effects of tranquilising and reducing agitation and insomnia have marked them as agents used off-label for manic episodes. Clonazepam is one of the most common benzodiazepines administered in such phases, thanks to its sedative action, also frequently co-administered along with antipsychotics to reduce their side effects. However, nowadays the use of clonazepam may be considered controversial due to the absence of recent scientific evidence assessing its effectiveness and tolerability in acute manic phases.⁵

Psychotherapy

Psychotherapy plays a crucial role in the management of mental health problems. The management of mania, as part of bipolar disorder, can benefit to a great extent from different psychotherapeutic approaches that improve the individuals’ overall well-being.²

Interpersonal psychotherapy

Intervention by interpersonal therapy is suggested for various psychiatric disorders. This type of therapy focuses on the symptoms of individuals, viewing them as a response to different intrapersonal situations. Therapists approach these symptoms as current medical conditions and by actively collaborating with patients try to cope with them rather than analysing past experiences. Various studies have approved the benefits of adjuvant interpersonal therapy along with medication, for maintaining mood stability, particularly in bipolar I disorder.⁶

Cognitive behavioural therapy

Cognitive behavioural therapy is yet another effective form of psychotherapy used in numerous psychological issues. The main idea of this therapy is to provide individuals with evidence-based information related to their challenges, modifying their perception towards more positive thoughts and behavioural patterns. According to a specific study, people with bipolar I disorder who also received cognitive therapy in addition to medications displayed a significant progress over one year, by improving their social functioning and managing manic indicators, preventing  the potential recurrence of manic episodes.⁶

Psychoeducation and family-focused therapy

Patients, caregivers, and relatives all participate in the treatment process of mania. Educating relatives about a condition enhances their ability to identify warning signs and mood changes at an early stage, ameliorating treatment approaches, for instance, by timely administering the right medication, and potentially even preventing hospitalisation. ⁶

Brain neuromodulation techniques

Stimulating neuronal responses by various techniques is a method used, although rarely, particularly in individuals with bipolar disorders who remain unresponsive to medications and psychotherapy. In an attempt to reduce this disorder’s burden, improve daily functioning, and reduce mood symptoms and specifically mania, different approaches including electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), and transcranial direct current stimulation (tDCS) have all been tested, although further studies are essential.⁷

The scientific literature on ECT is not yet very ample, but existing data highlights the effectiveness of this technique in reducing manic and hypomanic episodes. Particularly, numerous studies suggest that ECT can improve and prevent recurrent manic symptoms, and potentially increase treatment effectiveness when combined with medications. On the other hand, supplemental studies in TMS are pivotal for evidencing its efficacy to alleviate mania, as data thus far is contradicting. Additionally, further studies are needed for tDCS to certify its ability to improve manic symptoms.⁷

Summary

In summary, mania is a complex state, typically featured in broader mental health disorders and most commonly bipolar I disorder. A manic episode is about one week, which an individual experiences extreme alterations in their behaviour, mood, and cognitive functioning. Specifically, manic symptoms related to a significantly euphoric state, rapid speech, irritability, and decreased need for sleep are noticeable in people in a manic state and may require hospitalisation. The acute phase of a manic period may follow relapsing manic episodes, underscoring the importance of adhering to effective management approaches not only for the rapid treatment of symptoms but also for maintaining lifelong well-being.

Among the treatment solutions for acute manic phases, medications such as the mood stabilisers lithium and valproate, and the antipsychotic agents such as olanzapine, risperidone, and aripiprazole have been demonstrated effective with varying degrees, either when used in monotherapy or combination treatment. In urgent cases, off-label use of benzodiazepines, like clonazepam, is also implicated for their rapid efficacy in minimising manic symptoms. Furthermore, psychotherapy is an important factor for the long-term management of manic episodes in mental health problems, reducing their recurrences and enhancing the way they are managed. Lastly, neuromodulating and specifically neuronal stimulating techniques like ECT could be beneficial for non-responsive mania in patients with bipolar disorders, although further studies are needed to validate their efficacy.