Management of mania is based on medication, provision of a low-stimulation environment, and protection from undertaking potentially harmful activities. Initial management is frequently best accomplished in a hospital. Because manic patients are often incapable of reasonable discussion and action, it is best to institute the appropriate therapeutic measures as soon as the diagnosis is made and to implement them quietly and firmly with a minimum of discussion and with the help of the patient's family whenever possible. Improvement is usually not noted until at least 14 days, and full improvement may take four to six weeks or longer. Because the therapeutic response to lithium is slow, antipsychotic drugs are usually begun immediately when mania is severe.
Antipsychotic drugs have a specific antimanic effect even if overt psychotic symptoms are absent.
Predictors of poor response to lithium include a history of poor response to the drug, rapid cycling, dysphoric symptoms, mixed symptoms of depression and mania, and medical or psychiatric comorbidity. There is preliminary evidence that another anticonvulsant, valproic acid, may also be effective in the treatment of acute mania. In the long-term management of rapidly cycling patients, it is useful to graphically chart the cycles and use of medications. Thyroid abnormalities should be vigorously sought and treated. Trials of lithium should not be terminated too early, because some rapid cyclers will begin to show improvement only after a year of treatment.