However, neurovegetative abnormalities are generally absent or mild. In addition, in these personality disorders, fluctuations in mood are often extremely rapid and may occur within hours. In contrast, in bipolar disorder, fluctuations in the pervasive mood take days, although manic patients may exhibit marked lability. Therefore, a drug history and toxic screen are critical parts of the workup for mania. 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.