Medications for Mania

Introduction

This leaflet is for anyone who wants to find out about the medications used to help stabilise unhelpful mood swings and to control mania. It discusses how they work, why they are prescribed, their effects, side-effects and some alternatives.  There are pointers to more detailed information elsewhere.

What is mania?

If you suffer from mania, you may find yourself feeling elated, over-confident and full of energy – ‘on top of the world’. You may sleep very little, talk very fast, and do things impulsively that are out of character.

In manic depression (also known as bipolar disorder), you may have both manic and depressive mood swings at different times.

These mood swings can be very unpleasant and destructive. For more information,  see our leaflet on Bipolar Disorder.

Mania is a condition that can come back again and again. Many doctors will advise taking medication to prevent this happening. Medication can be used to treat mania once it has started, or to prevent it from starting.

Mood Stabilisers

To Treat Mania: To Prevent Mania:
LithiumValproate LithiumValproate
Carbamazepine
Lamotrigine

Antipsychotics

To Treat Mania: To Prevent Mania:
Atypical: Olanzapine, Risperidone, Quetiapine
Typical: Chlorpromazine, Haloperidol
Usually used together with a mood stabiliser, not usually on their own

Benzodiazepines

To Treat Mania: To Prevent Mania:
Diazepam
Lorazepam
Clonazepam

More about the Wonderdrug Lithium

Lithium has for 40 years been the most commonly used drug to prevent relapse.

How does it work?

We don’t know, but we think that it may correct some of the chemical imbalances in the brain cells that make people likely to have depression or mania.

What effect does it have?

It ‘evens out’ mood swings in either direction.

How is it taken?

In tablet form, once or twice a day.

It is important to continue with the Lithium when you are feeling better – suddenly stopping it may trigger depression or mania.

What are the side effects?

You may notice:

  • a slight shaking of the hands;
  • dry mouth;
  • a metallic taste in the mouth;
  • tiredness;
  • weight gain;
  • thirst;
  • urinating more often;
  • under-active thyroid gland.

Not everybody will get these side-effects. If you do have any of these effects, it is worth bearing in mind that most will go away with time as your body gets used to the Lithium.

Is Lithium dangerous?

Lithium is a safe drug when taken at the correct dose. However, you don’t have to go very far above the safe dose before it becomes unsafe. A test to measure the amount of Lithium in your blood is the best way of making sure you are getting the right dose.

These signs suggest that your Lithium level is too high. Contact your doctor immediately if you notice:

  • you feel very thirsty;
  • bad diarrhoea or vomiting;
  • obvious shaking of your hands and legs;
  • twitching of your muscles;
  • you get muddled or confused.

Sensible precautions while taking Lithium

The body gets rid of Lithium in your urine, so the amount of Lithium in your blood is easily affected if you lose fluid. If you take in less, by drinking less, or lose more, through sweating or urinating, the higher your level of Lithium will be.

Your ability to get rid of Lithium in your urine is affected by the amount of salt in your blood – if you have less salt, you pass less Lithium in your urine, and so the level of Lithium in your blood may rise.

Some other drugs and medicines, whether prescribed by a doctor or available over?the?counter, may interfere with Lithium. Please check with your doctor or pharmacist before starting any new medication, wherever you have got it from. So:

  • drink plenty of non-alcoholic fluids; (Diet drinks can help to prevent weight gain)
  • if you are on holiday in a hot climate, drink more fluids than usual and don’t spend a long time out in the sun;
  • avoid low-salt diets;
  • be careful if you are exercising heavily – you may get too dry or lose too much salt in your sweat;
  • don’t have a sauna.

Blood tests

These are needed to:

  • check the amount of Lithium in the body (see above);
  • check that your kidneys and thyroid gland are working properly.

The blood test is usually done 12 hours after the last dose of Lithium.

  • If you take it twice a day, and are having the test in the morning, remember to miss your morning dose on the day of the test.
  • At first these tests are done every week or fortnight. After the level of Lithium in your blood has become steady, they need only be done every three or four months.

Mania

More about Valproate

This medication is becoming more widely-used to treat mania.

It is also used to prevent recurrence of extreme mood swings,  but it is not yet licensed for this use in Britain.  A study is underway to compare its effectiveness with Lithium. See: www.psychiatry.ox.ac.uk/balance

Like lithium we don’t know how it works.

  • sleepiness;
  • dizziness;
  • increased appetite and weight gain;
  • feeling of sickness, nausea;
  • skin rashes;
  • changes in blood count;
  • irregular periods.
  • pancreatitis (less than 1 in 10,000 cases): abdominal pain, nausea and vomiting.
  • liver failure (less than 1 in 50,000 cases): weakness, loss of appetite, lethargy, drowsiness and sometimes repeated vomiting and abdominal pain. If you have any of these symptoms, get help immediately.

Your doctor will usually take blood before you start treatment, and then for the first six months of treatment to monitor your blood count and liver function.

More about Carbamazepine

This is usually given to people who don’t get on with Lithium. Some doctors believe that it may be better for people who have frequent episodes.

What are the side effects?

It usually causes fewer side-effects than Lithium. The most common ones are:

  • feeling tired or dizzy;
  • blurred vision;
  • nausea;
  • stomach ache;
  • diarrhoea or constipation;
  • about 10% of people will develop a mild rash. About 1 in 200 people may develop a serious rash that requires urgent treatment;
  • 1 in 50 people can develop changes in the blood count, but these are rarely serious. These changes are more likely to occur at the start of treatment so your doctor may take blood tests for a while. You should consult your doctor immediately if you get a fever, sore throat, ulcers in your mouth, easy bruising, or a rash – particularly if the rash is of small purple spots.

More about Lamotrigine

This may be help to prevent future mood swings, particularly of severe depressive episodes.

Lamictal (lamotrigine) is a medication that belongs to the drug class anticonvulsants. Lamictal is available as a generic drug, and it is used alone or in combination with other antiseizure medications for treating certain types of seizures. Common side effects may include: dizziness, somnolence, headache, double vision, blurred vision, nausea, vomiting and rash.

Lamictal doses depend on the condition being treated and on whether it is used alone or in combination with other antiseizure medications. Drug interactions include: valproic acid, carbamazepine, phenytoin, primidone and olanzapine. The safety of using Lamictal during pregnancy has not been established. Lamictal is secreted into breast milk, and breastfeeding while taking Lamictal is not recommended.

Other Antipsychotics

These may be used alone, or with Lithium or Valproate. They can help if you become too active, psychotic or aggressive when you are manic.

There are two groups of antipsychotics; the older ‘typical’ group and the newer ‘atypical’ group. The older group are more likely to cause muscle stiffness or tremor.The most commonly used antipsychotics are now “atypical”.

What are the side-effects?

All antipsychotics may cause sleepiness or dizziness. If you take them for a long time you may put on weight. Older drugs from the ‘typical’ group, such as haloperidol, may also cause tremor or muscle stiffness.

They can be used to prevent relapse, but are usually used with one of the mood-stabilisers described above, when treatment with one drug has not been effective.

How about Benzodiazepines?

These drugs are usually given, just for a few days, along with the drugs mentioned above. They help treat the symptoms of irritability, overactivity and lack of sleep.

What are the side effects?

  • sedation;
  • unsteadiness;
  • if used for more than a couple of weeks, they can be addictive.

How effective are these medications in treating mania?

Lithium, Valproate and Olanzapine are all equally effective.  Carbamazepine has been used, but there is less evidence that it works. Whichever drug is used, mania is not an easy condition to treat, and you may take several weeks to recover. It is important to stick with the treatment and take it regularly.

How do I choose between the different medications?

  • In the acute phase, you might not be well enough to be too involved in the decisions about which drug to use.
  • If you have been ill before, doctors will often try to treat you with what has worked for you in the past.
  • When you are well, it might be worth agreeing with your doctor which medication you would prefer if you become ill again.

What else can I do to get over the acute phase?

  • You may not believe that you are unwell when you are high.
  • It important that you have family or friends who you can trust to tell you how you are.
  • If you don’t trust the professionals treating you, tell them why.

How effective are these medications in preventing mania?

  • Lithium is probably the most effective. It reduces relapse by 30–40%.
  • It is possible that Valproate is just as effective, but we won’t know until the Balance trial mentioned earlier has been completed.
  • Carbamazepine is slightly less effective.

How do I choose between treatments?

  • Lithium will usually be recommended for long-term treatment.
  • Carbamazepine may be suggested if your illness is prone to rapid relapses.
  • Some people may need a combination of drugs.
  • Much depends on how well you get on with a particular medication. What suits one person may not suit another.

Breast feeding and pregnancy

Pregnancy

  • If a mother is taking Lithium or Valproate, they are twice as likely to have their baby damaged as a mother who is not taking these medications. The risk is slightly less with Carbamazepine
  • This still means that 9 out of 10 babies born to a mother on Lithium or Valproate would be fine
  • If you do get pregnant accidentally, don’t suddenly stop your tablets as this could make you very ill.
  • Weigh up the risks of stopping the treatment and the risks of carrying on with it
  • If you do decide to carry on with treatment, your doctor may suggest that you take small doses regularly during the day. This can reduce the peaks of the drug in your blood stream.

Breast-feeding

  • Most drugs taken by a mother will be present in their milk, but the concentration will vary.
  • Most experts think that you should NOT breast-feed if you are taking Lithium. Valproate and Carbamazepine can sometimes cause problems in babies, so you should discuss this with your doctor.

What happens if I don’t take medication?

…In the acute phase:

Mania can be very disruptive and serious. It can alarm your family, you may lose your job, get into debt, or even get into trouble with the police. Your mood may take weeks or months to correct itself, and a lot of damage can be done during that time.  On average, an untreated manic episode will last around 6 months.

…In the prevention phase:

The most accurate predictor of having a manic episode is how often you have had them in the past. The more manic episodes you’ve had, the more likely you are to have another one.

Previous Manic Episodes

Chance of having another episode in the next year

Not taking Lithium Taking Lithium
1-2 10% (1 in 10) 6-7% (6-7 in 100)
3-4 20% (1 in 5) 12%  (12 in 100)
5+ 40% (4 in 10) 26%  (26 in 100)
Attacks also tend to get more frequent as you get older.

If you have had a manic episode, it’s worth giving some thought to treatments that might stop it from happening again.

Life events and stress can precipitate relapse. If this seems to be the case in your life, then you might want to consider a course of counselling or psychotherapy. This may help you cope with stress better, and help you find more stability in life.

Other ways of controlling “highs”

  • Some medical treatments used to treat other conditions can cause mania, so it is important to discuss your medicines with your doctor.
  • If you feel you are going high, get advice early.  Adjusting your medication, resting and avoiding stress may be enough to prevent a full relapse.
  • Find out as much as you can about the illness and its treatments.
  • People often have warning signs that they are going high. Not sleeping is one of the most important. It has been shown that if you can sit down with a professional and a family member, and draw up a list of warning signs and possible triggers, this can help to prevent relapses.
  • If you are going through a stressful time, and have early warning signs of mania such as insomnia, you may be able to prevent a relapse by taking a short course of a sleeping tablet, or an antipsychotic such as olanzapine.

Manic

Where can I find out more?

The information leaflet that comes with the tablets will describe the side-effects in more detail. If you have concerns, discuss them with your doctor.

What is a ‘licensed’ drug? Are unlicensed drugs dangerous?

  • In Britain, drugs are licensed by the European Agency for the Evaluation of Medicinal Products. A license is only granted if the medicine is safe and seems to help patients.
  • A drug may be unlicensed because there hasn’t been enough research into its effect in treating a particular condition. This doesn’t necessarily mean it is dangerous.
  • Drugs are commonly used to treat conditions for which they don’t have a license. For example, it is common to use benzodiazepines in the acute phase of mania, but they are not officially licensed for this condition.

References

The British Association for Psychopharmacology guidelines for treatment of bipolar disorder: a summary. Goodwin GM, Young AH. J Psychopharmacol. 2003 Dec;17(4 Suppl):3-6.

Bipolar disorder. Geddes J. Evid Based Ment Health. 2003 Nov;6(4):101-2.

NICE: Final Appraisal Determination: Olanzapine and valproate semisodium in the treatment of acute mania associated with bipolar I disorder.