HOW TO TREAT MANIC EPISODE 2025

HOW TO TREAT MANIC EPISODE 2025

GUIDELINES FOR THE DIAGNOSIS AND TREATMENT OF COMMON MENTAL DISORDERS

(Enacted under Decision No. 2058/QĐ-BYT dated May 14, 2020, by the Minister of Health)

Article 18

MANIC EPISODE

CHIEF EDITOR

Associate Professor, PhD Nguyễn Trường Sơn

CO-EDITOR

Associate Professor, PhD Lương Ngọc Khuê

PhD Nguyễn Doãn Phương

CONTRIBUTING AUTHORS

PhD Trần Thị Hà An

MSc Trịnh Thị Vân Anh

PhD Vũ Thy Cầm

MSc Trần Mạnh Cường

PhD Nguyễn Văn Dũng

PhD Vương Ánh Dương

PhD Lê Thị Thu Hà

MSc Trần Thị Thu Hà

MSc Phạm Công Huân

MSc Đoàn Thị Huệ

Specialist Doctor II Nguyễn Thị Minh Hương

MSc Vũ Thị Lan

1. Nguyễn Phương Linh

Specialist Doctor II Nguyễn Thị Phương Loan

MSc Bùi Văn Lợi

MSc Nguyễn Thị Phương Mai

PhD Trần Nguyễn Ngọc

MSc Bùi Nguyễn Hồng Bảo Ngọc

MSc Trương Lê Vân Ngọc

MSc Bùi Văn San

PhD Dương Minh Tâm

MSc Phạm Xuân Thắng

MSc Lê Thị Phương Thảo

MSc Lê Công Thiện

MSc Vương Đình Thủy

Associate Professor, PhD Nguyễn Văn Tuấn

Specialist Doctor II Ngô Văn Tuất

MSc Đặng Thanh Tùng

MSc Vũ Sơn Tùng

MSc Cao Thị Ánh Tuyết

MSc Nguyễn Thị Ái Vân

Specialist Doctor II Hồ Thu Yến

MSc Nguyễn Hoàng Yến

CONTRIBUTORS TO EVALUATION AND FEEDBACK

Associate Professor, PhD Nguyễn Thanh Bình

PhD Vũ Thy Cầm

PhD Nguyễn Hữu Chiến

Specialist Doctor II Võ Thành Đông

PhD Lê Thị Thu Hà

Specialist Doctor II Đỗ Huy Hùng

PhD Nguyễn Mạnh Hùng

MSc Nguyễn Trọng Khoa

Specialist Doctor II Ngô Hùng Lâm

Associate Professor, PhD Phạm Văn Mạnh

Specialist Doctor II Trần Ngọc Nhân

PhD Dương Minh Tâm

MSc Đặng Duy Thanh

PhD Vương Văn Tịnh

Specialist Doctor II Lâm Tứ Trung

PhD Lại Đức Trường

PhD Cao Văn Tuân

Associate Professor, PhD Nguyễn Văn Tuấn

SECRETARIAT TEAM

MSc Đặng Thanh Tùng

MSc Trương Lê Vân Ngọc

BA Đỗ Thị Thư

Article 18

MANIC EPISODE

I. DEFINITION  

According to ICD-10, a manic episode is characterized by elevated or irritable mood, along with increased pace and volume of physical and mental activity. When organic causes and substance use are excluded, it is considered the initial phase of bipolar affective disorder.

II. ETIOLOGY  

1. Biological Factors:  

   – Epidemiological and genetic evidence highlights a strong role of heredity, with disease prevalence relatively consistent across individuals and social adversities.  

   – Dysregulation of the hypothalamic-pituitary-adrenal axis, thyroid abnormalities.  

   – Imbalance in neurotransmitters/receptors, particularly dopamine system activity.  

2. Environmental Factors:  

   – Studies suggest recent negative life events or chronic stress can precipitate and predict the onset or recurrence of mood episodes.  

   – Most research indicates negative life events often precede manic or hypomanic episodes.  

3. Neuroimaging Insights:  

   – Deficits in neuronal and glial cell density, glial activity, neuronal structure/integrity, and biochemical changes in the prefrontal cortex, as well as its functional connectivity with other cortical regions.  

   – Evidence of hyperactivity in the ventral striatum and amygdala, dysregulation in the thalamus, and relative overactivity in the cerebellum compared to baseline.

III. DIAGNOSIS  

1. Definitive Diagnosis  

A manic episode is diagnosed when the following criteria are met:  

1. A period of markedly elevated, expansive, or irritable mood, abnormal for the individual.  
2. At least three of the following symptoms during the mood disturbance:  

   – Increased activity or restlessness.  

   – Pressured speech (racing thoughts).  

   – Flight of ideas or racing thoughts.  

   – Loss of social inhibition, leading to inappropriate behavior.  

   – Decreased need for sleep.  

   – Grandiosity or inflated self-esteem.  

   – Distractibility or frequent shifts in plans/activities.  

   – Reckless behavior without recognizing risks (e.g., excessive spending, risky investments, reckless driving).  

   – Increased sexual activity or sexual exhibitionism.  

1. The mood disturbance must:  

   – Persist for at least one week.  

   – Be severe enough to significantly impair occupational, social, or relational functioning, or require hospitalization to prevent harm to self or others.  

   – Not be directly caused by a substance or medical condition.  

1. May include mood-congruent psychotic symptoms(e.g., grandiose delusions, voices praising supernatural powers) or mood-incongruent symptoms (e.g., delusions of reference, persecution, sexual content, or commenting voices).  

Subtypes by Severity and Symptoms:  

– Hypomania (F30.0): Milder symptoms, no psychosis.  

– Mania Without Psychotic Symptoms (F30.1).  

– Mania With Psychotic Symptoms (F30.2).  

2. Differential Diagnosis  

– Mood disorder due to a medical condition.  

– Substance-induced mood disorder.  

– Cyclothymic disorder.  

– Psychotic disorders (schizoaffective disorder, schizophrenia, delusional disorder).  

– Narcissistic personality disorder.  

– Antisocial personality disorder.  

3. Ancillary Testing  

3.1. Basic Labs  

– Blood: Hematology, biochemistry, microbiology (HIV, HBV, HCV).  

– Urine: General analysis, drug screening, syphilis serology.  

– Thyroid hormone levels.  

3.2. Imaging/Functional Tests  

– Chest X-ray, abdominal ultrasound.  

– EEG, ECG, cerebral blood flow, transcranial Doppler.  

– CT/MRI brain (select cases).  

3.3. Psychological Assessments  

– Young Mania Rating Scale (YMRS).  

– Personality: MMPI, EPI.  

– Pittsburgh Sleep Quality Index (PSQI).  

3.4. Monitoring Tests  

– Metabolic effects of drugs: Blood glucose, lipids (cholesterol, triglycerides, LDL, HDL) every 3 months.  

– Leukopenia monitoring: Complete blood count monthly.  

– Liver, kidney function, ECG every 3 months.  

– HLA-B*1502 genetic testing for antiepileptic drug allergy risk (e.g., carbamazepine).

IV. TREATMENT  

1. Treatment Principles  

– Early hospitalization for severe mood episodes; outpatient treatment for mild cases.  

– Detect early signs of mood disturbance for timely intervention.  

– Assess severity, clinical structure, and presence of psychotic symptoms.  

– Initiate prompt treatment with antipsychotics for mania and mood stabilizers, tailoring drug choice and dosage to the patient’s condition.  

– Combine sedatives as needed.  

– Prevent relapse post-acute phase and focus on psychosocial rehabilitation.  

2. Treatment Framework  

2.1. Pharmacotherapy  

– Acute Phase:  

  – Mood Stabilizers: 1-3 agents:  

    – Divalproex (750 mg/day – 60 mg/kg/day).  

    – Valproate (500-1500 mg/day).  

    – Carbamazepine (200-1600 mg/day).  

    – Oxcarbazepine (600-2400 mg/day).  

    – Lamotrigine (100-400 mg/day).  

    – Topiramate (50-400 mg/day).  

    – Gabapentin (300-1800 mg/day).  

  – Antipsychotics: 1-3 agents:  

    – Typical:  

      – Haloperidol (5-30 mg/day).  

      – Chlorpromazine (25-500 mg/day).  

      – Levomepromazine (25-500 mg/day).  

    – Atypical:  

      – Risperidone (1-10 mg/day).  

      – Olanzapine (5-30 mg/day).  

      – Quetiapine (50-800 mg/day).  

      – Clozapine (25-900 mg/day).  

      – Aripiprazole (5-30 mg/day).  

  – Benzodiazepines: 1 agent:  

    – Diazepam (5-30 mg/day).  

    – Lorazepam (1-4 mg/day).  

    – Clonazepam (1-8 mg/day).  

    – Bromazepam (3-6 mg/day).  

  – Combination Therapy: For severe mania or psychosis, combine mood stabilizers (e.g., valproate, carbamazepine) with antipsychotics.  

– Maintenance Phase: Use effective acute-phase drugs:  

  – Valproate (200-500 mg/day).  

  – Carbamazepine (200-400 mg/day).  

  – Risperidone (2 mg/day).  

  – Olanzapine (10 mg/day).  

  – Quetiapine (100 mg/day).  

– Adjunctive Treatments: Neuroprotectants (piracetam, citicoline, ginkgo biloba, vinpocetine, choline alfoscerate, cinnarizine), beta-blockers, vitamins/minerals, zopiclone, eszopiclone.  

2.2. Electroconvulsive Therapy (ECT)  

– Effective for severe, agitated mania or treatment-resistant cases.  

2.3. Psychosocial Interventions  

– Cognitive-Behavioral Therapy (CBT).  

– Family therapy.  

– Social therapy.  

– Mental health education.  

V. PROGNOSIS AND COMPLICATIONS  

– High relapse rate. Functional recovery lags behind symptom resolution.  

– Complications arise from risky behaviors and comorbid medical conditions.  

VI. PREVENTION  

– Early intervention is critical for restoring occupational/social function and reducing disease burden, potentially altering the underlying illness course.  

– Early detection of relapse signs for timely intervention.  

– Treatment adherence reduces recurrence, hospitalization rates, and episode severity.

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