Mania euphoric

Lithium is the drug of choice for bipolar disorder with euphoric mania, whereas valproate has better efficacy for mixed states, irritable/dysphoric mania, and rapid cycling compared with lithium. 

It is common for both the depressive and manic phases to occur simultaneously in what is termed a mixed state or dysphoric mania. During these mixed episodes, the patient s mood is characterized by symptoms of both a depression and mania. Mixed episodes often have a poorer outcome than classic euphoric mania and, as a rule, respond better to certain anticonvulsants and atypical antipsychotic drugs than to lithium. As many as 50% of admissions to inpatient psychiatric facilities for the treatment of manic episodes appear to be for mixed manic states. The recognition... 

Lithium remains the treatment of choice for bipolar patients who experience classic euphoric episodes of mania. Current evidence suggests that those with mixed episodes or rapid cycling episodes respond preferably to anticonvulsants or atypical antipsychotic drugs. In addition to its use as a mood stabilizer, lithium is effective in converting unipolar antidepressant nonresponders to responders. Finally, lithium may also be an effective treatment for patients with clnster headaches. 

Preferred for Euphoric mania Mixed episode Mixed episode... 

Consequently, the choice for a primary mood stabilizer in acute therapy now includes lithium, valproate, carbamazepine, and the atypical antipsychotics. Among these, lithium and valproate remain first-line agents. Valproate and lithium are probably equally effective in the treatment of classic euphoric mania, but valproate and, for that matter, carbamazepine do not appear to provide the same degree of protec-... 

When selecting a mood stabilizer, four factors can guide selection (1) the phase of the current episode (i.e., euphoric mania vs. mixed mania), (2) the relative frequency of various episode types in the past as determined by review of the patient s life chart, (3) the patient s past response to particular mood stabilizers, and (4) the response of immediate family members (i.e., parents and siblings) to particular mood stabilizers. 

As a rule, we prefer lithium when treating bipolar patients who most often manifest classic euphoric mania. We also prefer lithinm for patients whose illness consists of a preponderance of depressive episodes with less freqnent manic or hypomanic episodes. We typically initiate lithium at 300-900mg/day given in a single bedtime dose or two divided doses. The target therapentic level is 0.8-1.2mEq/L. 

As many as 1 in 10 patients experience episodes of mania akin to those seen in bipolar disorder after TBl. Right-sided brain injury, particularly in the frontal lobe or so-called limbic structures, has the greatest potential to produce a secondary mania. The manic symptoms include euphoric or irritable mood, decreased need... 

Treatment with steroids may initially evoke euphoria. This reaction can be a consequence of the salutary effects of the steroids on the inflammatory process or a direct effect on the psyche. The expression of the unpredictable and often profound effects exerted by steroids on mental processes generally reflects the personality of the individual. Psychiatric side effects induced by glucocorticoids may include mania, depression, or mood disturbances. Restlessness and early-morning insomnia may be forerunners of severe psychotic reactions. In such situations, cessation of treatment might be considered, especially in patients with a history of personality disorders. In addition, patients may become psychically dependent on steroids as a result of their euphoric effect, and withdrawal of the treatment may precipitate an emotional crisis, with suicide or psychosis as a consequence. Patients with Cushing s syndrome may also exhibit mood changes, which are reversed by effective treatment of the hypercortisolism. 

Educate family members and the patient about the characteristics of the disorder(s) being treated, e.g., euphoric mania, mixed mania, psychotic mania, severe... 

According to the Expert Consensus Panel for Mental Retardation Rush and Frances, (2000), the mainstays of the pharmacological treatment of acute mania or bipolar disorder in adults are anticonvulsant medications (divalproex, valproic acid, or carbamazepine) or lithium. Both divalproex or valproic acid and lithium were preferred treatments for classic, euphoric manic episodes. Divalproex or valproic acid was preferred over lithium and carbamazepine for mixed or dysphoric manic episodes and rapid-cycling mania. For depressive episodes associated with bipolar disorder, the addition of an antidepressant (SSRI, bupropion, or venlafaxine) was recommended. According to the Expert Consensus Panel, the presence of MR does not affect the choice of medication for these psychiatric disorders in adults. 

Neuroleptic drugs are often used in mood stabilizer combinations. However, there have been few controlled studies of the use of such combinations, and interactions are potentially dangerous. The advantages and disadvantages of all currently used mood stabilizer combinations have been extensively reviewed (641). Some effects are well known neurotoxicity, hypotension, somnambulistic-like events, and cardiac and respiratory arrest associated with the combination of lithium and traditional neuroleptic drugs considered as a first-line treatment for classic euphoric mania with psychotic features. 

Lithium was the original mood stabilizer and Is still a first-line treatment option but may be underutilized since It Is an older agent and Is less promoted for use In bipolar disorder than newer agents May be best for euphoric mania patients with rapid-cycling and mixed state types of... 

Bipolar disorder is characterized by episodes of mania or hypomania, which include hyperactivity, decreased need for sleep, and a euphoric or irritable mood. Additionally, persons with bipolar disorder may have episodes of depression similar to those seen in major depressive disorder. The lifetime prevalence of severe bipolar disorder is about 1% and 3-5% if milder cases are included, afflicting men and women equally. Both bipolar disorder and major depressive disorder tend to be episodic, and in the periods of time between episodes, persons may experience few or no symptoms. The etiology of bipolar disorder is predominately genetic, with a 70% concordance in monozygotic twins. The neurobiology of bipolar disorder is less well understood, and few animal models have been developed. Treatment of bipolar disorder usually involves mood stabilizer medications, including lithium, and the anticonvulsants valproate and carbamazepine. At times, antidepressant and antipsychotic medications are also used. 

A 45-year-old woman had a long history of dysthymia and depression. She had taken many antidepressants, including tricyclics, SSRIs, amfebutamone, and venlafaxine. She had no history of mania or hypomania. She took sertraline 250 mg/day, with only a transient response, and mirtazapine 15 mg/day was added. Within 4 days she developed clear symptoms of hypomania, with euphoric mood, mild grandiosity, pressure of speech, increased energy, and a reduced need for sleep. Mirtazapine was withdrawn and sertraline continued within 3 days the hypomanic symptoms had remitted. The depressive disorder then re-emerged (3). 

Lithium is frequently combined with both traditional and atypical antipsychotics in euphoric acute mania with psychotic features. Case reports of neurotoxicity (e.g., delirium, cerebellar dysfunction, extrapyramidal symptoms, and severe tremors) have been reported in elderly patients receiving lithium and traditional antipsychotics. Combining lithium with calcium channel blockers is not recommended because of reports of neurotoxicity and severe bradycardia with verapamil and diltiazem. Acute neurotoxicity and delirium have been reported in patients receiving ECT with lithinm (even at reduced dosages) therefore lithium should be withdrawn and discontinued at least 2 days before ECT and should not be resumed until 2 to 3 days after the last treatment. 

By the late 1960s, lithium became the drug of choice for treatment of manic depression. Today, lithium is one of the most reliable drugs for lowering the manic high of bipolar depression. Lithium has proved an efficient treatment for mania with a response rate of 60 percent to 80 percent in classic euphoric mania cases. It is also sometimes used in treatment-resistant unipolar depression. Lithium is commonly taken as a salt, lithium carbonate, and is sold under a variety of brand names (Carbolith, Cibalith-S, Duralith, Eskalith , Lithane, Lithizine, Lithobid). Not only is it unique for calming the manic phase of depression, its chemical structure and properties are like no other antidepressant. 

Acute mania as part of bipolar I disorder is supposed to result from overexcitation of limbic neurons. This can arise either from loss of inhibitory tonic orbitofrontal control of limbic neurons or from various intra- and intercellular alterations (the full mechanism is unknown as yet). Manic episodes are often classified into euphoric (classical), dysphoric, mixed (along with clinical manifestations of major depressive disorder), mania with psychotic/catatonic features, and mania with a rapid cycling course of the disease. 

Until recently, most studies on antimanic agents were exclusively conducted in patients with bipolar I disorder and euphoric mania, resulting in firm evidence that lithium is especially effective in this type of mania. Valproate shows equal overall efficacy in mania however, fewer studies support its efficacy in euphoric mania compared with lithium. Valproate usually has a more rapid onset of action than lithium as its wide therapeutic window allows loading treatment strategies. Valproate may be the preferred choice in patients with numerous (more than eight) previous manic episodes or more than four depressive episodes, and who... 

Clozapine has been shown to be efficacious in both euphoric and dysphoric mania. ... 

Lithium is the first-line drug for the treatment of bipolar disorder, since it is efficacious in acute euphoric mania without psychotic features (beneficial in up to 80% of cases), and for maintenance treatment of bipolar I disorder (mood stabilizer). It has some antidepressant capacity, although this is not well established. 

Euphoric mania, first-degree relatives with mood disorders, less than 3 previous manic episodes, absence of psychosis, good previous response... 

Lithium and vaiproate are usually considered the first-line treatment options for acute exacerbation of non-psychotic mania. Lithium is most effective in euphoric mania and vaiproate is probably more effective in mixed states. Moreover, good prognostic signs for iithium may include ... 

Flence, various factors may lead the clinician to choose a particular medication, among them the type of mania (i.e. euphoric, dysphoric, mixed, or rapid cycling). As mentioned before, some evidence suggests a greater efficacy of carbamazepine, olanzapine, risperidone, olanzapine, or valproate compared with lithium in the treatment of mixed states. ... 

In non-psychotic patients, oxcarbazepine and valproate have been shown to exert similar efficacy in controlling mood symptoms in schizoaffective disorder. It is reasonable (although not tested) to use them in combination with SCAs in iller patients. Carbamazepine seems to be equipotent to lithium in controlling mood symptoms however, lithium is probably less effective than carbamazepine in improving depressive episodes as part of schizoaffective disorder. All in all, lithium and valproate are the first-line treatment of acute non-psychotic mania. Lithium is most effective in euphoric mania and valproate is probably more effective in mixed states. The time to onset of action of lithium may be somewhat slower than that of valproate, although data are not well established. 

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