Bipolar I disorder — acute mania and maintenance (MEQ)

(i) Working diagnosis. First manic episode meeting bipolar I threshold: abnormally elevated/irritable mood with increased energy for more than 7 days, marked functional disruption (police involvement, reckless spending/sex), decreased sleep need, pressured speech, grandiosity, flight of ideas, impaired insight — substance screen negative so far. Working label: bipolar I disorder, current manic episode (severity high; consider involuntary pathway). Psychosis not clearly present yet but risk remains dynamic.[5]

(ii) Assessment priorities. Risk: suicide (including mixed features emergence), violence, sexual disinhibition, financial/forensic harm, driving, absconding, vulnerability. Capacity for treatment decisions; least-restrictive care under local Mental Health Act principles if insight and risk require. Medical exclusion: full physical, neuro exam, FBC/U&E/eGFR/TFT/LFT/glucose/lipids/ECG, pregnancy test if relevant, consider imaging if atypical features. Collateral ongoing. Baseline metabolic and ECG before SGA/lithium.[5][6]

(iii) Acute pharmacology (examples). Reduce stimulation; restore sleep (short-term benzodiazepine e.g. lorazepam as per protocol). First-line antimanic options: lithium carbonate start often 400–800 mg oral daily, titrate to 12-hour trough often 0.8–1.2 mmol/L in acute mania, with eGFR/TFT/calcium/level monitoring; and/or olanzapine 10–20 mg oral daily (metabolic monitoring) or sodium valproate loading/titration with LFT/FBC and strict pregnancy prevention if applicable. Severe mania often needs mood stabiliser + SGA combination. Cipriani antimanic NMA supports multiple effective agents.[4][5][6]

(iv) Antidepressant monotherapy. STEP-BD showed adjunctive antidepressants (paroxetine or bupropion) on a mood stabiliser did not beat mood stabiliser plus placebo for durable recovery — and in bipolar I, antidepressant monotherapy risks switch/mixed states and cycle acceleration. Future depression should use polarity-safe agents (e.g. quetiapine, lurasidone, OFC, lamotrigine pathways) with mood-stabiliser cover if an antidepressant is ever used.[2][5]

(v) Maintenance. After first mania, plan at least 6–12 months maintenance (often longer if residual symptoms/high risk). Offer lithium first-line when suitable: BALANCE showed lithium superior to valproate monotherapy for bipolar I relapse prevention, with combination also effective. Educate on trough timing, toxicity, interactions (NSAIDs, ACEI/ARB, thiazides). Cite lithium’s anti-suicide meta-analytic signal while maintaining renal/thyroid surveillance. Psychoeducation, sleep regularity, substance cessation, early-warning-sign plan, family involvement.[1][3][5][6]