Department of Psychiatry and Behavioral Health Stony Brook University Renaissance School of Medicine Stony Brook, New York
Acknowledgments The authors express great gratitude to Professor Max Fink for his characterization of delirious mania. We also thank Dr. Fink for his continued guidance and support during the preparation of this manuscript.
Disclosures The authors report no financial relationships with any companies whose products are mentioned in this article, or with manufacturers of competing products.
Knowing which medications to avoid is as important as knowing which agents to administer. Be vigilant in avoiding high-potency antipsychotics, as these medications can worsen extrapyramidal symptoms and may precipitate seizures or neuroleptic malignant syndrome (NMS).28 Anticholinergic agents should also be avoided because they worsen confusion. Although lithium is effective in BD, in delirious mania, high doses of lithium and haloperidol may cause severe encephalopathic syndromes, with symptoms that can include lethargy, tremors, cerebellar dysfunction, and worsened confusion; it may also cause widespread and irreversible brain damage.59 While positive outcomes have been documented when using a combination of antipsychotics and lithium,8,60 this approach should be considered carefully and tailored to individual cases, taking into account the severity of manic and psychotic symptoms in addition to the level of catatonia.
Due to long periods of hyperactivity, withdrawal, and diaphoresis, patients with delirious mania may be severely dehydrated with metabolic derangements, including elevated CPK due to rhabdomyolysis from prolonged exertion, IM antipsychotics, or rigidity. To prevent acute renal failure, this must be immediately addressed with rapid fluid resuscitation and electrolyte repletion.61
Benzodiazepines.The rapid use of lorazepam should be initiated when delirious mania is suspected. Doses of 6 to 20 mg have been reported to be effective if tolerated.5,20 Typically, high-dose lorazepam will not have the sedative effect that would normally occur in a patient who does not have delirious mania.2 Lorazepam should be titrated until full resolution of symptoms. Doses up to 30 mg have been reported as effective and tolerable.62 In our literature review, 50% of patients (18/36) responded or partially responded to lorazepam. However, only 3 case reports documented a complete remission with lorazepam, and many patients needed ECT for remission of symptoms.
ECTis generally reserved for patients who are not helped by benzodiazepine therapy, which is estimated to be up to 20%.5 ECT is highly effective in delirious mania, with remission rates ranging from 80% to 100%.1 ECT is also effective in acute nondelirious mania (comparable to depression); however, it is only used in a small minority of cases (0.2% to 12%).35 In our review, 58% of cases (21/36) reported using ECT, and in all cases it resulted in complete remission.
A dramatic improvement can be seen even after a single ECT session, though most patients show improvement after 4 sessions or 3 to 7 days.1,2,5 In our review, most patients received 4 to 12 sessions until achieving complete remission.
