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Characteristics and duration of mania:
implications for continuation treatment
12 LATEST ADVANCES IN
TH
PSYCHIATRY SYMPOSIUM
PSYCHIATRY IN THE 21st CENTURY: FROM MOLECULE TO CLINIC
Psychopharmacology Special Interest Group of the Royal College of Psychiatrists
P rofessor Allan Young from the
Centre for Mental Health at
Imperial College, London dis-
cussed the issue of continuation
therapy following an acute episode
of mania. Guidelines recommend
that continuation treatment
should last for 6-12 months after
symptom remission; much longer
than might be thought.1
Episodes of mania are often
managed by several treating teams
at different phases of the illness. A
clear overview of the individuals
pattern of illness and continuity of
care in the transition periods
between phases is increasingly
important. Goodwin and Jamison2
defined the treatment phases of
mania:
Acute treatment: until clinical
response, ideally symptomatic
remission
Continuation phase: ongoing treat-
ment from the point of clinical
response to the point at which
spontaneous recover y might be
expected in untreated patients
Maintenance treatment: to prevent
or attenuate future mood
episodes.
However, there may be some
doubt about the natural duration
of mania among practitioners fol-
lowing the development of effective
treatments over the past 60 years.
The characteristics of mania
are defined in the Diagnostic and
Statistical Manual of Mental
Disorders, 4th edition (DSM-IV; see
26
12th Latest Advances in Psychiatry Symposium
In the continuation phase of treatment for acute mania, knowledge of the
Wednesday 13th March 2013
Royal College of Physicians,
Regents Park, London
natural duration of an untreated episode and the recognition of mixed states
are key issues. Steve Titmarsh reports on Professor Allan Youngs lecture on
this important topic given at a satellite symposium organised by Lundbeck at
A collaboration between Progress and the
the 12th Latest Advances in Psychiatry meeting in London in March.
Table 1). Its core symptom is an
abnormally and persistently ele-
vated, expansive or irritable
mood, lasting at least one week, or
any duration if hospitalisation is
needed. DSM-IV requires that at
least three other symptoms are
present to a significant degree and
that they persist. These include:
increased self-esteem or grandios-
ity; a decreased need for sleep;
being more talkative than usual or
feeling pressure to keep talking;
flight of ideas or the subjective
experience of racing thoughts; dis-
tractibility; increased goal-directed
activity; and excessive involvement
in pleasurable activities with high
potential for painful results. 3
Hypomania, a milder form of
mania, lasts at least four days in
the DSM-IV definition.
Mixed mania is ver y strin-
gently defined by DSM-IV: the cri-
teria for both major depressive
and manic episodes must be met.
Many affective episodes include
subsyndromal symptoms from the
opposite pole. When manic or
hypomanic episodes occur with
subsyndromal depressive symp-
toms, the term dysphoric mania
is often used. The incidence of
subsyndromal mania in bipolar
depression was illustrated in the
Systematic Treatment Enhance -
ment Program for Bipolar
Disorder (STEP-BD) study where
it was found in more than half (54
per cent) of the 1380 subjects.4 In
Progress in Neurology and Psychiatry May/June 2013
recognition of this phenomenon,
in DSM-5, there is a proposal to
allow for the modification of
episode characterisation through
the introduction of a specifier
describing the presence of symp-
toms of the opposite pole.
Duration of mania
The onset and duration of a manic
episode is influenced by many fac-
tors, especially medication. The
background risk of a switch to
post-depression mania is 10-20 per
cent. A manic switch may occur in
some cases through the use of
antidepressants. 5 Mania may be
precipitated by stopping lithium
abruptly:6 this may also be true of
other medications. Misuse of sub-
stances such as cannabis is associ-
ated with an increased duration of
mania.7
The Royal College of
Psychiatr ys website states that
untreated, a manic episode gen-
erally last three to six months. 8
However, there may be substan-
tial inter-individual variation.
Angst and Sellaro reviewed well-
conducted studies on bipolar dis-
order, published before the era of
effective treatment.9 One of the
largest of these was by Wertham,
published in 1929, which involved
2000 patients with mania. This
study found that the median
duration of untreated mania was
four to six months, but interquar-
tile values ranged between two to
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12th Latest Advances in Psychiatry Symposium
four (Q1) and eight to ten
months (Q3).10
So what might have been
thought of as episode recurrence
just a few weeks after an initial
episode has been treated is likely
to be a relapse of the initial
episode. It is probably not a true
recurrence at all, rather a break-
through of the initial episode.
Therefore recurrence should
only be thought of as occurring
after the period of spontaneous
natural recover y which could
even be a year or more after the
initial episode, Professor Young
explained.
Implications for continuation
treatment
Understanding the natural
course of mania has significant
implications for continuation
treatment. Following an acute
manic episode, the duration of
the hypothetical untreated
episode represents a period of
ongoing vulnerability to episode
relapse, hence the recommenda-
tion that continuation treatment
should be for 6-12 months after
remission.1
Data on the natural duration of
mixed episodes are rare. However,
in treating mixed mania, it is
important to consider that
episodes of mixed or rapid cycling
may well have a longer duration
than pure mania11,12 and a med-
ication that is effective in pure
mania may not be the treatment
of choice for a mixed episode. For
instance, most efficacy data on the
treatment of mixed mania comes
from the post hoc analysis of ran-
domised controlled trials. These
data suggest that lithium may not
be so efficacious in mixed states as
valproate, risperidone or olanzap-
ine.1 However, these data are not
conclusive.
Professor Young added that the
use of newer anti-manic agents in
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z Satellite symposium
A distinct period of abnormally and persistently elevated, expansive or
irritable mood, lasting at least one week (or any duration if hospitalisation
is needed
Three or more of the following symptoms are present to a significant
degree and persist:
- Increased self-esteem or grandiosity
- Decreased need for sleep
- More talkative than usual or pressure to keep talking
- Flight of ideas or subjective experience that thoughts are racing
- Distractibility
- Increased goal-directed activity or psychomotor agitation
- Excessive involvement in pleasurable activities with a high potential for
painful consequences
Table 1. DSM-IV symptoms in a manic episode3
continuation and maintenance 2009;166:173-81.
5. Salvadore G, Quiroz JA, Machado-Vieira R,
treatment is supported by trials of et al. The neurobiology of the switch process
up to around 52 weeks.13,14 In con- in bipolar disorder: a review. J Clin Psychiatry
trast, a continuation trial of 2010;71:1488-501.
6. Mander AJ, Loudon JB. The rapid recurrence
haloperidol lasted only nine
of mania following abrupt discontinuation of
weeks.15 lithium. Lancet 1988;2(8601):15-7.
Professor Young concluded by 7. Strakowski SM, DelBello MP, Fleck DE, et al.
The impact of substance abuse on the course
emphasising that the continua-
of bipolar disorder. Biol Psychiatry 2000;
tion phase of treatment covers a 48:477-85.
period of ongoing vulnerability to 8. www.rcpsych.ac.uk/expertadvice/problems/
relapse following acute mania, bipolardisorder /bipolardisorder.aspx (accessed
3 April 2013).
commensurate with the estimated 9. Angst J, Sellaro R. Historical perspectives
duration of an untreated manic and natural history of bipolar disorder. Biol
episode. In mixed states, this Psychiatry 2000;48:445-57.
10. Wertham FI. A group of benign chronic
phase of vulnerability may be psychoses: prolonged manic excitements with
even more prolonged. Current a statistical study of age, duration and fre-
guidelines recommend that con- quency in 2000 manic attacks. Am J Psychiatry
1929;86:17-78.
tinuation treatment should last 11. Keller MB, Lavori PW, Coryell W, et al .
for 6-12 months after symptom Differential outcome of pure manic,
remission. mixed/cycling and pure depressive episodes in
patients with bipolar illness. JAMA 1986;225
3138-42.
References 12. Angst J, Preisig M. Course of a clinical
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Progress in Neurology and Psychiatry May/June 2013 27