What is the drug of choice for a manic episode? What are the side effects?

Author: Sun Yi, Chief Physician, Beijing Huilongguan Hospital

Reviewer: Zhang Yu, researcher at Chinese Center for Disease Control and Prevention

Treat manic episodes with drugs, and treat the acute phase for at least three months.

After the acute phase of treatment, the condition gradually improves and the symptoms gradually stabilize. The dosage can be adjusted and maintained with a small dose. Generally speaking, from clinical experience, the duration of maintenance treatment is not less than one year.

The first choice of drug treatment for manic episodes is lithium salt, that is, lithium carbonate. Lithium carbonate has a very good therapeutic effect on patients with manic episodes, with an effective rate of over 80%.

The therapeutic dose of lithium carbonate is gradually increased, and the initial dose may be 0.25 grams, 2-3 times a day, and the dose is increased every 2-3 days. The dose is increased over a period of one to two weeks, and the maximum dose can be increased to 2 grams per day.

During the treatment of lithium carbonate, the therapeutic dose and toxic dose of blood lithium concentration are very close. When the therapeutic dose is reached, the blood lithium concentration is about 0.6-1.4mmol/L, and when it exceeds 1.5mmol/L, there is a possibility of lithium poisoning. Therefore, when taking lithium carbonate to the therapeutic dose, poisoning is often prone to occur, so the blood lithium concentration should be closely monitored.

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Generally, after taking lithium carbonate for one week, you need to have a blood test to check the blood lithium concentration once a week. After the condition is relieved, during the maintenance treatment period, it should be tested about once a month.

Many family members or patients go to the hospital for treatment. After the prescription is given, they do not queue up at the hospital to get the medicine, but buy the medicine online, thinking that this saves time and is convenient. They do not go for follow-up visits during the medication period. This practice is actually very dangerous, because if you do not go to the hospital for treatment, you cannot monitor the blood lithium concentration. If you take too much medicine, it is easy to cause lithium poisoning and cause harm to the body.

In addition, lithium treatment has some side effects:

It may be a side effect of the digestive system, manifested as dry mouth, thirst, nausea, vomiting, stomach discomfort, stomach pain, and some people may even have diarrhea and constipation;

It may also be a side effect of the nervous system. For example, after taking lithium carbonate, you may experience drowsiness, impaired consciousness, tremors, hand tremors, tendon hyperreflexia and other nervous system phenomena.

It may also affect the cardiovascular system, hematopoietic system, etc., so when taking lithium salts, you must monitor its side effects.

Because lithium salt therapy has these side effects, clinically, lithium salt therapy is contraindicated for patients with, for example, nephritis, renal failure, severe cardiovascular disease, severe central nervous system disease, etc.

In addition, lithium salt treatment should be used with caution for elderly and frail patients, women who are breastfeeding or pregnant, and children under 12 years old.

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In addition to the first-line drug lithium carbonate, there are some anti-epileptic drugs, such as carbamazepine, sodium valproate, and magnesium valproate, which are second-line drugs for the treatment of manic episodes.

In addition, there are some traditional antipsychotic drugs, such as chlorpromazine, fluphenazine, and haloperidol, which are also very effective in treating manic episodes.

However, traditional antipsychotic drugs have many side effects, especially those that manifest in the extrapyramidal system. For example, after taking the drug for one or two weeks, the patient may experience akathisia, unable to sit, stand, or lie down, and pace back and forth in the room. Tremors may also occur, which is hand tremors. For example, when serving tea or pouring water, hand tremors may occur. These are all extrapyramidal reactions.

In addition, muscle tone disorders may also occur. For example, due to the rigidity of the eye muscles, the eyes may roll up, and the neck or other parts may feel a little stiff.

Another type is that after taking these drugs for a long time and in large quantities, some tardive movement disorders may occur, such as oral-lingual-cheek triad, which is characterized by involuntary twitching of the mouth and cheek muscles, and some movements, such as opening the mouth.

After these phenomena occur, the patient feels very uncomfortable, the treatment effect is often not very good, and the medication needs to be stopped. Of course, some drugs can also counteract these reactions, such as benzodiazepines, such as clonazepam and diazepam, which can relieve some of the patient's side effects.

In addition to the traditional antipsychotic drugs mentioned above, there is also a second-generation antipsychotic drug, such as risperidone, olanzapine, aripiprazole, etc. Some of these drugs have the same effect as lithium salts. These drugs do not have obvious extrapyramidal side effects, but they will cause more serious lipid metabolism syndrome. After taking the medicine, the patient may gain weight in the short term, and this drug will also have some effects on the patient's endocrine system and cardiovascular system, so many patients are resistant to this drug.

Of course, there are currently many types of drugs for treating manic episodes, probably dozens of them. For patients, it is impossible to understand every drug very clearly. What everyone needs to do is to take the medicine as prescribed by the doctor and communicate with the doctor in time if there are any questions. Only in this way can the safety of the medication be guaranteed to the greatest extent.