---
title: "Mania: Acute Treatment"
url: https://mghmclean.org/residents/handbk/part2b/acute.htm
description: "Other agents: atypical neuroleptics (olanzapine is FDA-approved for mania, substantial evidence also supports risperidone); benzodiazepines (adjunctive), ECT"
published: 2026-08-10
updated: 2026-08-10
---

# Mania: Acute Treatment

Published 2026-08-10

PART 3 / CH 42

Paul Hammerness and Tim Kelly

| Treatment | Lithium | Valproate | Tegretol |
|---|---|---|---|
| Mania types | All | Mixed, rapid-cycling | Mixed, rapid-cycling |
| Starting dose | 300mg BID/TID | 250mg BID/TID(or load 15-30mg/kg PO on day 1) | 100-200mg BID |
| Target serumlevel | 0.6-1.0 mEq/L | 50-120 mcg/mL | 6-12 mcg/mL |
| Labs | Lytes, TFT, CBC, EKG, U/A, betaHCG | LFT, CBC, betaHCG | LFT, CBC, TFT, EKG, betaHCG |
| Side effects | GI, thyroid, renal, neuro (sedation or tremor) | GI, platelets, neuro (sedation or tremor) | Rash, p450 auto-Induction, sedation/dizziness |

Other agents: atypical neuroleptics (olanzapine is FDA-approved for mania, substantial evidence also supports risperidone); benzodiazepines (adjunctive), ECT

source: Schatzberg AF and Nemeroff CB (1998) APP Textbook of Psychopharmacology,

## Psychosis: Acute Treatment

Tim Kelly

A. Atypical antipsychotics are emerging as first line treatment

· Numerous studies show these drugs to be at least as good as, and sometimes superior to, typical neuroleptics in most regards.

· Risk of EPS and tardive dyskinesia is significantly less.

B. Initiation of atypical agents

|  | Clozapine | Olanzapine | Risperidone |
|---|---|---|---|
| Start | 25mg QHS | 5-10mg QHS | 0.5-1mg QHS |
| Titrate | +25mg QD (inpatient) or QOD (outpatient) | variable | +0.5-1mg QD |
| Target | 200-500mg QD | 75% controlled with 5-15mg QD | generally 3-4mg QD |
| Serum Level | 350-370 for rx-refractory | n/a | n/a |
| Side effects | see table | sedation, wt. gain, type 2 diabetes mellitus.20mg: akathisia | sedationhyperprolactinemia>6mg: EPS |
| Benefits | best for rx-refractory; may decrease suicide risk | low EPS/TD;no monitoring | low EPS at low dosages |

source: Schatzberg AF and Nemeroff CB (1998) APP Textbook of Psychopharmacology,