A 28-year-old woman with Bipolar Disorder I presents to the emergency department with acute mania: pressured speech, flight of ideas, decreased need for sleep (2 hours), and goal-directed activity for 5 days. She is not on any mood stabilizer. Vital signs are stable. Physical examination is unremarkable. What is the most appropriate immediate next step in management?

Explanation

## Management of Acute Mania in Bipolar Disorder I **Key Point:** Acute mania with psychomotor agitation requires rapid behavioural control via antipsychotic (first-generation or second-generation) combined with mood stabilizer initiation. ### Rationale for Correct Answer **High-Yield:** In acute mania with agitation and psychomotor overactivity, antipsychotics provide rapid tranquilization (within hours) and reduce risk of harm to self/others. Intramuscular formulations achieve faster onset than oral. - Haloperidol 5 mg IM is a standard acute intervention for acute mania with agitation [cite:Kaplan & Sadock's Synopsis of Psychiatry 11e Ch 7] - Simultaneously initiating oral mood stabilizer (lithium, valproate, or lamotrigine) addresses underlying mood disorder - Combination therapy (antipsychotic + mood stabilizer) is guideline-recommended for acute mania [cite:American Psychiatric Association Practice Guidelines for Bipolar Disorder] ### Why Lithium Monotherapy Is Suboptimal | Aspect | Lithium Alone | Lithium + Antipsychotic | |--------|---------------|------------------------| | Onset of symptom control | 5–7 days | Hours (antipsychotic) + days (lithium) | | Risk of acute deterioration | Higher | Lower | | Agitation control | Delayed | Rapid | | Therapeutic level | 0.6–1.2 mEq/L (5–7 days) | Achieved in parallel | **Clinical Pearl:** Antipsychotics reduce acute agitation and psychotic features; mood stabilizers prevent relapse and long-term mood cycling. Both are needed in acute mania. ### Pre-Treatment Workup Baseline investigations (CBC, renal function, thyroid, glucose, lipid profile) should be done but should NOT delay urgent antipsychotic administration in acute agitation. These are typically done in parallel during admission. --- ## Why Each Distractor Is Wrong