PS6.1 | Mania in Primary Care — Summary & Reflection

KEY TAKEAWAYS

A manic episode is a distinct period of abnormally elevated or irritable mood + increased energy, lasting ≥1 week (or any duration if hospitalisation required; hypomania requires ≥4 days without severe impairment or psychosis). Core associated features: DIG FAST (Distractibility, Irritability/inflated self-esteem, Grandiosity, Flight of ideas, Activity increase, Sleep reduced, Talkativeness/pressured speech). DSM-5 requires ≥3 (or 4 if only irritable).

Bipolar disorder (I = manic episodes; II = hypomanic + depressive) has heritability ~60–80%, dopaminergic pathway hyperactivity, circadian dysregulation. Precipitants include antidepressant monotherapy, steroids, stimulants, and sleep deprivation.

MSE in mania: pressured speech, flight of ideas, grandiose delusions (psychotic features = mania, not hypomania), absent insight. Insight absent = primary barrier to consent.

Primary-care management (3-step): Safety assessment → acute behavioural control (haloperidol IM/oral antipsychotic if needed) → early specialist referral for diagnosis + long-term management.

Lithium: therapeutic range 0.6–1.2 mEq/L; prophylactic target 0.6–0.8; acute up to 1.0–1.2; toxicity >1.5. Baseline: creatinine/eGFR, TSH/T4, ECG. Monitor: serum level (12h post-dose), renal, thyroid every 3–6 months. Interactions: NSAIDs, ACE inhibitors, thiazides raise levels.

DO NOT use antidepressant monotherapy in bipolar depression — risk of switching to mania or cycling acceleration.

Mental Healthcare Act 2017: emergency assessment and admission without consent when imminent risk; decriminalised suicide attempts; replaced 1987 Act.

REFLECT

Consider a patient you might encounter in primary care — perhaps a young adult brought in by their family, behaving dramatically and insisting nothing is wrong. What assumptions might you make about this patient's behaviour before you have completed a full assessment? How might stigma, cultural context (e.g. attributing the behaviour to spiritual possession or a domestic conflict), or the patient's confident demeanour influence your initial diagnostic framing? What specific clinical tools from this module — the duration criterion, the DIG FAST mnemonic, collateral history, the MSE — would help you move from first impression to structured diagnosis? And how might your management decision differ if this exact presentation occurred in a setting where a psychiatrist was unavailable for 48 hours?