Acute mania algorithm, RT, lithium caveats — structured clinical viva

Working diagnosis. Bipolar I, current manic episode (duration, impairment, irritability, grandiosity, severe sleep loss). Citalopram may be a destabiliser. Assaultive behaviour and refusal raise capacity and legal-status issues.^[3]

Assessment priorities. Safety of staff/patient; MSE with risk (violence, absconding, sexual/financial harm, suicide if mixed); capacity; collateral; pregnancy status before valproate; baselines for lithium/SGA; UDS.^[3]

Behavioural pathway. De-escalation first; offer oral medicines; if IM RT required — name agents/doses (e.g. lorazepam 1–2 mg IM; olanzapine 5–10 mg IM; never IM olanzapine + parenteral BDZ); seclusion only as last resort with continuous observation.^[2]

Antimanic plan. Stop citalopram. Lithium titration to acute trough ~0.8–1.2 mmol/L with 5–7 day levels after change; toxicity education; combination SGA (e.g. olanzapine 10–20 mg/day) for severe mania. Valproate load ~20–30 mg/kg/day only if chosen after pregnancy exclusion and labs — not automatic in women of childbearing potential.^{[1][3][4][5][6]}

Prevention. Lithium-first maintenance when tolerated; sleep plan; early-warning signs; monitoring schedule; psychoeducation.^[7][3]