›Treatment goals
›Mania
›Rapid agitation control and sleep restoration
›Psychosis reduction if present
›Depression
›Suicide risk reduction
›Functional recovery
›Mixed features
›Avoid antidepressant monotherapy
›Prioritize mood stabilizer and antipsychotic strategy
›Nonpharmacologic core
›Sleep protection
›Quiet room and reduced stimulation
›Regular sleep window
›Nutrition and hydration
›Oral intake support
›IV fluids if poor intake or rhabdomyolysis risk
Acute mania and agitation medications
›Antipsychotics for acute mania
›Olanzapine
›PO
›5 to 10 mg once
›Repeat 5 to 10 mg after 2 hours if needed
›Typical maximum 20 mg in 24 hours
›IM
›5 to 10 mg once
›Repeat 5 to 10 mg after 2 hours if needed
›Typical maximum 30 mg in 24 hours
›Key cautions
›If benzodiazepine given, avoid IM co-administration within local safety window due to respiratory depression risk
›Sedation monitoring and fall precautions
›Haloperidol
›PO
›2 to 5 mg once
›Repeat 2 to 5 mg every 4 to 8 hours as needed
›Typical maximum 20 mg in 24 hours without specialist input
›IM
›2 to 5 mg once
›Repeat 2 to 5 mg every 30 to 60 minutes as needed
›Typical maximum 10 to 20 mg in 24 hours without specialist input
›Key cautions
›EPS risk
›If dystonia, benztropine 1 to 2 mg IM or IV or diphenhydramine 25 to 50 mg IV or IM
›QTc prolongation risk
›ECG monitoring when feasible
›Risperidone
›PO
›1 to 2 mg once
›Titration 1 mg daily as needed
›Typical maximum 6 mg per day
›Key cautions
›Akathisia monitoring
›Orthostasis monitoring
›Quetiapine
›PO
›50 to 100 mg at bedtime for sleep restoration strategy
›Titration 50 to 100 mg per day as tolerated
›Typical maximum 600 to 800 mg per day in inpatient settings
›Key cautions
›Orthostasis and sedation
›Metabolic risk planning
›Benzodiazepines for acute agitation adjunct
›Lorazepam
›PO
›1 to 2 mg once
›Repeat 1 to 2 mg every 2 to 4 hours as needed
›Typical maximum 6 to 8 mg in 24 hours without specialist input
›IM or IV
›1 to 2 mg once
›Repeat 1 mg every 30 to 60 minutes as needed
›Typical maximum 4 to 6 mg in 12 hours without monitored bed
›Key cautions
›Respiratory depression risk with other sedatives
›Delirium worsening risk in older adults
Mood stabilizers for acute mania and maintenance linkage
›Lithium
›Initiation considerations
›Avoid initiation in dehydration or significant renal impairment
›Drug interaction risk with NSAIDs, ACE inhibitors, ARBs, and thiazides
›Dosing anchors
›Typical start 300 mg PO twice daily
›Titration every 3 to 5 days in outpatient settings
›Monitoring
›Trough level timing 12 hours after dose
›Target levels per phase of treatment and local protocol
›Valproate
›Initiation considerations
›Avoid in pregnancy due to teratogenic risk
›Hepatic disease caution
›Dosing anchors
›Typical start 250 to 500 mg PO twice daily
›Loading strategies in inpatient settings per psychiatry
›Monitoring
›Serum level per protocol
›Platelets and liver enzymes
›Carbamazepine
›Initiation considerations
›Drug interaction risk via enzyme induction
›Hematologic monitoring needs
›Dosing anchors
›Typical start 200 mg PO twice daily
›Titration every 3 to 5 days
›Monitoring
›CBC and sodium for hyponatremia risk
›Serum level per protocol
Bipolar depression treatment strategies
›First-line medication strategies in many guidelines
›Quetiapine
›PO
›Start 50 mg at bedtime
›Increase to 300 mg at bedtime over several days as tolerated
›Sedation and orthostasis monitoring
›Lurasidone
›PO
›20 to 40 mg daily with food
›Titration up to 120 mg daily as tolerated
›Akathisia monitoring
›Lithium
›Anti-suicidal effect signal in long-term data
›Monitoring burden and toxicity precautions
›Lamotrigine
›Slow titration requirement
›Rash risk mitigation
›Not an acute rapid-onset agent
›Antidepressants
›If used, avoid monotherapy in bipolar I
›Combine with mood stabilizer or antipsychotic per specialist plan
›Monitor for switching and agitation
Catatonia and severe depression with psychosis
›Catatonia pathway
›Lorazepam challenge approach
›1 to 2 mg IV or IM once
›Reassess response within 30 to 60 minutes
›Repeat dosing per response and monitoring capacity
›If refractory or severe, ECT consultation pathway
›Malignant catatonia concern triggers ICU-level care
›Psychotic depression in bipolar disorder
›Antipsychotic plus mood stabilizer strategy
›Avoid antidepressant monotherapy
›Inpatient stabilization often required
Nonpharmacologic definitive therapy considerations
›Electroconvulsive therapy (ECT)
›Indications
›Severe depression with high risk
›Catatonia
›Treatment resistance
›Safety planning
›Medical clearance needs
›Anesthesia evaluation pathway
Guideline and evidence level mapping
›Evidence framing notes
›Acute agitation management commonly aligns with emergency psychiatry consensus and ED agitation pathways
›Antipsychotics and benzodiazepines supported by broad clinical trial and practice guideline evidence
›Class-style recommendation mapping for internal use
›Class I
›If imminent danger, rapid tranquilization with monitoring and least restrictive approach
›Class IIa
›Antipsychotic monotherapy for acute mania without contraindications
›Class IIb
›Benzodiazepine adjunct when agitation persists or catatonia suspected
›ACEP-style mapping for internal use
›ACEP Level B
›Structured de-escalation and pharmacologic sedation protocols reduce agitation-related harm in ED systems
›ACEP Level C
›Routine neuroimaging not indicated without red flags