Delirious mania: clinical features and treatment response.

OBJECTIVE: To examine clinical characteristics and treatment responses of patients presenting with delirium and mania to a psychiatric inpatient unit.

METHOD: Chart review of 16 cases admitted to McLean Hospital with delirium and mania was conducted. We examined the demographics, psychiatric symptoms, clinical course, and response to treatment with medications and electroconvulsive therapy (ECT).

RESULTS: Patients with delirium and mania had negative medical and neurological work-ups and were more likely to be younger, female and with a prior diagnosis of bipolar disorder. Sudden onset of symptoms, incontinence/inappropriate toiletting, and denudativeness are distinctive features of the syndrome. Consistent and significant benefit was seen with ECT. In many cases, high dose benzodiazepines were helpful. In a small number of cases, clozapine was also beneficial but this effect took an average of four weeks to be seen, while atypical antipsychotics, lithium and valproate produced variable results and took an average of three and a half weeks to work, if at all. Typical antipsychotics and anticholinergic drugs led to clinical worsening.

LIMITATIONS: Most patients were on more than one medication and hence treatment responses cannot be definitively ascribed to a specific intervention. Studies of larger groups of such patients in different clinical settings need to be done to confirm our observations.

CONCLUSIONS: Delirious mania is a severe psychiatric syndrome which can be accurately recognized and effectively treated. The definitive treatment for this condition is ECT. In cases where ECT is not available, high dose benzodiazepines should be used. Clozapine, quetiapine, lithium and valproate cannot be considered first-line treatments and these medications take an unacceptably long time to work even when helpful; typical antipsychotics and anticholinergic drugs should be avoided.