Mania and Mixed States addresses high-risk phases of bipolar spectrum illness where speed, structure, and safety matter most. This page converts guidelines into actions you can run in EDs, inpatient units, and outpatient clinics. Begin with structured assessment: confirm polarity and mixed features; review substances, stimulants, steroids, sleep loss, and antidepressant exposure; check safety (impulsivity, spending, driving, aggression, suicidality). Start antimanic agents promptly—lithium or valproate with an atypical antipsychotic when severity, agitation, or psychosis dictates; add rapid sleep restoration with behavioral darkness and cautious pharmacologic aids. If you’re aligning care with a bipolar mania conference, you’ll find algorithms for acute mania, mixed depression, and maintenance; guidance on stopping antidepressants during mixed/manic states; and stepwise approaches when response lags. Because circadian disruption often precipitates episodes, we build interpersonal and social rhythm therapy (IPSRT) into the plan from day one.

Risk falls when the system choreographs the basics. We lay out safety plans, means safety, and caregiver engagement; medical screens (pregnancy test when relevant, metabolic labs, lithium/valproate baselines, ECG when indicated); and pathways for catatonia or severe agitation that prioritize dignity and least-restrictive measures. For mixed states, we emphasize agents with antidepressant and antimanic balance while avoiding destabilizers. Once sleep stabilizes, psychoeducation and relapse-prevention scripts teach early warning signs (reduced need for sleep, accelerated speech, goal flooding), trigger management, and protective routines for travel or night-shift work. Equity features—interpreters, transport/tele access, cost navigation—keep momentum after discharge. Registries track episodes, sleep, function, and adverse effects; case huddles decide when to taper antipsychotics, when to add maintenance lithium/lamotrigine, and how to deprescribe safely. For refractory episodes or suicidality, consider TMS/ECT for Depression and coordinated psychotherapy that supports relationships and work/school continuity.