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3. What are the main clinical features of a manic episode? What is the evidence base for current treatment approaches?
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased activity or energy, lasting at least one week and present most of the day, nearly every day (or any duration if hospitalization is necessary). B. During the period of mood disturbance and increased energy or activity, three (or more) of the following symptoms (four if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior: 1) Inflated self-esteem or grandiosity. 2) Decreased need for sleep (eg, feels rested after only three hours of sleep). 3) More talkative than usual or pressure to keep talking. 4) Flight of ideas or subjective experience that thoughts are racing. 5) Distractibility (ie, attention too easily drawn to unimportant or irrelevant external stimuli), as reported or observed. 6) Increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation (ie, purposeless non-goal-directed activity). 7) Excessive involvement in activities that have a high potential for painful consequences (eg, engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments). C. The mood disturbance is sufficiently severe to cause marked impairment in social or occupational functioning or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. D. The episode is not attributable to the physiological effects of a substance (eg, a drug of abuse, a medication, other treatment) or to another medical condition. NOTE: A full manic episode that emerges during antidepressant treatment (eg, medication, electroconvulsive therapy) but persists at a fully syndromal level beyond the physiological effect of that treatment is sufficient evidence for a manic episode and, therefore, a bipolar I diagnosis Treatment
First-line --- Each of the following medications are considered first-line monotherapy because each has consistently demonstrated its efficacy in multiple randomized trials; the drugs are presented in our general order of preference based upon the number of trials conducted, risk of side effects, and cost:
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