Bei der Therapie einer Manie kommen folgende Verfahren zum Einsatz:
- Medikamentöse Behandlung mit
- antimanisch wirkenden Substanzen
- „Mood Stabilizern“
- (atypischen) Neuroleptika
- neueren Antidepressiva vom Typ SSRI
- Benzodiazepine
- Psychotherapie/Psychoedukation
- Elektrokrampftherapie (EKT)
Die Behandlung ist häufig schwierig, da den betroffenen Patienten oftmals die Einsicht in die Notwendigkeit der Therapie fehlt. In der akuten Manie ist dies die Regel und bei erstmaligen manischen Episoden, aber auch in den anschließenden freien Intervallen scheuen viele Patienten therapeutische Interventionen und verbindliche Absprachen für den Fall eines Rezidivs. Im Rahmen manisch-depressiver bzw. bipolarer Störungen kommt es meiner Erfahrung nach besonders häufig zu Massnahmen gegen den Willen. Besonders belastend für die erkrankten Patienten ist der Umstand, dass sie sich wegen ihrer manischen Entgleisungen sehr oft auch im Freundeskreis und im familiären Umfeld Unverständnis und Ablehnung gegenüber sehen. Im Gegensatz zur nach aussen gezeigten Überheblichkeit, Selbstsicherheit und (verbalen) Angriffslustigkeit sind manische Patienten sehr kränkbar und ertragen kaum Vorschriften oder Begrenzungen anderer Art. Für viele Patienten ist es ein Horror, in einem Zimmer eingeschlossen zu werden oder gegen ihren Willen Medikamente einnehmen zu müssen.
Leider ist oft eine Hospitalisation erforderlich, nur selten und bei ungewöhnlich guter Compliance gelingt die ambulante Beherrschung einer akuten Manie. Eindeutige Indikationen für eine Hospitalisation, auch gegen den Willen, sind Selbst- oder Fremdgefährdung, die nicht nur die Suizidalität, sondern auch die unkontrollierte Veräusserung von eigenen oder fremden Vermögenswerten, die Abschlüsse ruinöser Verträge etc. einschließt.
Trotz oder gerade wegen der angedeuteten Schwierigkeiten ist die Herstellung einer therapeutischen Beziehung die größte Herausforderung für den behandelnden Arzt und andere Helfende. Unbedingt unterlassen sollte man Machtproben, auf Provokationen einzugehen bedeutet, in eine Falle getappt zu sein! Da die Erwartungshaltung durch ungeschulte Anwesende einen besonderen zusätzlichen Druck, sowohl auf den Patienten als auch auf den Arzt auszuüben vermag, ist es sinnvoll, möglichst rasch den involvierten Personenkreis zu reduzieren, möglichst auf Professionelle, allenfalls noch die engsten Angehörigen. Für die dann anstehenden „Verhandlungen“ sollte ein möglichst offener, aber reizarmer Ort gewählt werden. Zeitdruck ist „tödlich“, ein gleichbleibend sanfter Druck in Richtung Entscheigungsfindung und Begrenzung bei gleichzeitig wohlwollender und freundschaftlicher Haltung ist die ideale Herangehensweise. Hilfreich ist zum Beispiel die Unterbringung in einem Einzelzimme, klar deklariert als „Rückzugsmöglichkeit“, mit festgelegten Stunden auf der Station, die an ausgehandelte Verhaltenskodizes gebunden sind. Das Ziel ist absolut erreicht, wenn es am Ende zu „Kompromissen“ kommt, die die notwendigsten Therapiemassnahmen miteinschliessen. Es muss (wie im übrigen grundsätzlich in der Arzt-Patient-Beziehung!) unbedingt vermieden werden, dem Patienten Unterwerfungsgesten abzuringen. Der notwendige Therapieplan muss wenn irgend möglich mit ihm gemeinsam „gefunden“ bzw. „erfunden“ werden.
Die therapeutische Begleitung manischer Patienten sollte so ausgerichtet sein, dass der Aktionsradius auf „unschädliche“ Dinge gerichtet wird, das kreative Potenzial sollte entfaltet werden, wichtige soziale Kontakte sllten geschont werden. Es soll darauf gedrängt werden, wichtige Entscheidungen auf später zu verschieben, die Wiederherstellung eines geordneten Schlaf-/Wachrhythmus, die Normalisierung der Ernährung und die psychophysische Erholung sollte in der Akutphase aktiv in den Vordergrund gestellt und zum Hauptthema der ärztlichen Gespräche gemacht werden.
Bei schweren und therapieresistenten Manien und bipolaren Störungen sowie bei amhaltender Fremd- und Selbstgefährdung keine eine Elektrokrampftherapie (EKT) wirksamer sein als eine medikamentöse Behandlung.
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