in general, olanzapine is best for treating acute manic episode....but I much prefer to have patients on lithium alone once they are euthymic: lithium is underutilized due to being off patent, but remains the best drug we have to prevent recurrence.

of course, no two patients are the same + we have yet to figure out how many "bipolar disorders" there are, so it is good to have other options and NOT to have a "one size fits all" approach.

If you asking fastest, ECT is fastest and oldest for acute mania 

Consider looking for role of mood stabilizers includin lithium.  You will find numerous articles on this topic.  Howeve,  ECT may aLao be considered  for quick relief but it is used with hypermanic patients when pharmacotherapy fails. 

 Lithium and anticonvulsants take a lot longer to achieve an antimanic effect as they need to build up blood concentrations. In milder forms of mania you may consider very short term hypnotics and lithium/anticonvulsants.

However, in more severe cases where you need a faster effect antipsychotic drugs are the choice - olanzapine, haloperidol and other are effective 

Lithium Carbonate should always be the first option, the evidence for this is overwhelmed (remember that the first studies were conducted with lithium in agitated psychotic patients); the use of other mood stabilizers either alone or associated with lithium carbonate is another good strategy. Regarding the use of antipsychotics, generally it uses them them for the purpose of sedate the patient (this aim can be achieved with a benzodiazepine without many adverse events). Recall that antipsychotics have a deleterious cognitive impact, besides the metabolic cost to the patient becomes unthinkable to use molecules as Olanzapine.

As I understand it, the question was the fastest way to treating mania (assume in the short term) not bipolar disorder as a long term choice when I agree lithium remains the gold standard

Antipsychotic drugs do also have antimanic effects they do not act only as tranquillisers

Comparative studies evaluating antipsychotic efficacy between lithium carbonate and antipsychotics are limited, therefore, the evidence available in this regard from studies not sponsored by the industry is very limited; one of the best known studies (Niufan et al published in the J Affect Disord in 2008) did not find a significant difference between the antipsychotic effect of olanzapine vs. lithium, although it reported more adverse events metabolic nature in olanzapine-treated group . Previously, Shopsin et al in 1975, Cookson et al in 1981, and Janicak et al in 1988, had reported no differences between atypical antipsychotics and litio.The only antipsychotic which has a faster evidence that lithium and atypical antipsychotic effect is haloperidol, but its use is limited by serious cognitive effects, and the risk of tardive dyskinesia.

I think that Olanzapine or Haloperidol. the latter would depend on the response (sde effects). ECT is a quick and easy way to get control and depends on previous experience or the degree of the illness and disruption caused. This is short term. The use of Lithium, Sodium Valproate and depot versions  of IM Olanzapine can be considered.

I fully agree with Dr Basson in the unquestionable efficacy of ECT, however this is not a first-line choice, and personally I think its use is more limited in the extent that we can have effective molecules in controlling mania. Besides the ECT it is not free of adverse events (tooth fractures, cognitive dysfunction, memory impairment, etc ...)

In this respect I need to make some reflections:

1. Mania by definition is a psychotic experience.

2. Depending on the type of mania must stand different therapeutic strategies. In this sense it provides more problems is the treatment of mixed mania.

3. The patient's age is extremely important, is not the same treat mania in a teenager (which is very likely that some substance abuse be involved) in a young adult or an elderly patient.

4. The history of response to previous treatment and stabilizing treatment you are using.

5. It is always important, before prescribing psychotropic drug use laboratory tests that should include serum ammonia, electrolytes, thyroid tests, and so on. We also have to keep in mind the pharmacological interactions, and most important adverse events, especially those of cardiovascular nature (QT prolongation), electrolytes, etc ...

I personally, and depending on the above considerations Use the following sequences:

First line: Lithium (or other mood stabilizer excluding lamotrigine) plus a Benzodiazepine of long half-life (Clonazepam is a good choice)

Second line: Add another mood stabilizer.

Third line: Add an antipsychotic, (Personal preferences: Aripiprazole, Risperidone, -if the patient is very agitated and violent a good option is Loxapina- and haloperidol). Personally I avoid the use of olanzapine and clozapine by the metabolic impact of both molecules.

Last line: ECT.

Something very important that we always keep in mind in bipolar patients:

- The goal of treatment should not be dealing with crises, but to avoid them.

- Always drug treatment should mediate the principle: get the best effect causing minor damage).

- Never use antidepressants and antipsychotics alone.

Long-term, I totally agree that lithium needs to be reinstated as the best prophylactic agent we have.

For an acute episode, while ECT may act the most rapidly, in ambulatory outpatients  olanzapine at bedtime both quells mania and prevents sleep deprivation.

I have a number of outpatients on lithium alone, but with olanzapine available as a p.r.n. should they have a sleepless night or any warning sign like thoughts racing: even 5 mg HS stops mania OR prevents sleep deprivation: one night of sleep deprivation can trigger a manic episode.

There is no doubt that neuroleptics and ECT work  faster than lithium does in acute manic states.  From early literature from Schou's group (who developed lithium as a treatment) to later work (but little in recent years)  there is good data on this. Unfortunately many studies assess progress too infrequently and show weekly scores and by 3-4 weeks results from both look similar.  So called atypical neuroleptics (or if you must 'antipsychotics') are more variable in their effects.  Some may be activating at lower doses and only anti-manic at higher doses.  I have had some remarkable rapid successes with ECT and with Olanzepine but I have had outright failures with both as well.  Standard or first generation neuroleptics give more consistently antigenic effect earlier.. I agree overall with Dr. Opler's note above. Several older studies and reviews from Schou may be useful.

Acta Psychiatr Scand. 1991 Nov;84(5):435-8.

Lithium and electroconvulsive therapy: adversaries, competitors, allies?

Schou M1.

For rapid treatment of acute mania on an inpatient unit, consider an accelerated oral loading of divalproex sodium, 30mg/kg for days 1 and 2, then followed by maintenance dosing at 20mg/kg. Here is the study which validates this approach: http://www.ncbi.nlm.nih.gov/pubmed/10665626

Thank you all so much for the insight!

Lots of people talk about depression, but rarely do I see such information on mania. This has been a huge help!

Thank you again.

A sufficient dose of a D1/D2 dopaminergic antagonist (flupenthixol/zuclopenthixol) to reduce D1 activity sufficienlty enough, haloperidol or equivalently potent D2 antagonist to reduce D2 activity sufficiently engouh + valproate to increase GABA inhibitory tone on dopaminergic neurons (both D1- and D2-types) and partially reduce the glutaminergic activatory tone on dopaminergic neurons. A shock monotherapy of haloperidol injection would do the job too as haloperidol "conquers" all kinds of psychomotor excitations; diazepam add-on is occassionally used as are hypnotics.  

The answers above covered pretty well the question. I find that antipsychotics ( typical and atypical ) side effects are not so troublesome in the short run of the manic crisis and in a add on strategy with lithium or valproate can make faster the recovery.