How do you use lithium levels to adjust treatment during mania?

If someone is getting manic, the mania in itself reduces lithium levels. You need for a period of about 6 weeks maintain a level close to 1 in contrast to a maintenance level of 0.75. I would, of course, use the appropriate antipsychotic to help during this period. If the patient has been Li responsive, this will definitely take care of the episode. Review the previous level to determine adjustments to your maintenance level.

On my inpatient service, we really like the Cooper test dose method to start lithium. For reference: Cooper et al., PMID 4699934.

This generally speeds up the process of getting to therapeutic effect with a minimum amount of exposure and as efficiently as possible. This surely improves the overall disability as well as hospital length of stay. We just had a hugely successful case of postpartum psychosis that benefited from this method. Each level after the first can allow for titration if symptoms persist, but of course, a minimum therapeutic dose is preferred, and titration should not be arbitrary even if a level seems low.