Treatment of mania

4.1 What is the best treatment for mania?

The first step in the treatment of mania is to stop the antidepressants. There are then two main lines of treatment in acute manic relapses. The first is to increase the long-term treatment–for example if the patient is already taking lithium then the levels should be checked and, providing it is being tolerated reasonably well, to increase the dose, aiming for a level of up to 1.0 mmol/l (occasionally up to 1.2 mmol/l). A similar approach can be adopted with valproate and carbamazepine. The alternative line is to give a specific antimanic treatment, usually an antipsychotic, either on its own or in combination with a long-term treatment (Fig. 4.1).

Fig. 4.1 Acute treatment of mania.

4.2 How are antipsychotics used in mania?

The most commonly used medicines for the acute treatment of mania are the antipsychotic drugs (neuroleptics).

Until the introduction of the newer (atypical) neuroleptics the standard treatment was with haloperidol or chlorpromazine. These older treatments are effective but tend to cause a lot of side-effects, particularly parkinsonian symptoms such as tremor, shuffling and abnormal movements. They often cause akinesia and lack of facial expression but can also precipitate restlessness or akathisia where the patient has trouble sitting or standing still–a very distressing state. Akathisia can also be mistaken for the overactivity of mania. The main difference is that the manic patient likes being active but hates feeling restless, usually locating the restlessness of akathisia directly in their limbs rather than in their mind.

Traditional antipsychotics also have the advantage of being both sedative and calming which can be a considerable benefit in the early stages of treatment of mania. They still have a place in the emergency treatment of manic excitement and haloperidol (5 or 10 mg IM) is a safe drug to inject in these circumstances, usually in combination with procyclidine 10 mg to prevent dystonic reactions.

Olanzapine, quetiapine and risperidone are the atypical antipsychotics that are licensed for the treatment of mania but it is probably true that all antipsychotic drugs, including the newest one, aripiprazole, improve manic symptoms. These drugs are relatively free of parkinsonian side-effects, and are generally well tolerated (Table 4.1). They are available in either rapidly dispersing tablets or liquid which can be helpful when compliance is in doubt. Olanzapine is now also available as an injection.

The reason that antipsychotics are preferred to other medicines such as lithium and carbamazepine is that they are easy to use so an effective dose can be quickly reached. Additionally, most GPs are familiar with their use.

4.3 How quickly does antipsychotic treatment work?

Some improvement in manic symptoms should be seen within a few days of starting the treatment (often due to a sedative effect), with a more substantial recovery over 6 weeks. It is worth continuing one treatment line for 6 weeks to assess response rather than changing or adding another treatment after a couple of weeks. (This can require steady nerves since if there is no improvement in the first 2 weeks everyone starts to wonder if you know what you are doing!) If the level of activity or disturbance is high and sleeplessness is a problem, prescribing benzodiazepines (diazepam or lorazepam) in combination with the antipsychotics can be a useful short-term measure.

4.4 What other treatments are effective in mania apart from antipsychotics?

VALPROATE

Valproate is the main alternative acute treatment and has the advantage of being effective, well tolerated and easy to use. Depakote is the formulation that is licensed for the treatment of mania as the studies have been done using this form (Bowden et al 2000, NICE Technology Appraisal 66). This particular formulation provides higher blood levels for the same apparent dose compared to other forms of valproate. The usual starting dose is 750 mg daily (250 mg tablets spread over two doses). It can then be increased gradually over a week up to 1500 mg or further to 2 g if necessary. It would seem likely that the other forms of valproate are also effective but licensed preparations are generally preferred (see National Institute for Clinical Excellence guidelines, www.nice.org.uk).

LITHIUM

Lithium is also an effective antimanic treatment and is used in similar doses and with similar blood levels to those used in preventive treatment (see Chapter 5). Higher doses with levels up to 1.0 mmol/l or even slightly higher than this are sometimes used. There are several difficulties in using lithium in mania:

Patients who are severely ill may be drinking little and are therefore liable to dehydration; this makes treatment with lithium more difficult and potentially dangerous.

It is difficult to find the effective dose rapidly as increases are usually done gradually: it can take a couple of weeks to reach a therapeutic dose and manic symptoms often need more urgent treatment than this.

Another reason relates to starting a long-term preventive treatment when a patient is manic and is not capable of making longer term decisions. Stopping lithium suddenly can cause a rebound manic effect (see Chapter 5). If lithium is started when patients are acutely manic and not committed to long-term treatment, they are likely to stop when they have recovered and this will risk precipitating a further episode of mania. This effect is not so apparent with antipsychotics and valproate.

For all these reasons antipsychotics or valproate are usually used first line; lithium is then added if the first line of treatment is not proving effective. In practice most patients are given a combination of treatment, with antipsychotics being added as an acute treatment to the longer term treatment, usually lithium.

CARBAMAZEPINE

Carbamazepine is also effective in the treatment of mania and it is useful to bear this in mind either as a primary treatment or increasing the dose if the patient is already on carbamazepine.

BENZODIAZEPINES

Benzodiazepines are also commonly used in mania. They are used generally for their sedative effect and particularly in cases where urgent calming and sleep induction are necessary. Lorazepam (0.5-1 mg) as an intramuscular injection is an effective emergency treatment for acute psychosis including mania (see Q 4.9). In the early days of treating excited manic patients many doctors give diazepam which has a long half-life, helps to improve sleep and has a calming effect during the day. Clonazepam is also used and there have been some studies to show this is effective in mania on its own, though it is unusual to treat mania only with benzodiazepines.

4.5 What if the mania is not improving on antimanic treatment?

This is a similar answer to that of treating depression that does not improve (see Q 3.9). The following questions should be considered before contemplating a change in medication:

Have you given the treatment long enough?: For example, at least 4 weeks with no or only minor response. It can be difficult to stick with the treatment when there is little improvement, but if the treatment is changed too early the benefits of the medication may be missed.

Have you tried a higher dose?: If the patient is not getting better, doses should be increased to the maximum dose that is recommended, provided that the treatment is reasonably tolerated before turning to an alternative antimanic.

Have you assessed concordance/compliance?: This is usually a problem in the treatment of mania as most patients have limited insight into their condition and so are unlikely to be taking the treatment correctly. There is also a fair chance that they are deliberately concealing their non-compliance rather than refusing. It is not uncommon to find a stack of tablets hidden away in a patient’s room when they have appeared entirely willing to take the treatment (see also Q 5.43). Can you arrange some supervision of the treatment and give it in a formulation that is harder to evade–a liquid or dispersible tablet?

Are they physically ill? (see Q 4.13): Specifically, is their thyroid function normal?

Have you got the diagnosis right?: For example, is this really an episode of mania or is this a drug or alcohol problem?

Is there another medication that they are taking that might be affecting their mania (e.g. steroids)?

4.6 What are the next lines of treatment in mania that has not responded to the first antimanic treatment?

If the first line being followed is with a single medication then try a combination of treatments: an antipsychotic should be one medication together with another antimanic, usually lithium or valproate.

Although there are some reservations on using lithium in acute mania, if there is little improvement lithium must be considered and at a sufficient dose to give a level of about 1.0 mmol/l.

There are other options available but these would usually be restricted to specialist use. These include carbamazepine, lamotrigine (see Q 3.4), benzodiazepines (including clonazepam) or ECT (see Q 3.22).

4.7 How long should antimanic drugs be taken?

As soon as the symptoms have begun to settle it is reasonable to start reducing the additional sedatives if these have been prescribed. If the patient is sedated by the antimanic treatment then this should also be cautiously reduced. These changes should be made slowly and on an experimental basis so that if symptoms re-emerge then the dose can be increased again.

Most doctors would wait 2-3 months after the manic symptoms have remitted to start slowly tapering the antimanic treatment, again watching for signs of relapse. This is the stage at which to have a discussion with the patient about longer term treatment.

4.8 How are psychotic symptoms in mania treated?

The antimanic treatments outlined above should lead to an improvement of psychotic symptoms as the other symptoms of mania abate. It is not essential to use antipsychotic medications when psychotic symptoms are present if other treatments (e.g. lithium or valproate) are being used. This differs from the advice in psychotic depression where antipsychotic drugs are always recommended. On the other hand mania without psychotic symptoms can be (and usually is) treated with antipsychotic drugs.

4.9 What treatment is useful in an emergency?

Acute manic excitement is a common psychiatric emergency which requires urgent sedation and calming. The usual treatment is with a sedative antipsychotic and a benzodiazepine. Oral medication is preferable unless the situation is so extreme that an injection is needed, either because rapid treatment is required or the patient is refusing or both.

4.10 Do antipsychotics increase the risk of switching into depression?

One of the advantages of the newer (atypical) antipsychotics is that they do not have the mental clouding or dulling effect commonly described with haloperidol and chlorpromazine which can be mistaken for depression.

It is common for depression at some level to follow mania and about a third of patients can expect this. This may be in part an understandable reaction when the reality of the fallout from the manic behaviour is starting to impact. It is possible that antipsychotics exacerbate this tendency but if the patient is taking lithium then this medicine may help to prevent the depressive swing. Atypical antipsychotics may be less likely to precipitate depression.

In either case it is important to be on the lookout for depression and warn patients and their families about the possibility of post-mania depression. If this occurs it would increase the indication for longer term preventive treatment.

4.11 What treatment is effective for hypomania?

Hypomania–and this is partly in its definition–is a mild or even subclinical condition that may not require treatment in its own right. However, if patients are experiencing a series of depressive and hypomanic episodes then a trial of a long-term treatment (usually lithium or valproate) is the appropriate line.

If it is necessary to treat hypomania, the same lines of treatment as for mania should be followed. The difference in emphasis would be in favouring lithium or valproate rather than antipsychotics as almost invariably a long-term perspective needs to be taken since the condition is less severe in the acute phase.

4.12 Is ECT an effective treatment for mania?

Electroconvulsive therapy can be a useful treatment in mania though it is rarely used. It is reserved for those whose mania has become life-threatening because of nutritional or hydration problems and usually when other treatments are also being tried. The author has given it only once in the last 10 years and that was to a patient who had become almost impossible to communicate with and who wouldn’t eat or drink although she gave no clear reason why not. The situation in which it is more commonly used is in the treatment of puerperal psychosis (see Q 6.18).

4.13 What investigations are needed?

Apart from the general consideration of physical health, only simple blood tests are indicated. A full blood count may show an infection for which the patient had not mentioned any symptoms. Renal function is usually checked, particularly when lithium is being considered or dehydration is a concern. Checking liver function, particularly when mania is complicated by alcohol misuse, is also important. Most psychiatrists would also do a urine drug screen to ensure that other drugs (particularly stimulants such as amfetamines and cannabis) are not being taken. However, the most important investigations are repeatedly considering the physical state through simple observation and laboratory investigation.

There have been concerns that antipsychotics can have cardiotoxic effects (lengthening of the QT interval) and one of the newer antipsychotics (sertindole) was withdrawn because of this. A normal ECG can be reassuring, particularly when the QT interval is within normal limits. If high doses of drugs are being used, particularly in elderly patients, then an ECG should be routine.

4.14 How should I talk to a manic patient?

It can be time consuming, exasperating and exhausting talking to someone who is manic–rather than talking you need mostly to be listening! The patient will probably be rude, provocative, dismissive and abusive, and will almost certainly pick on a soft spot: how you are dressed, how you talk, anything the patient knows about you. Recognise that the patient is trying to wind you up rather than reacting to the provocation. Arguing back will only escalate the situation, though this is often hard to resist.

The patient may be joking with you, but be very careful about being jocular yourself as it often backfires.

Think what message you want to give the patient: the two most likely ones are about medicine and hospital. Try to give this message when you are given a chance, usually without much more explanation than ‘It’s because I think that you are ill’. Justify this in a basic way–for example ‘You’re not sleeping and you are getting agitated’–but it is rarely helpful to go into detail. Expect to repeat the message several times and try to stick with one line rather than letting the patient divert you.

Sometimes the patient will take up your offers while seeming to have very little insight. Giving a choice of medicine can sometimes be helpful so that it does not seem that the patient is giving in entirely to you.

Who does your patient trust, or who usually has some influence with them? Try to use this person as well, but be wary of putting such an individual in a difficult position; they may well prefer you to be making the decisions and they will probably already be very fraught, having been kept up all night anyway.

There is rarely a shortcut to getting manic patients to take some treatment, but with patience and persistence you can usually succeed. If not, you are likely to need to go down the route to detention in hospital.

If you are feeling rushed and trying to get away quickly you are very unlikely to make much progress!

4.15 How is the need for hospitalisation judged?

Making the decision to admit someone to hospital can be an easy one when the patient is very ill and putting themselves and others at risk. However, it can be a very difficult decision when the patient has only mild symptoms but is getting into difficulties in relationships and jeopardising their work. The decision about admitting someone into hospital is usually related to how effectively the family or other carers are able to cope with the patient and how cooperative the patient is with treatment.

When the illness is severe and the patient is psychotic then a period in hospital is very likely to be needed as the situation is very unpredictable. If there is violence or serious recklessness–particularly if they are driving–then the decision to admit is clear.

An agreement with the patient is desirable but this cannot be at the expense of ignoring potential dangers–the patient is likely to be minimising the problems and manic patients can be quite persuasive. This downplaying of the dangers, combined with the fact that this assessment will be time consuming and you are busy, can easily lead to decisions being made that on reflection don’t seem quite so sound.

If hospitalisation isn’t essential today, leave it open to review again tomorrow when it may be clearer. Take into account what the family says: the patient may well be behaving much better when you are there–manics can usually ‘hold it together’ for short periods of time and are likely to be doing so when the doctor calls!

Get an agreement about treatment and get this started. Checking if the patient is both saying they are willing to take the treatment and also putting this into action is a very important part of the assessment of whether they need to go into hospital. If they are not taking any treatment they will not get better in the near future.

The hardest judgement to make is how reckless does someone need to be to go into hospital. Is the fact that the person is irritable and annoying everyone sufficient reason? Probably not. But when does this cross over into seriously affecting relationships with family, neighbours and workmates which would be a good reason for taking someone out of this situation and into hospital? Likewise, seriously embarrassing behaviour by someone who is usually quiet and responsible can be very hard to live down and should prompt admission.

It is difficult to provide some of the benefits of hospitalisation at home. Being in hospital removes an individual from the social situation and if necessary the staff can stop patients from going out. This is usually impossible to reproduce at home even with frequent visits by community staff unless there is a very determined family. It is very unusual for someone who is manic to willingly stay put at home!

4.16 How is the need for compulsory detention for treatment in hospital judged?

The general assessment about hospitalisation is obviously relevant (see Q 4.15). However, if someone who is manic is not agreeable to going into hospital, then consider invoking legal powers (in England and Wales under the Mental Health Act 1983). The principles in most legal powers are:

If there is serious violence, people are getting hit or there is great recklessness (e.g. running down the middle of the road) then the decision to admit compulsorily is usually clear (Case vignette 4.1). Occasionally there may be a problem where the patient is not being violent though may be very provocative and irritating and someone else is hitting them!

4.17 Can other specialist staff help in coping with a manic patient?

The mainstay of community psychiatry in the UK is the community psychiatric nurse (CPN). Experienced CPNs have usually had experience both in the hospital and the community so that they are familiar with a broad range of psychiatric problems and have also managed patients in extreme mental states. They often have a long-term relationship with both patients and their families which can prove invaluable in judging the seriousness of the mania and also what action is appropriate. CPNs are usually familiar with what medications have proved useful previously and how the illness tends to progress. In some cases they will be able to monitor the mental state on a daily basis and ensure that the medication is both available and ingested!

Social workers will need to be involved when compulsory detention is being considered, and will usually coordinate and organise this process, ensuring that the patient is admitted if they are detained. Social workers can also be helpful in providing practical help to families as well as patients.

Other members of the Community Mental Health Team include psychologists and occupational therapists. Their role is usually in the longer term care of people with manic depression (see Q 5.45). However these other team members can also be a useful resource in encouraging a manic patient to take some treatment, particularly if they have a strong relationship of trust with a patient or their family.

4.18 How often do patients commit serious crimes when they are manic?

It is surprising that manic patients do not feature more heavily in the statistics of psychiatric patients who have committed offences. One reason may be that they are so obviously ill that they are diverted from custody and being charged at a very early stage and so never reach court. Manic patients in hospital are often treated on intensive care units because of their intimidation and aggression and can be some of the most challenging patients to treat; however, it does seem that serious crimes of violence are rare. The fact that manics usually only become aggressive when they are thwarted may mean that violence is more common in hospital than outside. Other crimes, such as speeding and driving recklessly and dangerously, are much more common. It is always worth enquiring if your manic patients are driving as this is probably the most dangerous thing they are likely to do when manic.

4.19 Is violence a problem in mania?

Irritability is almost universally present in mania. It may not be apparent on first encounter, but as soon as the patient is thwarted or prevented from doing what is desired, then irritability will emerge.

The risk of violence is increased if there are other factors associated with aggression. The underlying personality and the person’s usual propensity to use aggression is the main one. Those people who are usually peaceful and not liable to use violence to pursue arguments are unlikely to be violent when they are manic. Those who habitually favour aggression as the way to resolve problems are very likely to continue this when manic. The disinhibition of the illness and the confrontational situations that patients usually end up in will exacerbate this propensity.

Other aspects that need to be borne in mind when assessing violence in any situation are:

gender–males are the more violent sex

age–youth rather than the middle age

drug and alcohol misuse–reflecting both the direct disinhibiting effect and often the personality of the user.

4.20 What is the best way to deal with violent behaviour in a bipolar patient?

The first line is to assess the diagnosis and current clinical state. This can be a rapid process in a patient you know well and whose manic symptoms are obvious. If the patient is in an acute episode of mania but acting violently then urgent treatment including sedation is required (see Q 4.9). However, this can only be provided when the situation is safe–in hospital this is usually achieved using experienced and skilled staff in sufficient numbers to physically restrain the patient if this is necessary.

In the community, you have to use what resources are available, always remembering that your own safety is important. Calling the police is a sensible precaution when visiting a manic patient who has been reported to be violent or who has a history of violence. Sometimes knowing the patient well can actually make it easier to misjudge the situation. You will probably be used to seeing them when they are well and so consider them to be a generally reasonable person; however mania often leads to extreme behaviour which is completely unexpected. You may also think that you have a good relationship with the patient, but again this can go out of the window if the patient has become very irritable.

If you know that the patient has a weapon you should not approach–remember that knives kill and wound many more people than guns both in the UK and elsewhere.

If the situation is not that extreme and you decide it is reasonable to try to intervene, then the first step is to try to just talk–and more importantly listen–to the patient (see also Q 4.14). This gives you a chance to assess the patient’s mental state and establish some rapport. Make sure you do not get into an argument–though this is very easy to do!

4.21 How do I resolve potentially violent situations involving bipolar patients?

Don’t immediately try to resolve the situation–just listen and allow yourself to get some confidence in your diagnosis. You can only intervene in a medical way if this is a medical problem–bipolars get into arguments and violence for the same reasons as other people and this episode may not be a medical problem. Treat the person with interest and respect however rude they are.

Try to offer a solution:

Would you like to come to hospital?: It may seem unlikely that this will be accepted but it is worth offering none the less–it may offer a quick solution.

Would you like to take some medicine to calm you down?: Offer a choice of medicines (e.g. diazepam or olanzapine). It may be that if the patient has some control over the choice they would be willing to take some treatment–perhaps even ask them what medicine they think would be helpful.

It can be very time consuming coming to a resolution, and in dealing with the situation everything else will have to be dropped–a quick fix is unlikely to succeed. Use the other people around–who does the patient trust? Can they help to persuade the patient to have some medicine or go to hospital? However, make sure that others are not getting into arguments and winding the patient up; they are likely to be feeling very emotional in this situation and they have probably been dealing with it for hours or days already.

If you are not succeeding then the police may have to take over and they will probably have to use force to restrain the patient. If it comes to this you will have to make use of the Mental Health Act to deal legally with the situation. Usually when the formalities have been completed the patient will be taken by the police to hospital. Make sure that the hospital has a good (written) account of what has happened; it is invaluable to have a dispassionate account of what actual violence occurred. Was anyone injured? Were weapons used?

If anyone has been seriously injured then the patient will usually need to be detained in custody until a safe place (not an open acute psychiatric ward) is organised. It is the author’s view that prosecution should be considered if any serious injury has occurred, but others think that if someone is ill this should not happen.

4.22 What can family and friends do to help a manic patient?

There is a difficult balance to be struck when trying to help someone who is manic. The patient will almost certainly try to persuade you that they are fine and don’t need any intervention. They often do this by a combination of cheerfully trying to get you to go along with them but also by getting irritable and annoyed if they are thwarted. Directly challenging patients often proves counterproductive but trying to make clear to them your view of their illness is important. Maintain your view that they are ill and what they need to do about it, without being drawn too much into argument.

It may take a lot of listening to get a chance to even make a simple point. Focusing on the practicalities is usually more productive than arguing about the principles which is often what happens. It is very time consuming dealing with people who are manic as they will talk endlessly to you and at you and productive dialogue is thin on the ground. You have to give them some time to speak but also to keep trying to draw them back to the important decisions that have to be made about their illness and its treatment. Some people are very skilful in edging patients along in a productive direction (e.g. taking treatment and medication) without it becoming a confrontation. This skill is more likely to be gained by experience rather than any particular techniques that can be learned. Do not get angry back as this is only rarely productive and usually escalates the situation.

4.23 Is an advance directive helpful when you are managing mania?

Having a good idea of what patients want you to do if they become ill again can be very valuable. An advanced directive is usually a written account of this (see Appendix 2). It will often include who should be involved–for example in the family, primary care or psychiatric staff. It may indicate what should be done about particular risks such as money, including taking away credit cards. The directive can specify what treatment the patient would prefer and hopefully this will have been worked out with a doctor beforehand.

There are plenty of positive uses for an advanced directive; however, they can still prove very difficult to implement. The patient may not accept at all what they have written down and on occasion it has been torn up in front of the doctor! The patient may well feel that it was someone else who really wrote it but felt under duress to agree; even so it gives you some basis to proceed with treatment. Some directives are unreasonably proscriptive–for example specifying who should be involved when they are either not available or not willing when the time arises. The treatment specified may not be appropriate and just because it is written down does not mean that it has to be implemented–you still have the usual responsibilities for your prescriptions. The directive may also specify that the patient does not wish to go to hospital or even that the illness should be allowed to continue its course–again you cannot ignore your responsibilities because of what is written down. If a patient is not capable of making decisions, then you have to act in their best interests, having taken account of all the relevant information that you have. In the end this may include detention through the usual legal channels.

Encourage patients to make advance directives and also encourage them to show them to people involved in their care, including the CPN and the family, so that everyone can have some input into their practicality.

PQ PATIENT QUESTIONS

4.24 How can I recognise that I am going manic?

It is often possible to identify a particular sequence of symptoms or behaviours that can act as a ‘relapse signature’ for each individual who experiences episodes of mania. Think back to what happened in the week or two before your illness became obvious. Look at the list of symptoms that occur in mania (see Box 1.1):

Do any of these symptoms occur early on in your illness?

Do you get particular ideas when you become manic–either grandiose or paranoid ideas or some very individual ideas (e.g. thinking that naturism should be universally adopted).

Ask other people what they notice early on that worries them (e.g. are you getting irritable or getting up very early to go running?).

Try to tie it to something measurable like sleep; if you are getting less than 6 hours something is probably going wrong.

Alternatively, think about what particular situations you get into with which people.

Write down your conclusions, or make a video so you can speak to yourself when you are manic, and decide in advance what you should do as it is difficult to make decisions when you are ill.

4.25 What can I do to help myself if I think that I am becoming manic?

All being well, you will have made a plan, even an ‘advance directive’, about what you should do in this circumstance. Try not to get annoyed when others are pressing you to implement the plan when you have lost insight. It is very easy when you are manic to find justifications for your behaviour and to blame others for the difficulties that you are running into.

Check out with your partner/friend/brother/sister whether they agree with you and what they think you should do.

Hopefully you will have agreed beforehand with your doctor what changes you will make to your treatment when you become manic. If you are on longer term preventive treatment then it may be appropriate to increase this. Alternatively–and particularly if you are not on a long-term treatment–it will be starting an antipsychotic drug which suits you reasonably well and has been effective for you in the past. The short-term use of sleeping pills or tranquillisers might be another option.

Make sure you take good care of yourself. Eat decent meals, and above all make sure that you give yourself the opportunity to rest and particularly to sleep. Depriving yourself of sleep will definitely exacerbate your mania.

Should you stop going to work? Get someone else’s advice on this as your judgement may not be good and it could be a big mistake turning up for work when you are disinhibited. Don’t start drinking alcohol or smoking cannabis to calm yourself down as this will probably make things worse–intoxication increases disinhibition. Stop driving–its illegal to drive if you are not capable and driving is the most common way that people get seriously injured.

Get some advice from your doctor or nurse about what you should do. Go early so that they can confirm if you are taking the right action, and agree when you will review this again and what you should do if your symptoms get worse.