My pdoc has a rule that (I don't remember it now even though I need to call for just this reason) I think 3 days of no sleep or 5 days with minimal sleep and I am to call immediately for med changes to prevent going out of control (which for me is usually going to be a bad mixed episode more than typical mania). But in general the rule should be if you're not sleeping call sooner rather than later b/c you're potentially going to feel less like calling as time passes and that can cause problems.