Bipolar disorder: assessment and management

National Institute for Health and Care Excellence


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  • This Guidelines summary includes recommendations that are relevant to the primary care setting. Please refer to the full guideline for the complete set of recommendations

Recognising and managing bipolar disorder in adults in primary care

Recognising bipolar disorder in primary care and referral

  • When adults present in primary care with depression, ask about previous periods of overactivity or disinhibited behaviour. If the overactivity or disinhibited behaviour lasted for 4 days or more, consider referral for a specialist mental health assessment
  • Refer people urgently for a specialist mental health assessment if mania or severe depression is suspected or they are a danger to themselves or others
  • Do not use questionnaires in primary care to identify bipolar disorder in adults

Managing bipolar disorder in primary care

  • When working with people with bipolar disorder in primary care:
    • engage with and develop an ongoing relationship with them and their carers
    • support them to carry out care plans developed in secondary care and achieve their recovery goals
    • follow crisis plans developed in secondary care and liaise with secondary care specialists if necessary
    • review their treatment and care, including medication, at least annually and more often if the person, carer or healthcare professional has any concerns
  • Offer people with bipolar depression:
    • a psychological intervention that has been developed specifically for bipolar disorder and has a published evidence-based manual describing how it should be delivered or
    • a high‑intensity psychological intervention (cognitive behavioural therapy, interpersonal therapy or behavioural couples therapy)
  • Discuss with the person the possible benefits and risks of psychological interventions and their preference. Monitor mood and if there are signs of hypomania or deterioration of the depressive symptoms, liaise with or refer the person to secondary care. If the person develops mania or severe depression, refer them urgently to secondary care
  • Psychological therapists working with people with bipolar depression in primary care should have training in and experience of working with people with bipolar disorder
  • Do not start lithium to treat bipolar disorder in primary care for people who have not taken lithium before, except under shared‑care arrangements
  • Do not start valproate in primary care to treat bipolar disorder
  • If bipolar disorder is managed solely in primary care, re‑refer to secondary care if any one of the following applies:
    • there is a poor or partial response to treatment
    • the person's functioning declines significantly
    • treatment adherence is poor
    • the person develops intolerable or medically important side-effects from medication
    • comorbid alcohol or drug misuse is suspected 
    • the person is considering stopping any medication after a period of relatively stable mood
    • a woman with bipolar disorder is pregnant or planning a pregnancy

Monitoring physical health

  • Develop and use practice case registers to monitor the physical and mental health of people with bipolar disorder in primary care
  • Monitor the physical health of people with bipolar disorder when responsibility for monitoring is transferred from secondary care, and then at least annually. The health check should be comprehensive, including all the checks recommended below and focusing on physical health problems such as cardiovascular disease, diabetes, obesity and respiratory disease. A copy of the results should be sent to the care coordinator and psychiatrist, and put in the secondary care records
  • Ensure that the physical health check for people with bipolar disorder, performed at least annually, includes:
    • weight or BMI, diet, nutritional status and level of physical activity
    • cardiovascular status, including pulse and blood pressure 
    • metabolic status, including fasting blood glucose, glycosylated haemoglobin (HbA1c) and blood lipid profile
    • liver function
    • renal and thyroid function, and calcium levels, for people taking long‑term lithium
  • Identify people with bipolar disorder who have hypertension, have abnormal lipid levels, are obese or at risk of obesity, have diabetes or are at risk of diabetes (as indicated by abnormal blood glucose levels), or are physically inactive, at the earliest opportunity. Follow NICE guidance on hypertension, lipid modification, prevention of cardiovascular disease, obesity, physical activity and preventing type 2 diabetes
  • Offer treatment to people with bipolar disorder who have diabetes and/or cardiovascular disease in primary care in line with the NICE clinical guidelines on type 1 diabetes, type 2 diabetes, type 2 diabetes—newer agents, and lipid modification

Promoting recovery and return to primary care

Continuing treatment in secondary care

  • Continue treatment and care in an early intervention in psychosis service, a specialist bipolar disorder service or a specialist integrated community‑based team. Share physical health monitoring with primary care
  • consider intensive case management for people with bipolar disorder who are likely to disengage from treatment or services

Return to primary care

  • Offer people with bipolar disorder whose symptoms have responded effectively to treatment and remain stable the option to return to primary care for further management. If they wish to do this, record it in their notes and coordinate transfer of responsibilities through the care programme approach
  • When making transfer arrangements for a return to primary care, agree a care plan with the person, which includes:
    • clear, individualised social and emotional recovery goals
    • a crisis plan indicating early warning symptoms and triggers of both mania and depression relapse and preferred response during relapse, including liaison and referral pathways
    • an assessment of the person's mental state
    • a medication plan with a date for review by primary care, frequency and nature of monitoring for effectiveness and adverse effects, and what should happen in the event of a relapse
  • Give the person and their GP a copy of the plan, and encourage the person to share it with their carers
  • Encourage and support the person to visit their GP and discuss the care plan before discharge and transfer

Employment, education and occupational activities

  • Offer supported employment programmes to people with bipolar disorder in primary or secondary care who wish to find or return to work. Consider other occupational or educational activities, including pre‑vocational training, for people who are unable to work or unsuccessful in finding employment

How to use medication

  • The secondary care team should maintain responsibility for monitoring the efficacy and tolerability of antipsychotic medication for at least the first 12 months or until the person's condition has stabilised, whichever is longer. Thereafter, the responsibility for this monitoring may be transferred to primary care under shared‑care arrangements

Using lithium

  • When starting lithium:
    • establish a shared‑care arrangement with the person's GP for prescribing lithium and monitoring adverse effects

Recognising, diagnosing and managing bipolar disorder in children and young people

Recognition and referral

  • Do not use questionnaires in primary care to identify bipolar disorder in children or young people
  • If bipolar disorder is suspected in primary care in children or young people aged under 14 years, refer them to child and adolescent mental health services (CAMHS)
  • If bipolar disorder is suspected in primary care in young people aged 14 years or over, refer them to a specialist early intervention in psychosis service or a CAMHS team with expertise in the assessment and management of bipolar disorder in line with the recommendations in this guideline. The service should be multidisciplinary and have:
    • engagement or assertive outreach approaches
    • family involvement and family intervention
    • access to structured psychological interventions and psychologically informed care
    • vocational and educational interventions
    • access to pharmacological interventions
    • professionals who are trained and competent in working with young people with bipolar disorder

      

References

full guideline available from…
National Institute for Health and Care Excellence, Level 1A, City Tower, Piccadilly Plaza, Manchester, M1 4BT
www.nice.org.uk/guidance/CG185

National Institute for Health and Care Excellence. Bipolar disorder: assessment and management. September 2014.
First included: Oct 14.


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