Description
Bipolar Affective Disorder: Requires 2 or more episodes of mood disturbance (at least one of which must have been hypomania or mania.
Hypomania: increased energy and activity, elated or irritable mood maybe increased sociability, talkative, over-familiar, increased sexual energy, reduced need for sleep. Level of functioning may be increased or decreased. Must have lasted at least 4 days.
Mania: more severe mood disturbance: presents like hypomania but more extreme – MUST have severe functional impairment OR psychotic features. Must have lasted at least 7 days.
Who to refer:
Patients presenting with depression when they report previously undiagnosed mania or hypomania.
Those with existing diagnosis of bipolar disorder who:
· Present with mania or severe depression – THIS REQUIRES URGENT REFERRAL
· Present with depression which is deteriorating or refractory to treatment or who then develop symptoms of hypomania
· Present with hypomania not responding to intervention as per their care plan (e.g. there may be a suggestion to offer a course of sleeping tablets or reduce antidepressant medication)
· Co-morbid alcohol or drug misuse is suspected
· A woman with bipolar affective disorder is pregnant or planning a pregnancy or up to 12 months post-partum can be referred directly by GPs in some areas: your local team will offer guidance on this. However, those requiring emergency help, or refferal to the Mother and Baby Unit need to be referred to the generic local mental health team first.
· Have ongoing symptoms despite good treatment adherence
Who not to refer:
· Medication advice for stable patients can be requested without need for full referral. This can be done by marking clearly on the referral ‘Advice Only’
· Patients requesting referral for diagnosis where the presentation does not fit with ICD-10 diagnostic criteria for bipolar affective disorder and there is no suspicion of other underlying mental health problems requiring specialist diagnosis and input
How to refer:
Please refer via SCI Gateway. An outline of patients’ current presentation and specifically any risks posed in the situation is helpful including risk of self-harm, vulnerability to exploitation, risk of financial or employability harm, risk to any dependents of neglect or other harm.
Summary of primary care management [based on NICE]
- Support patient and carer to follow care plans made in secondary care. Consult crisis plans and liaise with specialists as needed.
- Review treatment including medication at least annually and more regularly if concerns from patient/carer or health professionals.
- Bipolar Depression:
- Offer psychological intervention from therapist trained in working with patients with bipolar disorder.
- Do not start any anti-depressants without asking for psychiatric advice. They can be used cautiously if people are also on a mood-stabiliser or anti-psychotic, but this should be a secondary care decision.
- Lithium and valproate should only be commenced by a specialist in a secondary care setting.
- Bipolar Hypomania and mania
- If a patient presents with hypomania it is worth checking their care plan as there may be guidance on how best to manage this. Refer to secondary care if symptoms are not responding to any interventions suggested in the most recent letter or care plan. If the patient’s level of functioning starts to deteriorate then refer to secondary care on an URGENT basis.
- Always refer a patient who presents with mania on an urgent basis. In the meantime:
- Advise the patient and carer to keep their environment as calm as possible and to avoid any important decisions until they have recovered.
- Consider stopping their antidepressant
- Initiation of antipsychotic requires input from specialist services. It the patient is known to have a history of mania, then telephone / email advice could be used to initiate medication, and there may be medication advice in the patient’s existing care plan.
Please see here for the management of psychiatric emergencies .
For guidance on referral and management:
NICE Guidance Bipolar disorder: assessment and management. CG 185 https://www.nice.org.uk/guidance/cg185
For patient information:
The ‘mind’ website has some helpful information for patients:
The Royal College of Psychiatry website has some useful information which is currently in the process of being updated:
The Lothian Bipolar Group is a really helpful local resource:
