Bipolar Disorder (Adults)

Diagnosis

The diagnosis can be made based on evidence of a single manic or mixed affective episode, but typically there is a history of manic, hypomanic or mixed episodes alternating with depressive episodes over time.

Manic episode:

Lasts at least a week and is characterised with elevated mood, irritability and increased energy, pressured speech, flight of ideas, grandiosity, reduced need for sleep, distractibility and impulsivity. The patient may have psychotic symptoms and will have significant functional impairment. Always refer a patient who presents with mania on an urgent basis and consider emergency referral: the Primary Care Management page gives advice on interim management.

Mixed episode:

Both prominent manic and depressive symptoms consistent with either a manic and/or depressive episode either within the same episode or alternating very rapidly in a short timescale. The symptoms should be present most of the day during a period of at least 2 weeks. The patient may have psychotic symptoms.

Hypomania:

Several days of elevated mood, increased energy, talkativeness, rapid thoughts, increased self-esteem, reduced sleep, distractibility and impulsive/reckless behaviour and some description of functional impairment.

Depression:

Low mood associated and anhedonia, associated with appetite and sleep changes, psychomotor change, feelings of guilt, hopelessness or worthlessness and poor concentration. Symptoms should be present consistently for at least two weeks. The patient may have psychotic symptoms.

Please note mood fluctuations in the course of a day, or with only a few days of varied mood, are not likely to represent a presentation of bipolar disorder. Prior to referral where there is uncertainty consider a mood diary to track mood. For example: https://www.bipolaruk.org/get-support/track-your-mood/mood-diary/.

Please do not start antidepressants in this context without secondary care advice – see Primary Care Management for other approaches to support.

C.M & D.C – 30-7-26

Who to refer:

Mania or severe depression (requires urgent referral) – or emergency referral if psychotic or posing a risk to themselves or others.
Hypomania or depression not responding to treatment, or a care plan already established in those with a known diagnosis.
Concern relating to risk.
Patients under the age of 55 who are prescribed valproate – please also see Valproate and Contraception.
A patient with bipolar disorder who is pregnant, or considering pregnancy, within the next 12 months (see Perinatal mental health).

Who not to refer:

A stable patient, concordant with medication (see valproate information above) and no issues with side-effects or comorbidity.
Patients with mood fluctuations in a course of a day / few days where the diagnosis is unlikely – please see above.
Patient requesting assessment where they do not fit the clinical criteria of the diagnosis.

Mania

ALWAYS refer mania on an urgent basis but in the meantime:

Advise the patient and carer to keep their environment as calm as possible and limit any important decisions until they have recovered.
Review any antidepressant prescriptions.
Consider use of night sedation or benzodiazepines, where appropriate.
Initiation of antipsychotic typically requires input from specialist services.
Consider the need for emergency mental health referral

Depression management

In addition to referral, please also:

Consider psychology referral.
Do not start any antidepressants without secondary care advice.
Mood stabilisers should typically only be commenced by a specialist in a secondary care setting.