{"id":3735,"date":"2022-05-03T11:47:20","date_gmt":"2022-05-03T10:47:20","guid":{"rendered":"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/bipolardisorderadults\/"},"modified":"2026-07-30T13:52:18","modified_gmt":"2026-07-30T12:52:18","slug":"bipolardisorderadults","status":"publish","type":"page","link":"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/mentalhealthadult\/bipolardisorderadults\/","title":{"rendered":"Bipolar Disorder (Adults)"},"content":{"rendered":"\n<title>Bipolar Disorder (Adults)<\/title>\n\n\n\n<h3 class=\"wp-block-heading\">Diagnosis<\/h3>\n\n\n\n<p class=\"wp-block-paragraph\">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.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Manic episode:<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">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.&nbsp; The patient may have psychotic symptoms and will have significant functional impairment. <em>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.<\/em><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Mixed episode:<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">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.&nbsp; The symptoms should be present most of the day during a period of at least 2 weeks. &nbsp;The patient may have psychotic symptoms.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Hypomania:<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">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.&nbsp;<\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>Depression:<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\">Low mood associated and anhedonia, associated with appetite and sleep changes, psychomotor change, feelings of guilt, hopelessness or worthlessness and poor concentration.&nbsp; Symptoms should be present consistently for at least two weeks.&nbsp; The patient may have psychotic symptoms.<\/p>\n\n\n\n<p class=\"wp-block-paragraph\">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.\u00a0 Prior to referral where there is uncertainty consider a mood diary to track mood.\u00a0 For example:\u00a0 <a href=\"https:\/\/www.bipolaruk.org\/get-support\/track-your-mood\/mood-diary\/\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/www.bipolaruk.org\/get-support\/track-your-mood\/mood-diary\/<\/a>.\u00a0 <\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong><em>Please do not start antidepressants in this context without secondary care advice \u2013 see Primary Care Management for other approaches to support<\/em>.<\/strong><\/p>\n\n\n\n<p class=\"wp-block-paragraph\"><strong>C.M &amp; D.C &#8211; 30-7-26<\/strong><\/p>\n\n\n\n<div class=\"wp-block-getwid-tabs\" data-active-tab=\"0\"><ul class=\"wp-block-getwid-tabs__nav-links\"><\/ul>\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Referral Guidelines<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<h4 class=\"wp-block-heading\">Who to refer:<\/h4>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Mania or severe depression (requires urgent referral) \u2013 or emergency referral if psychotic or posing a risk to themselves or others.<\/li>\n\n\n\n<li>Hypomania or depression not responding to treatment, or a care plan already established in those with a known diagnosis.<\/li>\n\n\n\n<li>Concern relating to risk.<\/li>\n\n\n\n<li>Patients under the age of 55 who are prescribed valproate \u2013 please also see <a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/sexualreprohealth\/contraception\/contraception-for-individuals-using-valproate-medicines\/\" target=\"_blank\" rel=\"noreferrer noopener\">Valproate and Contraception<\/a>.<\/li>\n\n\n\n<li>A patient with bipolar disorder who is pregnant, or considering pregnancy, within the next 12 months (see <a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/mentalhealthadult\/perinatalmentalhealth\/\" target=\"_blank\" rel=\"noreferrer noopener\">Perinatal mental health<\/a>).<\/li>\n<\/ul>\n\n\n\n<h4 class=\"wp-block-heading\">Who not to refer:<\/h4>\n\n\n\n<ul class=\"wp-block-list\">\n<li>A stable patient, concordant with medication (see valproate information above) and no issues with side-effects or comorbidity.<\/li>\n\n\n\n<li>Patients with mood fluctuations in a course of a day \/ few days where the diagnosis is unlikely \u2013 please see above.<\/li>\n\n\n\n<li>Patient requesting assessment where they do not fit the clinical criteria of the diagnosis.<\/li>\n<\/ul>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Primary Care Management<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<h4 class=\"wp-block-heading\">Mania<\/h4>\n\n\n\n<p class=\"wp-block-paragraph\">ALWAYS refer mania on an urgent basis but in the meantime:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Advise the patient and carer to keep their environment as calm as possible and limit any important decisions until they have recovered.<\/li>\n\n\n\n<li>Review any antidepressant prescriptions.<\/li>\n\n\n\n<li>Consider use of night sedation or benzodiazepines, where appropriate.<\/li>\n\n\n\n<li>Initiation of antipsychotic typically requires input from specialist services.<\/li>\n\n\n\n<li>Consider the need for <a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/guidelines\/mentalhealthadult\/emergenciesmentalhealthadults\/edinburgh-mental-health-emergencies-mhas\/\" target=\"_blank\" rel=\"noreferrer noopener\">emergency mental health referral<\/a><\/li>\n<\/ul>\n\n\n\n<p class=\"wp-block-paragraph\"><\/p>\n\n\n\n<h4 class=\"wp-block-heading\">Depression management<\/h4>\n\n\n\n<p class=\"wp-block-paragraph\">In addition to referral, please also:<\/p>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Consider psychology referral.<\/li>\n\n\n\n<li>Do not start any antidepressants without secondary care advice.<\/li>\n\n\n\n<li>Mood stabilisers should typically only be commenced by a specialist in a secondary care setting.<\/li>\n<\/ul>\n<\/div><\/div>\n\n\n\n<div class=\"wp-block-getwid-tabs__nav-link\"><span class=\"wp-block-getwid-tabs__title-wrapper\"><a href=\"#\"><span class=\"wp-block-getwid-tabs__title\">Resources and Links<\/span><\/a><\/span><\/div><div class=\"wp-block-getwid-tabs__tab-content-wrapper\"><div class=\"wp-block-getwid-tabs__tab-content\">\n<h4 class=\"wp-block-heading\">Prescribing guidance and risks \u2013 lithium and valproate:<\/h4>\n\n\n\n<ul class=\"wp-block-list\">\n<li>Valproate MHRA:\u00a0 <a href=\"https:\/\/www.gov.uk\/guidance\/valproate-reproductive-risks\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/www.gov.uk\/guidance\/valproate-reproductive-risks<\/a><\/li>\n\n\n\n<li>Detailed NHS Lothian lithium guidance (intranet): <a href=\"http:\/\/intranet.lothian.scot.nhs.uk\/Directory\/MedicinesManagement\/MentalHealth\/Guidelines\/Lithium%20Handbook.pdf\" target=\"_blank\" rel=\"noreferrer noopener\">http:\/\/intranet.lothian.scot.nhs.uk\/Directory\/MedicinesManagement\/MentalHealth\/Guidelines\/Lithium%20Handbook.pdf<\/a><\/li>\n<\/ul>\n\n\n\n<h4 class=\"wp-block-heading\">General and Patient information:<\/h4>\n\n\n\n<ul class=\"wp-block-list\">\n<li>NICE:\u00a0 <a href=\"https:\/\/www.nice.org.uk\/guidance\/cg185\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/www.nice.org.uk\/guidance\/cg185<\/a><\/li>\n\n\n\n<li>Mind:\u00a0 <a href=\"https:\/\/www.mind.org.uk\/information-support\/types-of-mental-health-problems\/bipolar-disorder\/about-bipolar-disorder\/\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/www.mind.org.uk\/information-support\/types-of-mental-health-problems\/bipolar-disorder\/about-bipolar-disorder\/<\/a><\/li>\n\n\n\n<li>RCPsych:\u00a0 <a href=\"https:\/\/www.rcpsych.ac.uk\/mental-health\/mental-illnesses-and-mental-health-problems\/bipolar-disorder\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/www.rcpsych.ac.uk\/mental-health\/mental-illnesses-and-mental-health-problems\/bipolar-disorder<\/a><\/li>\n\n\n\n<li>Bipolar Scotland:\u00a0 <a href=\"https:\/\/bipolarscotland.org.uk\" target=\"_blank\" rel=\"noreferrer noopener\">https:\/\/bipolarscotland.org.uk<\/a><\/li>\n<\/ul>\n<\/div><\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"<p>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.&nbsp; Manic episode: Lasts at least a week and is characterised with elevated mood, irritability and increased energy,<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":4125,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_searchwp_excluded":"","footnotes":""},"categories":[319],"class_list":["post-3735","page","type-page","status-publish","hentry","category-bipolardisorderadult"],"publishpress_future_workflow_manual_trigger":{"enabledWorkflows":[]},"rttpg_featured_image_url":null,"rttpg_author":{"display_name":"NHS Lothian","author_link":"https:\/\/apps.nhslothian.scot\/refhelp\/author\/nhs-lothian\/"},"rttpg_comment":0,"rttpg_category":" <a href=\"https:\/\/apps.nhslothian.scot\/refhelp\/category\/mentalhealthadult\/bipolardisorderadult\/\" rel=\"tag\">Bipolar Disorder (Adult)<\/a>","rttpg_excerpt":"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.&nbsp; Manic episode: Lasts at least a week and is characterised with elevated mood, irritability and increased 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