Bipolar disorder
Definition: Bipolar disorder (also known as bipolar affective disorder or manic-depressive disorder) is a serious long-term mental illness, which is usually characterized by episodic depressed and elated moods and increased activity (hypomania or mania). Bipolar disorder is thought to be caused by an interplay between genes and environment.
When to suspect
Depression is suggested by persistent feelings of sadness or low mood, loss of interest of pleasure or low energy.
Be aware that while symptoms of depression are not required for a diagnosis of bipolar disorder, at onset, most people with bipolar disorder present with a depressive episode, and a proportion of people with a diagnosis of unipolar depression will actually have bipolar disorder.
A mixed episode is suggested by a mixture, or rapid alternation (usually within a few hours), of manic/hypomanic and depressive symptoms.
Hypomania: Symptoms of mania which are not severe enough to cause marked impairment in social/occupational functioning and the absence of psychotic features. Example: mild elevation of mood, irritability, increased energy or activity, feelings of well-being, physical and mental efficiency, increased sociability, talkativeness or over-familiarity.
Symptoms and signs that may help distinguish bipolar disorder from unipolar depression include: hypersomnia, lability, weight instability, earlier age of onset, abrupt onset, more frequent episodes with shorter duration, comorbid substance misuse, higher post-partum risk, psychosis, psychomotor retardation, catatonia, lower likelihood of somatic symptoms or family history of bipolar disorder.
Mania: abnormally elevated mood, extreme irritability, aggression, increased energy or activity, restlessness, decreased need for sleep, pressure of speech, incomprehensible speech, flight of ideas or racing thoughts, distractibility, poor concentration, increased libido, disinhibition, sexual indiscretions, extravagant or impractical plans, or psychotic symptoms of delusions or hallucinations.
Suspect bipolar disorder: mania, hypomania, depression and a history of episodes of mania/hypomania, or a mixture of both manic and depressive symptoms.
Specialist mental health assessment is required to confirm diagnosis in adults and children.
Differential diagnosis
Substance misuse
Organic brain disease
Mood disorder due to underlying medical condition
Latrogenic causes
Schizophrenia
Metabolic disorders
Cyclothymia
Personality disorders
Unipolar depression
Anxiety disorders
Attention deficit hyperactivity disorder (ADHD) and conduct disorder
Obsessive-compulsive disorder
Managment: Review
Management: Primary Care
Management: Relapse
While waiting specialist assessment do not start antipsychotic medication unless on a consultant advice, consider tapering antidepressant medication on specialist advice if mania develops, and advice the person to stop driving during acute illness and that their insurance may not be valid.
In confirmed bipolar disorder - prescribe medication initiated in secondary care and undertake any monitoring required, ensure person is offered appropriate psychological interventions that have either been developed specifically for bipolar disorder, monitor mood and follow crisis plans, review the person's physical health, mental health and medication at least annually and ensure the person/carer is informed about support available to them.
If the person needs to be admitted to hospital, every attempt should be made to persuade them to go voluntarily. If the person refuses to go to hospital, compulsory admission may be necessary if the person: requires assessment and/or treatment in a hospital; needs to be admitted in the interests of their own health or safety; or Compulsory admission may be arranged under sections 2, 3, or 4 of the Mental Health Act.
When determining the required urgency of admission/referral, also consider other potentially harmful consequences of poor judgment and associated actions during an acute episode, that may adversely effect the person's employment, personal relationships, and finances, and also the risks posed by driving, sexual activity, and alcohol/drug use.
If a person with bipolar disorder is being managed solely in primary care, re‑refer them to secondary care if: poor/partial response to treatment, adherance is poor, functioning declines significantly, develop intolerable/medically important side effects of medication, comorbid alcohol or drug misuse is suspected, the person is considering stopping taking their medication or a women is pregnant/planning pregnancy.
Assess the severity of depression and risk of suicide. Determine the risk of harm to others.
Refer all people with suspected bipolar disorder to specialist mental health service to confirm the diagnosis, treat the acute episodes and establish a care plan.
If no care plan in place - If the person develops mania or severe depression, and is judged to be at immediate risk of harm to themselves or others, arrange same-day specialist assessment by the local crisis resolution and home treatment team.
If the person develops mania or severe depression, and is not judged to be at immediate risk of harm to themselves or others, urgently refer for a specialist assessment by the community mental health service.
If a care plan (or equivalent) is in place manage according to the care plan and where possible comply with their advance statement, or crisis plan.
If the person develops signs of hypomania or deterioration of depressive symptoms, refer them for a specialist assessment by the community mental health service or seek specialist advice.
Whilst awaiting specialist assessment, do not alter or start treatment except on specialist advice.
Assess for early warning signs of relapse. Give advice on avoiding relapse.
Ask about symptoms that could be due to adverse effects of medication.
Assess symptom control by asking about symptoms of mania, hypomania, or depression, and seek specialist advice regarding ongoing management if needed
Ensure that there are arrangements in place for monitoring of lithium, valproate, and antipsychotics (if applicable).
If being managed in primary care assess mental and physical health at least annually or assess mental health more regularly if the person/carer expresses concern, there is sleep disturbance or significant life events.
Ask about alcohol intake and substance misuse, and encourage people who smoke to stop.
Ask about the person's diet, and level of physical activity, check the person's weight, and measure their waist circumference.
Measure the person's pulse and blood pressure, and assess and manage the person's cardiovascular risk.
Blood tests: Fasting glucose, HbA1c, lipid profile, U&Es, FBC, LFTs, TFTs. Calcium level.
Manage any health concerns appropriately.
Send a copy of results to care co-ordinator. If the person does not attend a review appointment (within 14 days) and unable to make contact, inform care co-ordinator.