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.
Care for Adults, Children, and Young People Across All Phases of Bipolar Disorder
Improving the Experience of Care
- Use this guideline in conjunction with the NICE clinical guideline on service user experience in adult mental health to improve the experience of care for adults with bipolar disorder using mental health services, and for adults, children and young people:
- promote a positive recovery message from the point of diagnosis and throughout care
- build supportive and empathic relationships as an essential part of care
- Follow the recommendations in general principles of care in the NICE clinical guideline on psychosis and schizophrenia in children and young people to improve the experience of care for children and young people with bipolar disorder.
Treatment and Support for Specific Populations
- Follow the recommendations in race, culture and ethnicity in the NICE clinical guideline on psychosis and schizophrenia in adults when working with people with bipolar disorder from black, Asian and minority ethnic groups
- See the NICE guideline on antenatal and postnatal mental health for guidance on the management of bipolar disorder during pregnancy and the postnatal period and in women and girls of childbearing potential
- Ensure that people with bipolar disorder and a coexisting learning disability are offered the same range of treatments and services as other people with bipolar disorder
- Ensure that older people with bipolar disorder are offered the same range of treatments and services as younger people with bipolar disorder
- Offer people with bipolar disorder and coexisting disorders, such as personality disorder, attention deficit hyperactivity disorder, anxiety disorders or substance misuse, treatment in line with the relevant NICE clinical guideline, in addition to their treatment for bipolar disorder. See the NICE clinical guidelines on antisocial personality disorder, borderline personality disorder, attention deficit hyperactivity disorder, generalised anxiety disorder, and psychosis with coexisting substance misuse, be alert to the potential for drug interactions and use clinical judgement
- Offer people with rapid cycling bipolar disorder the same interventions as people with other types of bipolar disorder because there is currently no strong evidence to suggest that people with rapid cycling bipolar disorder should be treated differently.
Information and Support
- Consider identifying and offering assistance with education, financial and employment problems that may result from the behaviour associated with bipolar disorder, such as mania and hypomania. If the person with bipolar disorder agrees, this could include talking directly with education staff, creditors and employers about bipolar disorder and its possible effects, and how the person can be supported
- Encourage people with bipolar disorder to develop advance statements while their condition is stable, in collaboration with their carers if possible
- Explain and discuss making a lasting power of attorney with adults with bipolar disorder and their carers if there are financial problems resulting from mania or hypomania.
Support for Carers of People with Bipolar Disorder
- Offer carers of people with bipolar disorder an assessment (provided by mental health services) of their own needs and discuss with them their strengths and views. Develop a care plan to address any identified needs, give a copy to the carer and their GP and ensure it is reviewed annually
- Advise carers about their statutory right to a formal carer's assessment provided by social care services and explain how to access this. See NICE's guideline on supporting adult carers
- Give carers written and verbal information in an accessible format about:
- diagnosis and management of bipolar disorder
- positive outcomes and recovery
- types of support for carers
- role of teams and services
- getting help in a crisis.
- As early as possible negotiate with the person with bipolar disorder and their carers about how information about the person will be shared. When discussing rights to confidentiality, emphasise the importance of sharing information about risks and the need for carers to understand the person's perspective. Foster a collaborative approach that supports both people with bipolar disorder and their carers, and respects their individual needs and interdependence
- Review regularly how information is shared, especially if there are communication and collaboration difficulties between the person and their carer
- Include carers in decision-making if the person agrees
- Offer a carer-focused education and support programme, which may be part of a family intervention for bipolar disorder, as early as possible to all carers. The intervention should:
- be available as needed
- have a positive message about recovery
- Identify children, young people and adults at risk of abuse or neglect who are dependent on, living with or caring for a person with bipolar disorder and:
- review the need for an assessment according to local safeguarding procedures for children or adults as appropriate
- offer psychological and social support as needed.
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) in line with recommendations 1.5.3.1–1.5.3.5 in the NICE clinical guideline on depression
- 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 in recommendation directly following, 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 the NICE guidelines 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 in adults: diagnosis and management, type 2 diabetes in adults: management, and lipid modification.
How to Use Medication
- When using any psychotropic medication for bipolar disorder ensure that:
- the person is given information that is suitable for their developmental level about the purpose and likely side effects of treatment including any monitoring that is required, and give them an opportunity to ask questions
- the choice of medication is made in collaboration with the person with bipolar disorder, taking into account the carer's views if the person agrees
- the overall medication regimen is regularly reviewed so that drugs that are not needed after the acute episode are stopped
- Discuss the use of alcohol, tobacco, prescription and non-prescription medication and illicit drugs with the person, and their carer if appropriate. Explain the possible interference of these substances with the therapeutic effects of prescribed medication and psychological interventions
- When offering psychotropic medication to older people, take into account its impact on cognitive functioning in older people and:
- use medication at lower doses
- take into account the increased risk of drug interactions
- take into account the negative impact that anticholinergic medication, or drugs with anticholinergic activity, can have on cognitive function and mobility
- ensure that medical comorbidities have been recognised and treated
- Do not offer gabapentin or topiramate to treat bipolar disorder.
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.
Diagnosis and Assessment
- Diagnosis of bipolar disorder in children or young people should be made only after a period of intensive, prospective longitudinal monitoring by a healthcare professional or multidisciplinary team trained and experienced in the assessment, diagnosis and management of bipolar disorder in children and young people, and in collaboration with the child or young person's parents or carers
- When diagnosing bipolar disorder in children or young people take account of the following:
- mania must be present
- euphoria must be present on most days and for most of the time, for at least 7 days
- irritability is not a core diagnostic criterion
- Do not make a diagnosis of bipolar disorder in children or young people on the basis of depression with a family history of bipolar disorder but follow them up
- When assessing suspected bipolar disorder in children or young people, follow recommendations for adults, but involve parents or carers routinely and take into account the child or young person's educational and social functioning.
Management in Young People
- When offering treatment to young people with bipolar disorder, take into account their cognitive ability, emotional maturity, developmental level, their capacity to consent to treatment, the severity of their bipolar disorder and risk of suicide or self-harm or any other risk outlined in recommendation 1.3.5 of the full guideline.
Mania
- To treat mania or hypomania in young people see NICE's technology appraisal guidance on aripiprazole for treating moderate to severe manic episodes in adolescents with bipolar I disorder and also consider the recommendations for adults in section 1.5 of the full guideline. Refer to the BNF for children to modify drug treatments, be aware of the increased potential for a range of side effects, and do not routinely continue antipsychotic treatment for longer than 12 weeks
- Do not offer valproate to girls or young women of childbearing potential. See the MHRA safety advice on valproate use by women and girls.
Bipolar Depression
- Offer a structured psychological intervention (individual cognitive behavioural therapy or interpersonal therapy) to young people with bipolar depression. The intervention should be of at least 3 months' duration and have a published evidence-based manual describing how it should be delivered
- If after 4 to 6 weeks there is no or a limited response to cognitive behavioural therapy or interpersonal therapy, carry out a multidisciplinary review and consider an alternative individual or family psychological intervention
- If there is a risk of suicide or self-harm or any other risk outlined in recommendation 1.3.5 of the full guideline, carry out an urgent review and develop a risk management plan as outlined in recommendation 1.4.1 of the full guideline
- After the multidisciplinary review, if there are coexisting factors such as comorbid conditions, persisting psychosocial risk factors such as family discord, or parental mental ill-health, consider:
- an alternative psychological intervention for bipolar depression for the young person, their parents or other family member or
- an additional psychological intervention for any coexisting mental health problems in line with relevant NICE guidance for the young person, their parents or other family member
- If the young person's bipolar depression is moderate to severe, consider a pharmacological intervention in addition to a psychological intervention. Follow the recommendations for pharmacological interventions for adults in section 1.6 of the full guideline but refer to the BNF for children to modify drug treatments, and do not routinely continue antipsychotic treatment for longer than 12 weeks. At 12 weeks, carry out a full multidisciplinary review of mental and physical health, and consider further management of depression or long-term management.
Long-term Management
- After the multidisciplinary review, consider a structured individual or family psychological intervention for managing bipolar disorder in young people in the longer term.
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