• Determine the urgency of any referral by assessing the risks to the individual and others.
• Admit urgently those people who are considered to be a danger to themselves or others.
• If admission is thought to be necessary but the person refuses, see Compulsory admission.
• Refer urgently for specialist mental health assessment:
• People for whom the degree of risk is increasing such that they are likely to become a danger to themselves or others.
• People with severe depression.
• People in a mixed episode.
• People with rapid cycling.
• For people on anti-manic medication, check that they are taking their medication at the prescribed dose and encourage adherence.
• For people with moderate depression and no increase in the degree of risk to self or others:
• Arrange a prompt specialist mental health review.
• Contact a mental health specialist for advice on initial management whilst the person is waiting to be seen.
• For people with mild depression:
• Provided the person's previous episodes of mild depression have not developed into chronic or more severe depression (and a more severe depression is not likely), an initial period of watchful waiting may be appropriate.
• Arrange for repeat assessment in primary care or by their mental health professional within 2 weeks (1 week in children and adolescents).
• If the person's previous episodes of mild depression have developed into chronic or more severe depression, or a more severe depression is otherwise likely:
• Seek specialist mental health advice and consider an early specialist mental health review.
• All pregnant women presenting with depression should be referred. For more information, see Depressive episode in pregnancy.
• Whilst awaiting specialist assessment, alter or start treatment only on specialist advice.
• Children and adolescents should only be treated by specialists.

• Whilst awaiting specialist assessment, the following options may be advised for adults and can be carried out in a primary care setting on specialist advice:
• Adjusting the dose of anti-manic medication if necessary.
• Starting a specific serotonin reuptake inhibitor (SSRI), provided the person is already taking anti-manic medication (tricyclic antidepressants are usually avoided). Avoid antidepressants in people who have:
• Rapid cycling disorder.
• A recent hypomanic or manic episode.
• A current or recent mixed episode.
• Starting quetiapine (provided the anti-manic drug the person is already taking is not an antipsychotic).
• The term anti-manic medication (or drugs) refers to antipsychotics, carbamazepine, lithium, and valproate [National Collaborating Centre for Mental Health, 2006]:
• Do not start lithium, valproate, or carbamazepine in primary care.
• For detailed information regarding anti-manic drugs and SSRIs, see Prescribing information.
• Consider referral, if appropriate, to a Crisis Resolution and Home Treatment Team to manage an episode at home and avoid admission.
• Structured psychological therapy should be considered for [NICE, 2006]:
• Moderate depression, if there is no significant improvement after an adequate trial of drugs, or
• After an episode, in addition to prophylactic medication, for people who are relatively stable and have mild-to-moderate symptoms, or
• Children and adolescents, in addition to prophylactic medication.
• With the new policy, Improving access to psychological therapies, such treatment may become more available in primary care [RCPsych and RCGP, 2008].

These recommendations are based on the National Institute for Health and Clinical Excellence (NICE) guideline Bipolar disorder: the management of bipolar disorder in adults, children and adolescents, in primary and secondary care [NICE, 2006].

• Referral:
• Recommendations regarding referral are based on NICE guidance.
• Starting drug treatment in primary care:
• There is very little published guidance regarding what drug treatment may be started in primary care:
• Two review articles recommend that all decisions about starting drug treatment should be made in collaboration with, and on the advice of, a specialist mental health professional [Griswold and Pessar, 2000; Mitchell et al, 2006].
• Antidepressants:
• Limited evidence suggests that antidepressants are effective for treating acute bipolar depression.
• Atypical antipsychotics and anticonvulsants:
• For acute depressive episodes:
• There is some evidence that atypical antipsychotics are effective for treating acute bipolar depression, although none are licensed in the UK for the treatment of bipolar depression.
• NICE found very weak evidence from one small trial (n = 23) that valproate semisodium is effective for treating bipolar depression [National Collaborating Centre for Mental Health, 2006].
• For long-term treatment:
• There is evidence that valproate semisodium and olanzapine are more effective than placebo in preventing relapse in bipolar disorder. Although NICE were unable to ascertain whether particular treatments were effective in reducing relapse of a particular type, it is generally believed that olanzapine and valproate semisodium have an effect on both poles of the illness (but are more effective at preventing mania) [NICE, 2006].
• Lithium:
• NICE identified no published randomized controlled trials of lithium monotherapy as treatment for bipolar depression. Several crossover studies were completed prior to 1980, and it is largely based on these that lithium is recommended as first-line treatment [National Collaborating Centre for Mental Health, 2006].
• Children and adolescents:
• There is either poor quality evidence or no published evidence to support the use of antidepressants, lithium, antipsychotics, or anticonvulsants in children and adolescents. It is therefore necessary to extrapolate (cautiously) from the adult evidence base. NICE has concluded that long-term maintenance is key to managing bipolar disorder in this age group, and treatment should be initiated and monitored by clinicians with expertise in this area.