• Refer all people in a hypomanic or manic episode for specialist mental health assessment.
• Determine the urgency of 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 mania.
• People in a mixed episode.
• People with rapid cycling.
• Arrange a prompt specialist mental health review for anyone with known bipolar disorder presenting with hypomania.
• Ask about, and advise, adherence to treatment in people on anti-manic medication.
• Contact a mental health specialist for advice on initial management while the person is waiting to be seen in secondary care.

• Whilst awaiting specialist assessment, the following options may be considered, and can be carried out in a primary care setting on specialist advice:
• Stopping the antidepressant (if the person is taking one):
• This may be done abruptly or gradually, depending on the person's current clinical need and any previous experience of discontinuation or withdrawal symptoms, and the risk of such symptoms relevant to the antidepressant in question.
• Adjusting the dose of anti-manic medication:
• If the person is taking lithium, check plasma levels and increase the dose (if necessary) to achieve a level of 0.8 mmol/L to 1.0 mmol/L.
• If the person is taking valproate, increase the dose until symptoms start to improve, or adverse effects limit further dose increase.
• If the person is taking an antipsychotic agent, increase the dose according to the instructions of a mental health specialist.
• If the person is taking carbamazepine, do not routinely increase the dose.
• Prescribing a short-term benzodiazepine (such as lorazepam) for behavioural disturbance or agitation.
• Starting one of the following antipsychotics: olanzapine, quetiapine, or risperidone.
• Do not start lithium or valproate in primary care.
• Carbamazepine is not routinely used for acute mania. Gabapentin, lamotrigine and topiramate are not recommended for treating acute mania.
• The National institute for Health and Clinical Excellence (NICE) recommends that, if acute mania is treated with antipsychotics (olanzapine, quetiapine or risperidone), the following should be taken into account:
• Individual risk factors for adverse effects (such as the risk of diabetes).
• The need to initiate treatment at the lower end of the therapeutic dose range recommended in the summary of product characteristics (particularly in children and adolescents), and to titrate according to response.
• Older people are at greater risk of sudden onset of depressive symptoms after recovery from a manic episode.
• In children and adolescents, the risks of increased prolactin levels with risperidone, and weight gain with olanzapine.
• For detailed information on lithium, atypical antipsychotics, valproate, and carbamazepine 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 after an episode, in addition to prophylactic medication, for people who are relatively stable and have mild-to-moderate symptoms [NICE, 2006].

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]:

• Starting drug treatments in primary care:
• NICE recommendations are generally not specific to primary or secondary care. CKS found little evidence regarding referral and what drug treatments 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].
• Recommendations regarding referral are considered to be good clinical practice by CKS.
• Both the definition of anti-manic medication and the recommendation that lithium, valproate, and carbamazepine should not normally be initiated in primary care, are from the NICE guideline.
• Antipsychotics and anticonvulsants:
• For acute mania:
• There is evidence that olanzapine, quetiapine, and risperidone are more effective than placebo for treating acute mania, and have equivalent efficacy to haloperidol.
• NICE concluded, on the basis of limited evidence, that valproate is effective in the treatment of mania. NICE also found evidence that carbamazepine is more effective than placebo for treating mania and acute mania. There is no good evidence that other anticonvulsants are effective for treating mania.
• For long-term treatment:
• There is evidence that, valproate semisodium, and olanzapine are more effective than placebo in preventing relapse in bipolar disorder. NICE was unable to ascertain whether particular agents were effective in reducing relapse of a particular type, although it is generally believed that lamotrigine is effective at preventing depressive relapse, whereas olanzapine and valproate semisodium are considered to have an effect on both poles of the illness (though they are more effective at preventing mania).
• Lithium:
• For acute mania:
• There is evidence that lithium is effective for treating acute mania compared with placebo. One trial found evidence that lithium was more effective than valproate and several other trials indicated equivalent efficacy to various antipsychotics.
• For long-term treatment:
• There is evidence that lithium is more effective than either placebo or imipramine for reducing manic relapses, and evidence that olanzapine is more effective than lithium for reducing manic episodes.
• Children and adolescents:
• There is either poor quality evidence or no published evidence to support the use of lithium, antipsychotics, or anticonvulsants in children and adolescents. It is therefore necessary to extrapolate (cautiously) from the adult evidence base. NICE concluded that long-term maintenance is key to managing bipolar disorder in this age group and treatment should be monitored by clinicians with expertise in this area.