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Bipolar disorder - Management
How should I manage someone with new or suspected bipolar disorder?
- Refer all people with new or suspected bipolar disorder for a specialist mental health assessment.
- Determine the urgency of any referral by assessing the risks to the individual and others.
- Refer for urgent assessment if:
- The person presents with mania, severe depression, or with a mixed episode, or
- They are a danger to themselves or other people.
- Consider whether the urgency of the situation requires the person to be admitted to hospital.
- While awaiting specialist assessment, do not alter or start treatment without specialist advice.
Clarification / Additional information
- Whilst awaiting specialist assessment the following options may be considered, and can be carried out in a primary care setting on specialist advice:
- For episodes of mania and hypomania, consider:
- Reducing or stopping an antidepressant, if the person is taking one.
- Prescribing a short-term benzodiazepine (such as lorazepam) for behavioural disturbance or agitation.
- Prescribing an antipsychotic (e.g. olanzapine, quetiapine, or risperidone).
- For a depressive episode:
- Do not normally start any medication in primary care. If bipolar disorder is confirmed, the mental health specialist will usually start an anti-manic drug (an antipsychotic, lithium, valproate, or carbamazepine) along with (if appropriate) an antidepressant.
- For a mixed episode:
- Do not normally start any treatment in primary care. If there is a significant delay in specialist mental health assessment, urgently seek specialist advice.
- For detailed information regarding antidepressants, atypical antipsychotics, lithium, valproate, and carbamazepine, see Prescribing information.
Basis for recommendation
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 drugs in primary care:
- Treatment options that can be carried out in a primary-care setting on specialist advice are adapted from NICE recommendations regarding referral and the management of acute episodes in people not taking anti-manic medication.
- CKS found little evidence regarding what drug treatment may be started in primary care in people with new or suspected bipolar disorder. However two review articles were identified which recommended 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].
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