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Bipolar disorder - Management
How do I assess risks in a person with new or suspected bipolar disorder?
- Risk assessment determines the urgency of referral to specialist mental health services.
- Assess the risk of suicide:
- Consider risk factors for suicide, such as:
- Previous suicide attempt.
- Hopelessness.
- Assess for suicidal ideation:
- Ask a single question such as 'Are you feeling suicidal?'
- If the answer is yes, assess for suicidal intent.
- Assess for suicidal intent by asking:
- Have you made any plans for ending your life?
- Do you have the means for doing this available to you?
- What has kept you from acting on these thoughts?
- Consider other risks of harm to the individual as a consequence of hypomanic or manic symptoms:
- Financial ruin arising from overspending.
- Traumatic injuries and accidents.
- Sexually transmitted infections and unplanned pregnancy arising from disinhibition and increased libido.
- Damage to reputation, income and occupation, and relationships.
- Self-neglect, exhaustion, and dehydration during a manic episode.
- Exploitation by others.
- Alcohol and substance misuse.
- Assess the risks of harm to others, including:
- Family, in particular children and other dependents.
- The public.
Clarification / Additional information
- Additional risk factors for suicide and attempted suicide in people with bipolar disorder include:
- Family history of suicide.
- Early onset of bipolar disorder.
- Predominance of depressive symptoms.
- Increasing severity of affective episodes.
- Mixed episodes.
- Rapid cycling.
- Comorbid anxiety disorder or eating disorder.
- Alcohol and substance abuse.
- Childhood physical and sexual abuse.
- Borderline personality disorder.
- Risks of harm to others include:
- To family, in particular children and other dependents, from:
- Neglect.
- Depressive or paranoid delusions.
- Grandiosity, overspending, poor judgement, and erratic or chaotic behaviour during a manic episode.
- Rarely, violence and aggression (particularly if there is a personal history of violent behaviour).
- To the public:
- Rarely, violence and aggression.
- Injuries arising from poor judgement or impulsive behaviour (e.g. whilst driving).
Basis for recommendation
- Risk assessment determines the urgency of referral to specialist mental health services.
- This statement is based on two recommendations in 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]:
- 'Do a risk assessment when bipolar is first diagnosed, or there is a significant change in mental state or personal circumstances', and
- 'Primary care clinicians should urgently refer patients with mania or severe depression who are a danger to themselves or other people, to specialist mental health services.'
- Assess the risk of suicide:
- The use of risk factors in the assessment of suicide risk is acknowledged in a number of guidelines and review articles [Newcastle North Tyneside and Northumberland Mental Health NHS Trust, 2001; NZGG, 2003; Stovall and Domino, 2003; British Columbia Medical Association, 2004; Schulberg et al, 2004; DH, 2007b].
- Risk factors listed in this CKS recommendation are for completed suicide in people with bipolar disorder; those listed in the Clarification section are for attempted suicide. All are derived from a systematic review of risk factors for suicide and attempted suicide in people with bipolar disorder [Hawton et al, 2005].
- CKS found no suicide risk assessment tools validated for use in primary care in people with bipolar disorder. This corresponds with the findings of a systematic review of screening for suicide risk in primary care settings [Gaynes et al, 2004]:
- The recommendation to assess for suicidal ideation by asking the question 'Are you feeling suicidal?' is based on one study which showed that the question is 83.3% sensitive and 97.7% specific in an adult, US, medical outpatient population relative to a more structured clinical interview administered before the medical interview [Olfson et al, 1996].
- Recommendations regarding the method of assessment of suicidal intent are based on guidelines and review articles that appear to represent expert opinion, two of which refer to the assessment of unipolar depression only [Royal New Zealand College of General Practitioners, 1999; WHO, 2000; Newcastle North Tyneside and Northumberland Mental Health NHS Trust, 2001; Stovall and Domino, 2003; British Columbia Medical Association, 2004; Singapore Ministry of Health, 2004].
- Consider other risks of harm to the individual as a consequence of hypomanic or manic symptoms and the risks of harm to others:
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