• A mixed episode is suggested by a mixture, or rapid alternation (usually within a few hours), of manic/hypomanic and depressive symptoms.
• Both sets of symptoms should be prominent for the greater part of the current episode of illness.

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• 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, including:
• 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.
• Consider the risks of harm to others:
• 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 from:
• Rarely, violence and aggression.
• Injuries arising from poor judgement or impulsive behaviour (e.g. whilst driving).

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• Refer urgently to secondary care.
• Admit urgently those people considered to be a danger to themselves or others.
• If admission is thought to be necessary but the person refuses, see Compulsory admission.

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• Driving must cease during the acute illness.
• For further information on the DVLA's medical rules regarding hypomania/mania, severe depression, or acute psychotic disorders see the DVLA 'At a glance guide' at www.dvla.gov.uk/medical/ataglance.
• Advise the person that it is their responsibility to inform the Driver and Vehicle Licensing Agency (DVLA) of any condition that may affect their ability to drive. The General Medical Council guidelines advise breaking patient confidentiality and informing the DVLA if the person cannot understand that driving during psychosis is unsafe (usually because of lack of insight into their illness) or if the person refuses to stop driving.

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• If the person needs to be admitted to hospital, every attempt should be made to persuade them to go voluntarily.
• If the person refuses to go to hospital, compulsory admission may be necessary if the person:
• Requires assessment and/or treatment in a hospital, and
• Needs to be admitted in the interests of their own health or safety, and/or for the protection of other people.
• Compulsory admission is arranged using the appropriate section (usually section 2) of the Mental Health Act (MHA):
• Section 2 allows for compulsory admission for up to 28 days.
• It requires an application from an Approved Mental Health Professional (AMHP, formerly an Approved Social Worker), or, rarely, the person's nearest relative, and recommendations from two doctors, one of whom is section 12-approved (usually a psychiatrist) and one who has previous acquaintance with the individual (usually the person's GP if at all practicable).
• Ideally the person should be examined jointly by the two doctors with the AMHP also present. Where this is not possible, each doctor may carry out a separate examination. If the AMHP is not present it is essential that at least one of the doctors discusses the person with the AMHP.
• Section 4 is used in exceptional cases to permit compulsory admission for up to 72 hours if there is 'urgent necessity', and 'undesirable delay' would occur while trying to arrange admission under section 2.
• It requires an application from an AMHP (or, rarely, the person's nearest relative) and just one medical recommendation, preferably from a doctor with previous acquaintance (usually the GP).
• Section 136 may be used by police to take someone from a public place to a place of safety and enable the person to be examined by a registered medical practitioner and interviewed by an Approved Social Worker. The person's GP, where known, may be informed.

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