• To ensure follow up, include all people with bipolar disorder on a register of serious mental illness.
• Arrange to review all people with bipolar disorder at least annually.
• Review more frequently:
• People managed solely in primary care.
• If there is sleep disturbance.
• After significant life events, such as loss of a job or bereavement.
• Attempt to make contact (within 14 days) with people who do not attend. Consider informing their key worker (who may be their psychiatrist, community psychiatric nurse, or social worker).
• At the review appointment(s):
• Do a physical health review.
• Do a mental health review.
• Address the needs of family and carers.
• Do a medication review:
• Check that the person is taking their medicines as prescribed.
• Ask about adverse effects and assess the risk of interactions: see Prescribing information.
• Ensure that there are arrangements for monitoring of lithium, valproate, carbamazepine, and antipsychotics.
• In women, discuss the need for contraception and any plans for pregnancy.
• If the person is not currently seeing a specialist, consider whether they need referral.

In depth

• As people with bipolar disorder have high levels of physical morbidity, assess and manage:
• Lipid levels (including cholesterol) in people 40 years of age and older (even if there are no other risk factors for cardiovascular disease).
• Plasma glucose levels.
• Weight and body mass index.
• Smoking status.
• Alcohol intake.
• Blood pressure.
• Note that smoking induces the metabolism of olanzapine and clozapine. If the person stops smoking, monitor for increased adverse effects and seek advice about dose adjustment if necessary.
• There are separate CKS topics on Alcohol - problem drinking, CVD risk assessment and management, Diabetes type 2, Hypertension - not diabetic, Lipid modification - CVD prevention, Obesity, and Smoking cessation.

In depth

• Ensure that the person has a documented care plan:
• If the person is being treated under the care programme approach (CPA), they should already have a documented care plan.
• If the person is solely managed in primary care or is not managed by CPA, develop a care plan by discussing and recording the following information, including the views of relatives and carers as appropriate:
• The person's current health status and social care needs (including how needs are to be met, by whom, and the person's expectations).
• Social supports, including family, friends, and voluntary sector involvement.
• Coordination arrangements with secondary care and/or mental health services, and a summary of what services are actually being received.
• Occupational status.
• Early warning signs of relapse.
• The person's preferred course of action (discussed when well) in the event of a clinical relapse, including who to contact and the person's own wishes around medication (this may be included in an advance directive).
• For relapse prevention, advise:
• Treatment adherence.
• Sleep hygiene and a regular lifestyle.
• Avoidance, if possible, of shift work, night flying and flying across time zones, or routinely working excessively long hours.
• Self-monitoring of symptoms (including triggers and early warning signs) and coping strategies.
• Provide information about self-help and advocacy groups (if this information has not already been given in secondary care):
• MDF, the Bipolar Organisation, has local self-help groups and its website provides practical advice (see www.mdf.org.uk or phone 08456 340 540).

In depth

• Consider:
• The impact of the disorder on relationships.
• The welfare of dependent children, siblings, and vulnerable adults.
• Carers' physical, social, and mental health needs.
• Referral of family or carers to a counsellor (or for other psychological therapy) if necessary.
• Advise family and carers:
• To encourage treatment adherence and regulation of lifestyle.
• To monitor for signs of relapse.
• About self-help and support groups and encourage them to get involved.

In depth

• Referral may be needed if the person presents with a relapse of symptoms.
• For further information, see hypomanic or manic, depressive, and mixed episodes.
• Referral should also be considered if:
• The person's functioning declines significantly or symptom control is inadequate.
• Treatment adherence is a problem.
• Comorbid alcohol or drug misuse is suspected.
• The person is considering stopping prophylactic medication after a period of relatively stable mood.
• A woman is planning a pregnancy or presents with an unplanned pregnancy.
• The person is a child or young person.

In depth