• Scenario: New or suspected bipolar disorder: covers the recognition, assessment, and management of a person with new or suspected bipolar disorder.
• Scenario: Known bipolar, depressive episode: covers the recognition, assessment, and management of a person with known bipolar disorder presenting with a depressive episode.
• Scenario: Known bipolar, hypomania or manic episode: covers the recognition, assessment, and management of a person with known bipolar disorder presenting with a hypomanic or manic episode.
• Scenario: Known bipolar, mixed episode: covers the recognition, assessment, and management of a person with known bipolar disorder presenting with a mixed episode.
• Scenario: Known bipolar, routine follow-up: covers the routine follow up in primary care of a person with known bipolar disorder.
• Scenario: Women of childbearing age: covers the management of a woman with bipolar disorder planning a pregnancy, presenting with an unplanned pregnancy, presenting with an acute episode in pregnancy, or planning to breastfeed.

• Suspect bipolar disorder in people who present with mania, hypomania, depression and a history of previous episodes of possible mania or hypomania, or a mixture of both manic and depressive symptoms.
• Mania is suggested by:
• Abnormally elevated mood, extreme irritability, and sometimes aggression.
• Increased energy or activity, restlessness, and a decreased need for sleep (e.g. the person feels rested after only 3 hours of sleep).
• Pressure of speech or incomprehensible speech.
• Flight of ideas or racing thoughts.
• Distractibility, poor concentration.
• Increased sexual drive, disinhibition, and sexual indiscretions.
• Extravagant or impractical schemes (e.g. business investments, spending sprees).
• Psychotic symptoms: delusions (usually grandiose) or hallucinations (usually voices speaking directly to the person).
• Hypomania is suggested by symptoms of mania that are not severe enough to cause marked impairment in social or occupational functioning, with the absence of psychotic features. Such people may present with:
• Mild elevation of mood or irritability.
• Increased energy and activity.
• Feelings of well-being, or physical and mental efficiency.
• Increased sociability, talkativeness, and over-familiarity.
• Depression is suggested by feelings of persistent sadness or low mood, loss of interest or pleasure, and low energy. Diagnosis is identical to that for unipolar depression: see the section on Assessment and diagnosis in the CKS topic on Depression, and the section on Diagnosis in the CKS topic on Depression in children.
• A mixed episode is suggested by a mixture, or rapid alternation (usually within a few hours), of manic/hypomanic and depressive symptoms.

In depth

• 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.
• Consider the risks of harm to others, including:
• Family, in particular children and other dependents.
• The public.

In depth

• 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.
• If admission is thought to be necessary but the person refuses, see Compulsory admission.
• While awaiting specialist assessment, alter or start treatment only on specialist advice.

In depth

• 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.

In depth

• 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.

In depth

In depth

In depth

In depth

• Depression is suggested by feelings of persistent sadness or low mood, loss of interest or pleasure, and low energy.
• Associated symptoms of depression that may also be present include:
• Disturbed sleep.
• Poor concentration or indecisiveness.
• Low self-confidence.
• Poor or increased appetite.
• Agitation or slowing of movements.
• Guilt or self-blame.
• Suicidal thoughts or acts.
• Diagnosis of a depressive episode is identical to that for unipolar depression. For more information, see the section on Assessment and diagnosis in the CKS topic on Depression, and the section on Diagnosis in the CKS topic on Depression in children.
• The presence of coexistent hypomanic or manic symptoms may suggest the person is having a mixed episode.

In depth

• 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:
• Self-neglect.
• Exploitation by others.
• Alcohol and substance misuse.
• Consider the risks of harm to others, including:
• To family, in particular children and other dependents, from:
• Neglect.
• Depressive or paranoid delusions.
• To the public from:
• Rarely, violence and aggression arising from psychotic symptoms.

In depth

• Determine the urgency of any 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 severe depression.
• People in a mixed episode.
• People with rapid cycling.
• For people on anti-manic medication, check that they are taking their medication at the prescribed dose and encourage adherence.
• For people with moderate depression and no increase in the degree of risk to self or others:
• Arrange a prompt specialist mental health review.
• Contact a mental health specialist for advice on initial management whilst the person is waiting to be seen.
• For people with mild depression:
• Provided the person's previous episodes of mild depression have not developed into chronic or more severe depression (and a more severe depression is not likely), an initial period of watchful waiting may be appropriate.
• Arrange for repeat further assessment in primary care or by their mental health professional within 2 weeks (1 week in children and adolescents).
• If the person's previous episodes of mild depression have developed into chronic or more severe depression, or a more severe depression is otherwise likely:
• Seek specialist mental health advice and consider an early specialist mental health review.
• All pregnant women presenting with depression should be referred. For more information, see Depressive episode in pregnancy.
• Whilst awaiting specialist assessment, alter or start treatment only on specialist advice.
• Children and adolescents should only be treated by specialists.

In depth

• Take regular exercise, preferably as part of a structured exercise programme.
• Try to schedule regular activities and have a daily routine.
• Engage in both pleasurable and goal-directed activities.
• Ensure adequate diet and sleep.
• Seek appropriate social support.

In depth

• 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.

In depth

In depth

In depth

In depth

• 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.

In depth

• A manic episode is suggested by:
• Abnormally elevated mood, extreme irritability, and sometimes aggression.
• Increased energy, activity, and restlessness, and a decreased need for sleep (e.g. the person feels rested after only 3 hours of sleep).
• Pressure of speech or incomprehensible speech.
• Flight of ideas or racing thoughts.
• Distractibility, poor concentration.
• Increased sexual drive, disinhibition, and sexual indiscretions.
• Extravagant or impractical schemes (e.g. business investments, spending sprees).
• Psychotic symptoms: delusions (usually grandiose) or hallucinations (usually voices speaking directly to the person).
• A hypomanic episode is suggested by symptoms of mania that are not severe enough to cause marked impairment in social or occupational functioning, with the absence of psychotic features. Such people may present with:
• Mild elevation of mood or irritability.
• Increased energy and activity.
• Feelings of well-being, physical and mental efficiency.
• Increased sociability, talkativeness, and over-familiarity.
• If depressive symptoms are rapidly alternating with hypomanic or manic symptoms, suspect a mixed episode.

In depth

Risk assessment determines the urgency of referral to specialist mental health services.

• Consider these 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.
• Exploitation by others.
• Alcohol and substance misuse.
• Consider the risks of harm to others, including:
• To family, in particular children and other dependents, from:
• Neglect.
• 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).

In depth

• 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.

In depth

• Avoid excessive stimulation.
• Engage in calming activities.
• Delay important decisions.
• Establish a structured routine (including a regular sleep pattern) in which the level of activity is reduced.

In depth

• 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.

In depth

In depth

In depth

In depth

• 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.

In depth

• 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.

In depth

• 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).

In depth

• 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.

In depth

• 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.

In depth

In depth

In depth

In depth

• 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.

In depth

• 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

• Refer the woman to a psychiatrist for an assessment and discussion of drug treatment.
• Explain to the woman that the psychiatrist may advise her to:
• Stop drug treatment prior to trying to conceive, and to remain off it throughout the pregnancy.
• Stop drug treatment prior to conception, and to restart it either after the first trimester or immediately after birth.
• Remain on her current drug treatment throughout conception, pregnancy, and birth.
• Switch to another drug treatment prior to attempting to conceive.
• Explain that the strategy which is chosen will depend on her wishes, and on the advice of the medical team who need to balance the risks of undertreatment (e.g. relapse) with the risk of harming the unborn child by remaining on drug treatment.
• Give general pre-conception advice (e.g. smoking and alcohol consumption), and prescribe folic acid.
• For more detailed information, see the CKS topic on Pre-conception - advice and management.

In depth

• For all women taking medication, immediately contact a psychiatrist to establish if drug treatment should be stopped.
• Refer urgently to a psychiatrist and specialist fetomaternal medicine service, for a risk assessment and further management, those women who are taking medication with a known teratogenic risk at the time of conception or in the first trimester (i.e. lithium, valproate, carbamazepine, lamotrigine, or paroxetine).
• Refer all other women to a psychiatrist for an assessment and a discussion of drug treatment.

In depth

• All pregnant women who have bipolar disorder and experience a depressive episode require referral or possibly admission.
• Admit urgently those women who are considered to be a danger to themselves or others.
• If admission is thought to be necessary but the woman refuses, see Compulsory admission.
• Refer urgently for specialist mental health assessment those women:
• For whom the degree of risk is increasing such that they are likely to become a danger to themselves or others.
• With severe depression.
• In a mixed episode.
• With rapid cycling.
• For all other women, arrange an appointment with a psychiatrist as soon as possible to discuss treatment options.
• Whilst awaiting specialist assessment, do not start or change treatment without specialist advice.

In depth

• All pregnant women with mania need referral or possibly admission. For more detailed management information, see Scenario: Known bipolar, hypomania or manic episode.

In depth

• Advise the woman not to breastfeed if she is taking lithium, a benzodiazepine, or lamotrigine.
• A selective serotonin reuptake inhibitor (SSRI) may be prescribed if an antidepressant is being considered, but not fluoxetine or citalopram.

In depth