Nice | Bipolar disorder

This is a an updated guideline from NICE on Bipolar Disorder. I don't think there is much new in this, but it does clarify what we should be doing at annual reviews, general health checks we should be doing and clarifies a definition of 'mania' and 'hypomania'.

Definitions

  • Mania – abnormally elevated mood or irritability and related symptoms with severe functional impairment or psychotic symptoms for 7d or more
  • Hypomania - abnormally elevated mood or irritability and related symptoms with decreased or increased function for 4d or more
  • Bipolar Disorder – mania with depression (1% adults)
  • Bipolar II Disorder – hypomania with depression (0.4% adults)

How should we recognise bipolar disorder in primary care?

Ask patients with depression about periods of hyperactivity or disinhibited behaviour. If these lasted 4d or more, refer to secondary care.

How should we recognise bipolar disorder in children and young people?

  • Irritability, unlike in adults, would not be a feature in a young person or child.
  • A family history in itself, with no manic or hypomanic symptoms in the child, wouldn't make you diagnose Bipolar, but that child may need closer follow-up.
  • Referral should be to CAMHS, or (young people over 14) to Early Intervention in Psychosis teams.

How should we manage Bipolar Disorder in Primary Care?

  • Follow secondary care plans (which should be given on discharge if not before)
  • Psychological Interventions (though in Hampshire, Italk won't see people with a diagnosis of Bipolar and Talking Changes and Steps2Wellbeing don't list it as one of the conditions they'll support).
  • Employment Support
  • Carer Support (ensure carers are aware that they can get a formal assessment through social services)
  • Information Sharing - Negotiate on information sharing with patients and carers.
  • Annual Review (at the least)
  • Health Checks (at least annually - and they say that the results should be sent to secondary care - which I'm sure they'll greatly appreciate...
    • Weight, BMI, diet, nutritional status, level of physical activity
    • CV status, including pulse and BP
    • Bloods – fasting glucose, cholesterol, HbA1c, LFT and (if on lithium) UE, TFT, Ca levels.
Do not start lithium (if not taken before) or sodium valproate in Primary Care.

When should we refer to secondary care?

  • If symptoms of hypomania
  • If symptoms of mania (urgent referral)
  • If deterioration of depression
  • If risk of self-harm or harm to others (urgent referral)
  • Known bipolar and
    • Poor or partial response to treatment
    • Functioning declines significantly
    • Treatment adherence is poor
    • Intolerable or significant side-effects
    • Drug or alcohol use suspected
    • Patient is considering stopping medication after a period of stability
    • Woman is planning pregnancy or is pregnant 

Lithium Monitoring

Most patients need dose monitoring every 6m, but it should be done every 3m if
  • Older
  • Taking interacting meds
  • At risk of renal, thyroid or Ca problemsPoor symptom control
  • Poor adherence
  • If last level was 0.8 or higher
  • Otherwise tests should be done every 6m:
  • Weight / BMI
  • U+E, Ca, TFT (more often if impairment)
  • Monitor for symptoms of neurotoxicity (paraesthesia, ataxia, tremor and cognitive impairment). Beware that these can occur at therapeutic levels.

Louise Hudman

I'm a freelance GP locum in Winchester & Southampton locum chambers, and Pallant Medical Chambers Clinical Guidelines Lead Partner.

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