Key priorities for implementation

The following recommendations have been identified as priorities for implementation. The full list of recommendations is in section 1.

Care for adults, children and young people across all phases of bipolar disorder

Support for carers of people with bipolar disorder

  • As early as possible negotiate with the person with bipolar disorder and their carers about how information about the person will be shared. When discussing rights to confidentiality, emphasise the importance of sharing information about risks and the need for carers to understand the person's perspective. Foster a collaborative approach that supports both people with bipolar disorder and their carers, and respects their individual needs and interdependence[2].

Recognising and managing bipolar disorder in adults in primary care

Managing bipolar disorder in primary care

  • Offer people with bipolar depression:

    • a psychological intervention that has been developed specifically for bipolar disorder and has a published evidence-based manual describing how it should be delivered or

    • a high‑intensity psychological intervention (cognitive behavioural therapy, interpersonal therapy or behavioural couples therapy) in line with recommendations 1.5.3.1–1.5.3.5 in the NICE clinical guideline on depression.

      Discuss with the person the possible benefits and risks of psychological interventions and their preference. Monitor mood and if there are signs of hypomania or deterioration of the depressive symptoms, liaise with or refer the person to secondary care. If the person develops mania or severe depression, refer them urgently to secondary care.

Managing mania or hypomania in adults in secondary care

Pharmacological interventions

  • If a person develops mania or hypomania and is not taking an antipsychotic or mood stabiliser, offer haloperidol, olanzapine, quetiapine or risperidone, taking into account any advance statements, the person's preference and clinical context (including physical comorbidity, previous response to treatment and side effects). Follow the recommendations on using antipsychotics in section 1.10.

  • If the person is already taking lithium, check plasma lithium levels to optimise treatment (see section 1.10). Consider adding haloperidol, olanzapine, quetiapine or risperidone, depending on the person's preference and previous response to treatment.

Managing bipolar depression in adults in secondary care

Psychological interventions

  • Offer adults with bipolar depression:

    • a psychological intervention that has been developed specifically for bipolar disorder and has a published evidence‑based manual describing how it should be delivered or

    • a high‑intensity psychological intervention (cognitive behavioural therapy, interpersonal therapy or behavioural couples therapy) in line with recommendations 1.5.3.1–1.5.3.5 in the NICE clinical guideline on depression.

      Discuss with the person the possible benefits and risks of psychological interventions and their preference. Monitor mood for signs of mania or hypomania or deterioration of the depressive symptoms.

Pharmacological interventions

  • If a person develops moderate or severe bipolar depression and is not taking a drug to treat their bipolar disorder, offer fluoxetine[3] combined with olanzapine[4], or quetiapine on its own, depending on the person's preference and previous response to treatment.

    • If the person prefers, consider either olanzapine (without fluoxetine) or lamotrigine[5] on its own.

    • If there is no response to fluoxetine combined with olanzapine, or quetiapine, consider lamotrigine on its own.

      Follow the recommendations on using antipsychotics and lamotrigine in section 1.10.

  • If a person develops moderate or severe bipolar depression and is already taking lithium, check their plasma lithium level. If it is inadequate, increase the dose of lithium; if it is at maximum level, add either fluoxetine[3] combined with olanzapine[4] or add quetiapine, depending on the person's preference and previous response to treatment.

    • If the person prefers, consider adding olanzapine (without fluoxetine) or lamotrigine[5] to lithium.

    • If there is no response to adding fluoxetine combined with olanzapine, or adding quetiapine, stop the additional treatment and consider adding lamotrigine to lithium.

      Follow the recommendations in section 1.10 on using lithium, antipsychotics and lamotrigine.

Managing bipolar disorder in adults in the longer term in secondary care

Psychological interventions

  • Offer a structured psychological intervention (individual, group or family), which has been designed for bipolar disorder and has a published evidence‑based manual describing how it should be delivered, to prevent relapse or for people who have some persisting symptoms between episodes of mania or bipolar depression.

Pharmacological interventions

  • Offer lithium as a first‑line, long‑term pharmacological treatment for bipolar disorder and:

    • if lithium is ineffective, consider adding valproate[6]

    • if lithium is poorly tolerated, or is not suitable (for example, because the person does not agree to routine blood monitoring), consider valproate or olanzapine instead or, if it has been effective during an episode of mania or bipolar depression, quetiapine.

      Discuss with the person the possible benefits and risks of each drug for them.

Recognising, diagnosing and managing bipolar disorder in children and young people

Recognition and referral

Diagnosis and assessment
  • Diagnosis of bipolar disorder in children or young people should be made only after a period of intensive, prospective longitudinal monitoring by a healthcare professional or multidisciplinary team trained and experienced in the assessment, diagnosis and management of bipolar disorder in children and young people, and in collaboration with the child or young person's parents or carers.

Management in young people

Mania
Bipolar depression
  • Offer a structured psychological intervention (individual cognitive behavioural therapy or interpersonal therapy) to young people with bipolar depression. The intervention should be of at least 3 months' duration and have a published evidence‑based manual describing how it should be delivered.



[2] Adapted from Psychosis and schizophrenia in adults (NICE clinical guideline 178).

[3] Although its use is common in UK clinical practice, at the time of publication (September 2014), fluoxetine did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

[4] At the time of publication (September 2014), olanzapine did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

[5] Although its use is common in UK clinical practice, at the time of publication (September 2014), lamotrigine did not have a UK marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

[6] At the time of publication (September 2014) semi-sodium valproate had a UK marketing authorisation for this indication in people who have had mania that has responded to treatment with semi-sodium valproate. Sodium valproate did not have a UK marketing authorisation for this indication, although its use is common in UK clinical practice. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

[7] At the time of publication (September 2014) aripiprazole had a UK marketing authorisation for up to 12 weeks of treatment for moderate to severe manic episodes in bipolar I disorder in young people aged 13 and older.

[8] At the time of publication (September 2014), olanzapine, risperidone, haloperidol, quetiapine, lamotrigine, lithium and valproate did not have a UK marketing authorisation for use in children and young people for this indication. The prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council's Good practice in prescribing and managing medicines and devices for further information.

  • National Institute for Health and Care Excellence (NICE)