Introduction

This quality standard covers recognition, assessment and management of bipolar disorder (including bipolar I, bipolar II, mixed affective and rapid cycling disorder) in adults (18 years and older) in primary and secondary care. For more information see the topic overview.

Bipolar disorder in children and young people is covered by the quality standard on bipolar disorder, psychosis and schizophrenia in children and young people.

Why this quality standard is needed

Bipolar disorder is a potentially lifelong and disabling condition characterised by episodes of mania (abnormally elevated mood or irritability and related symptoms with severe functional impairment or psychotic symptoms for 7 days or more) or hypomania (abnormally elevated mood or irritability and related symptoms with decreased or increased function for 4 days or more) alternating with episodes of depressed mood. It is often comorbid with other disorders such as anxiety disorders, substance misuse, personality disorders and attention deficit hyperactivity disorder (ADHD).

The peak age of onset is 15–19 years, and there is often a substantial delay between onset and first contact with mental health services. People often initially present to services with depression, ill‑defined psychotic symptoms or an impulse control problem, which can mean that bipolar disorder is only diagnosed some years after the initial presentation.

The lifetime prevalence of bipolar I disorder (mania and depression) is estimated at 1% of the adult population, and bipolar II disorder (hypomania and depression) affects approximately 0.4% of adults. Bipolar disorder occurs approximately equally in both sexes. For some women, the experience of psychosis in the postnatal period may be the first indicator of bipolar disorder. For women with established bipolar disorder, childbirth brings an increased risk of psychosis and represents a substantial clinical challenge.

There is evidence of an increased incidence and differences in the manner of presentation of bipolar disorder in people from black and minority ethnic groups.

Around 25% of people with bipolar disorder have never sought help from healthcare services. Those who seek help may not receive a correct diagnosis of bipolar disorder for at least 6 years from the first appearance of symptoms. Adults with bipolar disorder are at high risk of suicide, which is greatly elevated during depressive episodes (bipolar disorder: the assessment and management of bipolar disorder in adults, children and young people in primary and secondary care [2014]).

The quality standard is expected to contribute to improvements in the following outcomes:

  • all‑age all‑cause mortality

  • excess under‑75 mortality rate in adults with severe mental illness

  • suicide rate

  • quality of life for people with severe mental illness

  • quality of life for carers

  • employment rates

  • service user experience of mental health services.

How this quality standard supports delivery of outcome frameworks

NICE quality standards are a concise set of prioritised statements designed to drive measurable improvements in the 3 dimensions of quality – patient safety, patient experience and clinical effectiveness – for a particular area of health or care. They are derived from high‑quality guidance, such as that from NICE or other sources accredited by NICE. This quality standard, in conjunction with the guidance on which it is based, should contribute to the improvements outlined in the following 3 outcomes frameworks published by the Department of Health:

Tables 1–3 show the outcomes, overarching indicators and improvement areas from the frameworks that the quality standard could contribute to achieving.

Table 1 NHS Outcomes Framework 2015–16

Domain

Overarching indicators and improvement areas

1 Preventing people from dying prematurely

Improvement areas

Reducing premature mortality in people with mental illness

1.5 i Excess under 75 mortality rate in adults with serious mental illness*

2 Enhancing quality of life for people with long‑term conditions

Overarching indicator

2 Health‑related quality of life for people with long‑term conditions**

Improvement areas

Ensuring people feel supported to manage their condition

2.1 Proportion of people feeling supported to manage their condition

Enhancing quality of life for carers

2.4 Health‑related quality of life for carers**

Enhancing quality of life for people with mental illness

2.5 i Employment of people with mental illness***

ii Health‑related quality of life for people with mental illness***

3 Helping people to recover from episodes of ill health or following injury

Improvement areas

Improving outcomes from planned treatments

3.1 Total health gain as assessed by patients for elective procedures

ii Psychological therapies

iii Recovery in quality of life for patients with mental illness

4 Ensuring that people have a positive experience of care

Overarching indicators

4a Patient experience of primary care

i GP services

ii GP out‑of‑hour services

4b Patient experience of hospital care

Improvement areas

Improving hospitals' responsiveness to personal needs

4.2 Responsiveness to inpatients' personal needs

Improving experience of healthcare for people with mental illness

4.7 Patient experience of community mental health services

Improving people's experience of integrated care

4.9 People's experience of integrated care**

Alignment across the health and social care system

* Indicator shared with Public Health Outcomes Framework (PHOF).

** Indicator shared with Adult Social Care Outcomes Framework (ASCOF).

*** Indicator shared with PHOF and ASCOF.

Indicators in italics are in development.

Table 2 The Adult Social Care Outcomes Framework 2015–16

Domain

Overarching and outcome measures

1 Enhancing quality of life for people with care and support needs

Overarching measure

1A Social care‑related quality of life**

Outcome measures

People manage their own support as much as they wish, so that are in control of what, how and when support is delivered to match their needs.

1B Proportion of people who use services who have control over their daily lives

Carers can balance their caring roles and maintain their desired quality of life.

1D Carer‑reported quality of life**

People are able to find employment when they want, maintain a family and social life and contribute to community life, and avoid loneliness or isolation.

1F Proportion of adults in contact with secondary mental health services in paid employment**

1H Proportion of adults in contact with secondary mental health services living independently, with or without support*

1I Proportion of people who use services and their carers who reported that they had as much social contact as they would like*

2 Delaying and reducing the need for care and support

Outcome measures

Everybody has the opportunity to have the best health and wellbeing throughout their life, and can access support and information to help them manage their care needs

Earlier diagnosis, intervention and reablement mean that people and their carers are less dependent on intensive services

2D The outcomes of short‑term services: sequel to service

3 Ensuring that people have a positive experience of care and support

Overarching measure

People who use social care services and their carers are satisfied with the experience of care and support services

3A Overall satisfaction of people who use services with their care and support

3B Overall satisfaction of carers with social services

3E Improving people's experience of integrated care**

Outcome measures

Carers feel that they are respected as equal partners throughout the care process

3C The proportion of carers who report that they have been included or consulted in discussions about the person they care for

People know what choices are available to them locally, what they are entitled to, and who to contact when they need help

3D The proportion of people who use services and carers who find it easy to find information about support

4 Safeguarding adults whose circumstances make them vulnerable and protecting from avoidable harm

Overarching measure

4A The proportion of people who use services who feel safe

Outcome measures

Everyone enjoys physical safety and feels secure

People are free from physical and emotional abuse, harassment, neglect and self‑harm

People are protected as far as possible from avoidable harm, disease and injuries

People are supported to plan ahead, and have the freedom to manage risks the way that they wish

4B Proportion of people who use services who say that those services have made them feel safe and secure

Aligning across the health and care system

* Indicator shared with Public Health Outcomes Framework.

** Indicator shared with NHS Outcomes Framework.

Table 3 Public health outcomes framework for England, 2013–16

Domain

Objectives and indicators

1 Improving the wider determinants of

health

Objective

Improvements against wider factors which affect health and wellbeing and health inequalities

Indicators

1.6 Adults with a learning disability/in contact with secondary mental health services who live in stable and appropriate accommodation**

1.8 Employment for those with long‑term health conditions including adults with a learning disability or who are in contact with secondary mental health services***

4 Healthcare, public health and preventing premature mortality

Objective

Reduced numbers of people living with preventable ill health and people dying prematurely, while reducing the gap between communities

Indicators

4.9 Excess under 75 mortality rate in adults with serious mental illness*

4.10 Suicide rate

* Indicator shared with NHS Outcomes Framework (NHSOF).

** Indicator shared with Adult Social Care Outcomes Framework (ASCOF).

*** Indicator shared with ASCOF and NHSOF.

Service user experience and safety issues

Ensuring that care is safe and that people have a positive experience of care is vital in a high‑quality service. It is important to consider these factors when planning and delivering services relevant to bipolar disorder in adults.

NICE has developed guidance and an associated quality standard on patient experience in adult NHS services and service user experience in adult mental health services (see the NICE pathways on patient experience in adult NHS services and service user experience in adult mental health services), which should be considered alongside this quality standard. They specify that people receiving care should be treated with dignity, have opportunities to discuss their preferences, and be supported to understand their options and make fully informed decisions. They also cover the provision of information to service users. Quality statements on these aspects of service user experience are not usually included in topic‑specific quality standards. However, recommendations in the development sources for quality standards that affect service user experience and are specific to the topic are considered during quality statement development.

Coordinated services

The quality standard for bipolar disorder in adults specifies that services should be commissioned from and coordinated across all relevant agencies encompassing the whole bipolar disorder care pathway. A person‑centred, integrated approach to providing services is fundamental to delivering high‑quality care to adults with bipolar disorder.

The Health and Social Care Act 2012 sets out a clear expectation that the care system should consider NICE quality standards in planning and delivering services, as part of a general duty to secure continuous improvement in quality. Commissioners and providers of health and social care should refer to the library of NICE quality standards when designing high‑quality services. Other quality standards that should also be considered when choosing, commissioning or providing a high‑quality service for adults with bipolar disorder are listed in related quality standards.

Training and competencies

The quality standard should be read in the context of national and local guidelines on training and competencies. All health and social care practitioners involved in assessing, caring for and treating adults with bipolar disorder should have sufficient and appropriate training and competencies to deliver the actions and interventions described in the quality standard. Quality statements on staff training and competency are not usually included in quality standards. However, recommendations in the development sources on specific types of training for the topic that exceed standard professional training are considered during quality statement development.

Role of families and carers

Quality standards recognise the important role families and carers have in supporting adults with bipolar disorder. If appropriate, health and social care practitioners should ensure that family members and carers are involved in the decision‑making process about investigations, treatment and care.