Quality statement 1: Referral for specialist mental health assessment

Quality statement

Adults presenting in primary care with symptoms of depression are offered a referral for a specialist mental health assessment if they have experienced overactivity or disinhibited behaviour lasting 4 days or more.

Rationale

The initial presentation in primary care for adults with bipolar disorder is usually with symptoms of depression. If the adult with bipolar disorder receives treatment for depression only, the intervention is ineffective and potentially harmful. If the adult presenting with depression has also experienced overactivity or disinhibited behaviour recently or in the past, depression may be a symptom of an underlying bipolar disorder. It indicates a need for further specialist mental health assessment.

Quality measures

Structure

Evidence of practice arrangements and written clinical protocols to ensure that adults presenting with symptoms of depression are referred for a specialist mental health assessment if they have experienced overactivity or disinhibited behaviour lasting 4 days or more.

Data source: Local data collection.

Process

a) Proportion of adults presenting in primary care with symptoms of depression who are asked if they have experienced overactivity or disinhibited behaviour lasting 4 days or more.

Numerator – the number in the denominator asked if they have experienced overactivity or disinhibited behaviour lasting 4 days or more.

Denominator – the number of adults presenting in primary care with symptoms of depression.

Data source: Local data collection.

b) Proportion of adults presenting in primary care with symptoms of depression who have experienced overactivity or disinhibited behaviour lasting 4 days or more who were referred for a specialist mental health assessment.

Numerator – the number in the denominator referred for a specialist mental health assessment.

Denominator – the number of adults presenting in primary care with symptoms of depression who have experienced overactivity or disinhibited behaviour lasting 4 days or more.

Data source: Local data collection.

Outcome

a) Referral rates for specialist mental health assessment.

Data source: Local data collection.

b) Recognition of bipolar disorder within the community.

Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GP practices, community health services and drug and alcohol misuse services) ensure that systems and protocols are in place for adults who present in primary care with symptoms of depression to be asked about experiences of overactivity or disinhibited behaviour lasting 4 days or more and referred for a specialist mental health assessment if needed.

Healthcare professionals ask adults who present in primary care with symptoms of depression about experiences of overactivity or disinhibited behaviour lasting 4 days or more, and follow local pathways and criteria for adults who need to be referred for a specialist mental health assessment.

Commissioners (such as clinical commissioning groups and NHS England local area teams) commission services that carry out specialist mental health assessments and ensure that local referral pathways are in place for adults who present in primary care with symptoms of depression who have also experienced overactivity or disinhibited behaviour lasting 4 days or more to receive a specialist mental health assessment.

What the quality statement means for service users and carers

Adults who see their GP with symptoms of depression are referred for a specialist mental health assessment if they have not been in control of their mood and behaviour for 4 days in a row or longer.

Source guidance

Definitions of terms used in this quality statement

Symptoms of depression

Key symptoms:

  • persistent sadness or low mood; and/or

  • marked loss of interests or pleasure.

Associated symptoms:

  • disturbed sleep (decreased or increased compared to usual)

  • decreased or increased appetite and/or weight

  • fatigue or loss of energy

  • agitation or slowing of movements

  • poor concentration or indecisiveness

  • feelings of worthlessness or excessive or inappropriate guilt

  • suicidal thoughts or acts.

[Depression in adults (NICE guideline CG90) appendix C: Assessing depression and its severity]

Referral for specialist mental health assessment

Adults with symptoms of depression presenting in primary care should be offered a referral for specialist mental health assessment if overactivity or disinhibited behaviour has lasted for 4 days or more. Overactivity or disinhibited behaviour may include:

  • elated, expansive or irritable mood

  • increased activity

  • decreased need for sleep

  • increased talkativeness

  • fast or racing thinking

  • inflated self‑esteem or self‑importance

  • increased sexual activity

  • attention easily drawn to irrelevant stimuli

  • excessive involvement in activities with high potential for undesired consequences, such as overspending or risky behaviours.

[Bipolar disorder (NICE guideline CG185) recommendations 1.2.5 and expert opinion]