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Bipolar disorder
July 2006
Why implement NICE guidance?
NICE guidelines are based on the best available evidence
The Department of Health asks NHS organisations to work towards implementing guidelines
Compliance will be monitored by the Healthcare Commission
Bipolar disorder is complex
Bipolar disorder is an episodic, potentially life-long, disabling disorder that can be difficult to diagnose
Need to improve recognition, reduce sub-optimal care and improve long-term outcomes
There is variation in management of care across healthcare settings
How to diagnose
Bipolar disorder is a cyclical mood disorder
Abnormally elevated mood or irritability alternates with depressed mood
•bipolar I – at least one manic or mixed episode•bipolar II – at least one major depressive episode
and at least one hypomanic episode
Presentation Key featuresMania Elevated, expansive or irritable mood
With or without psychotic symptoms
Marked impairment in functioning
Hypomania Elevated, expansive or irritable mood
No psychotic symptoms
Less impairment of functioning
Depression Mild, moderate or severe
With or without psychotic symptoms
Rapid cycling At least four episodes in 1 year
Mixed states Manic and depressive features present during same episode
Look for key features
Incidence and prevalenceAnnual incidence
7 per 100,000
Estimated lifetime prevalence – bipolar I 4–16 per 1000
Peak onset between 15 and 19 years of age
Suicidebipolar I – 17% attempt suicidebipolar disorder – 0.4% die annually by suicide
Comorbidity is common
Anxiety 30–50%
Substance misuse disorders (drugs and alcohol) 30–50%
Personality disorders, in particular borderline personality disorder (exercise caution when diagnosing)
What this guideline coversDiagnosis in adolescents
Pharmacological treatment for:
•acute phase•long term management•rapid cycling•use of antidepressants•women of child bearing potential
Psychological therapy
Weight gain management
Annual physical health check
Diagnosis in adolescents
Diagnosing bipolar I disorder
Use adult criteria, except that:
•mania must be present •euphoria must be present most of the time (for the
past 7 days) •note irritability if it is episodic, severe, results in
impaired function and is not in character or is out of keeping with the context
Supporting diagnosis in adolescents
Increase knowledge and awareness in primary care and community settings
Ensure prompt referrals to secondary care
Use modified adult criteria to diagnose children and adolescents
Consider alternative diagnoses and other possible causes
Treat the acute phase
Consider an antipsychotic if:
•manic symptoms are severe
•there is marked behavioural disturbance
Consider valproate or lithium if:
•there has been previous response and good compliance with one of these drugs
Consider lithium if:
•symptoms are less severe
Initiate long-term pharmacological treatment
After a manic episode with significant risk and adverse consequences
Bipolar I: two or more acute episodes
Bipolar II: evidence of significant functional impairment or risk of suicide or frequently recurring episodes
Choose long-term drugs
Base choice of lithium, olanzapine or valproate* on:
•previous response•risk and precipitants of manic versus depressive
relapse •physical risk factors•patient preference and history of adherence•cognitive state assessment if appropriate
* Valproate should not be prescribed routinely for women of child-bearing potential
Try alternatives if needed
If continuing symptoms or relapse, use alternative monotherapy or add second prophylactic agent:
•lithium and valproate•olanzapine and lithium•valproate and olanzapine
If this proves ineffective:
•consult, or refer to, an expert in pharmacological treatment of bipolar disorder
•prescribe lamotrigine or carbamazepine
Support long-term pharmacological treatment
Ensure prescribing advisers are aware of NICE guidance, and what to consider when choosing treatment
Focus on optimising appropriate long-term treatment
Support service user education and empowerment in pharmacological treatment and management decisions
Make use of early intervention teams, regional mental health trusts and CAMHS teams
Modify treatment for rapid cycling
For an acute episode base treatment on that for manic and depressive episodes and:
•review previous treatments; if inadequately delivered or adhered to, consider a further trial of previous treatments
•optimise long-term treatment; each trial of medication should usually last at least 6 months
•encourage patients to keep a mood diary
Use antidepressants with care
Acute manic phase
Stop antidepressants at onset of acute manic phase and decide if discontinuation is abrupt or gradual based on:
•current clinical need•previous experience of discontinuation/withdrawal
symptoms•the risk of discontinuation/withdrawal symptoms
Consider need for treatment
Is long-term antidepressant treatment needed after an acute depressive episode?
No evidence for reduced relapse rates
May be associated with increased risk of mania
Educate staff and service users
Raise awareness of effective antidepressant prescribing
Highlight the importance of a thorough review of pharmacological history
Support patient fears about antidepressant withdrawal
Review prescribing policies and formularies, update as appropriate
Consider psychological therapy
For those who are stable, individual structured psychological therapy should include:
•at least 16 sessions over 6 to 9 months•psychoeducation •promotion of medication adherence •monitoring of mood, detection of early warnings
and prevention strategies •coping strategies
Implement psychological therapy
Offer individual structured psychological therapy
Identify key people to support mood monitoring and coping strategies
Identify training needs
Review access to services
Work collaboratively and engage the client, family or carers
Take possible pregnancy into account
Valproate should not be used routinely for women who may become pregnant. It may:
•cause foetal abnormalities•affect the child’s cognitive development
If prescribed, ensure adequate contraception. Explain risks during pregnancy and to the health of the unborn child
An antipsychotic may be used with caution
Provide care for women of child-bearing potential
Review care pathways and management of bipolar disorder in women of child-bearing potential
Raise awareness of the effects of bipolar disorder and treatment on:
•conception •pregnancy •child
Engage with patients, discuss contraception and family planning
Mitigate drug-related weight gain
Review medication strategy and consider:
•dietary advice and support •advising regular increased aerobic exercise•referring to a specialist mental health diet clinic or
health delivery group•referring to a dietitian if needed for people with
complex comorbidities
Support patients in controlling weight
Review risk of weight gain when prescribing, offer early dietary advice and support
Offer diet clinics or health delivery groups locally
Identify a named key worker with appropriate training, use the care programme approach (CPA)
Document in clinical notes/individualised care plan
Review annually
Over the course of the year an annual review should include:
• lipid levels, including cholesterol, in patients over 40• plasma glucose levels• weight• smoking status and alcohol use• blood pressure
Establish review systems
Agree responsibility locally
Establish monitoring and early warning systems
Develop systems for responsibility and intervention
Communicate results
Follow up non attendance
Target resources
Recommendations considered to have greatest impact on resources are:
•pharmacological management of women of child-bearing potential
•psychological management•weight management •annual review of physical health
Costs and savings
Recommendation Cost £m
Pharmacological management of women of child-bearing potential
3.6
Psychological management 20.8
Weight management 3.6
Annual review of physical health 3.4
Estimated saving achieved through increased psychological management
-11.4
National cost impact 20.1
Access tools online
Costing tools
•costing report•costing template
Implementation advice
Available from: www.nice.org.uk/CG038
Access the guideline online
Quick reference guide – a summary www.nice.org.uk/CG038quickrefguide
NICE guideline – all of the recommendations www.nice.org.uk/CG038niceguideline
Full guideline – all of the evidence and rationale www.nice.org.uk/CG038fullguideline
Information for the public – a plain English version www.nice.org.uk/CG038publicinfo