Case Identification and Assessment in Adults, Children and Young People

National Collaborating Centre for Mental Health (UK)

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National Collaborating Centre for Mental Health (UK). Bipolar Disorder: The NICE Guideline on the Assessment and Management of Bipolar Disorder in Adults, Children and Young People in Primary and Secondary Care. London: The British Psychological Society and The Royal College of Psychiatrists; 2014 Sep. (NICE Clinical Guidelines, No. 185.)

See 2018 Partial Update

April 2018: Footnotes and cautions have been added and amended to link to the MHRA's latest advice and resources on sodium valproate. Sodium valproate must not be used in pregnancy, and only used in girls and women when there is no alternative and a pregnancy prevention plan is in place. This is because of the risk of malformations and developmental abnormalities in the baby. November 2017: Footnotes for some recommendations were updated with current UK marketing authorisations and MHRA advice. Links to other guidelines have also been updated. Some research recommendations have been stood down. See these changes in the short version of the guideline.

April 2018: Footnotes and cautions have been added and amended to link to the MHRA's latest advice and resources on sodium valproate. Sodium valproate must not be used in pregnancy, and only used in girls and women when there is no alternative and a pregnancy prevention plan is in place. This is because of the risk of malformations and developmental abnormalities in the baby. November 2017: Footnotes for some recommendations were updated with current UK marketing authorisations and MHRA advice. Links to other guidelines have also been updated. Some research recommendations have been stood down. See these changes in the short version of the guideline.

Bipolar Disorder: The NICE Guideline on the Assessment and Management of Bipolar Disorder in Adults, Children and Young People in Primary and Secondary Care.

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5Case Identification and Assessment in Adults, Children and Young People

5.1. Introduction

Despite some advances in the field of case identification, bipolar disorder is often unrecognised outside specialist settings focusing on mood disorders. This raises the issue as to whether specific instruments should be used for screening the general population, at risk populations such as those in prison, or those already diagnosed with depression in primary care settings or even in generalist mental health services.

Lack of recognition or delayed diagnosis can be associated with negative consequences for the individual, their families and society; for example, a high risk of attempted suicide in people with undiagnosed bipolar disorder (Shi et al., 2004b). Furthermore, delayed diagnosis is highly likely to affect treatment and lead to suboptimal outcomes. There are also wider social and economic consequences such as increased medical costs and loss of productivity because of an inability to work (Matza et al., 2005).

Several reasons are often put forward as explanations as to why bipolar disorder might be missed as a diagnosis. Most important of these is that an individual with bipolar disorder often presents in primary care with a depressive episode. Additionally, during a hypomanic or manic phase people may often feel that they do not need to contact a healthcare professional, or if they are already using mental health services they may not spontaneously report their symptoms (Bruchmuller & Meyer, 2009; Dunner, 2003; Hirschfeld & Vornik, 2004). In children and young people, correct identification and diagnosis of bipolar disorder can be particularly problematic. There is little evidence about case identification in this population (Waugh et al., 2013), and the precursors of bipolar disorder in this age range are varied and include anxiety disorders, mood disorders and externalising behavioural disorders (Nurnberger et al., 2011).

To decrease the likelihood of not recognising bipolar disorder in clinical practice, several screening instruments have been developed over the last few years and evaluated to identify potential bipolar disorder. Some focus more on trait-like features of bipolarity or cyclothymia such as the General Behaviour Inventory (Depue et al., 1989) or the Hypomanic Personality Scale (Eckblad & Chapman, 1986), while others, such as the Mood Disorder Questionnaire (MDQ) (Hirschfeld et al., 2000), the Bipolar Spectrum Diagnostic Scale (Ghaemi et al., 2005b) or the Hypomania Checklist-32 (Angst et al., 2005a), ask about lifetime history of mania or hypomania. The latter instruments are shorter than the scales assessing trait-like features. They are easy-to-use self-report tools which have been validated in adult samples against diagnoses made using structured clinical interviews (for example, (Meyer et al., 2011; Smith et al., 2011a; Waugh et al., 2013). None of these screening tools is meant as the sole means used to diagnose bipolar disorder, but rather to prompt further assessment.

There is a large number of rating scales but there has been little development specifically of brief instruments suitable for screening in a non-specialist environment. Primary care practices are increasingly using technology-based solutions, so screening tests need to be simple and easy to complete by patients without assistance.

5.2. Case Identification

5.2.1. Clinical review protocol

The review protocol summary, including the review questions, can be found in Table 6 (a complete list of review questions and full review protocols can be found in Appendix 7; further information about the search strategy can be found in Appendix 8).

Table 6

Review protocol summary for the review of case identification instruments.

For the purposes of this review, pooled diagnostic accuracy meta-analyses on the sensitivity and specificity of specific case identification instruments for bipolar disorder were conducted (dependent on available data). In the absence of adequate data, it was agreed by the GDG that a narrative review of case identification instruments would be conducted and guided by a pre-defined list of consensus-based criteria (for example, the clinical utility of the instrument, administrative characteristics, and psychometric data evaluating its sensitivity and specificity).

The GDG advised that the review should focus on case identification instruments that are relevant to non-specialist settings such as primary care, given that bipolar disorder is often unrecognised outside of specialist settings (see section 5.1). Furthermore, when evaluating case identification instruments, the following criteria were used to decide whether an instrument was eligible for inclusion in the review:

Clinical utility: the instrument should be feasible and implementable in routine clinical care, especially primary care. The instrument should contribute to the identification of further assessment needs and inform decisions about referral to other services.

Instrument characteristics and administrative properties: a case identification instrument should be brief, easy to administer and score, and be able to be interpreted without extensive and specialist training. The GDG agreed that, in order to support its use in a range of non-specialist settings such as primary care, the instrument should contain no more than 15 items and take no more than 5 minutes to administer.

Non-experts from a variety of care settings (for example, primary care, general medical services, and educational, residential or criminal justice settings) should be able to complete and interpret the instrument with relative ease. The instrument should be available in practice, and free to use where possible.

Psychometric data: the instrument should have established reliability and validity (although this data will not be reviewed here). It must have been validated against a gold standard diagnostic instrument such as DSM-IV or ICD-10 and it must have been reported in a paper that described its sensitivity and specificity (see section 3.5.2 for a description of diagnostic test accuracy terms).

5.2.2. Studies considered¹³

The literature search yielded 6,954 citations. Of those, 165 were potentially relevant. Twenty-two were excluded (see Appendix 34). Studies conducted only in specialist mental health populations, or special groups, were not considered because it would make it difficult to generalise to the general population attending primary care, which is the focus of this review. Studies that did not use instruments in English were also excluded, to ensure greatest applicability to the UK. Only studies where there was evidence that the reference standard included a structured diagnostic interview were included.

Four studies met all of the eligibility criteria. References of included studies were hand searched. Two studies evaluated case identification instruments for adults and two for children. They were published in peer-review journals between 2003 and 2009. The four included studies (N = 2,125) evaluated one instrument for adults and two for children and included 100 to 1,066 participants receiving both a screening instrument and a diagnostic interview. Case identification instruments included between ten and 13 questions. Studies were conducted in the community and in psychiatric settings (for further information about each study see Table 7).

Table 7

Study information table for trials comparing a brief identification instrument with a ‘gold standard’ clinical interview.

Of the four studies, two evaluated the Mood Disorder Questionnaire (MDQ): DODD2009 (Dodd et al., 2009), HIRSCHFELD2003 (Hirschfeld et al., 2003). One study evaluated the CMRS-P: HENRY2008 (Henry et al., 2008); and one study evaluated the Conners’ Abbreviated Parent Questionnaire: TILLMAN2005 (Tillman & Geller, 2005).

5.2.3. Clinical evidence review

Overall, the studies were assessed as having a low risk of bias, but information about the timing of the index test and reference standard was generally not described (for further information see Appendix 11). The index tests (case identification instruments) were conducted independently of the reference tests (diagnostic interviews) and the time between case identification and diagnostic interview was not relevant given the stability of the diagnosis. Only one study evaluated the instrument in the general population (HIRSCHFELD2003); one in a general population of women only (DODD2009); the other two were undertaken in clinical settings (see Table 7).

Review Manager 5 (Cochrane Collaboration, 2011) was used to summarise the test accuracy data reported in each study using forest plots and summary ROC plots.

The three instruments varied in their specificity and sensitivity. As shown in Figure 4, the area under the curve varied reflecting differences in the effectiveness of the measures (see section 3.5.2 for more information about how this was interpreted). The sensitivity and specificity of each measure is included in Table 7.

Figure 4

Summary ROC plot of brief case identification instruments.

Evidence about the sensitivity and specificity of instruments to identify people with bipolar disorder comes from only a few studies, and only one instrument has been evaluated in more than one study. No study was conducted in the UK.

The MDQ is a self-rated tool and has 13 items with a yes/no answer, plus a further two assessing the temporal clustering of symptoms and functional impairment (4-point scale). It may not be very useful as a screening tool in the general population given the reported sensitivities in community populations.

The child and adolescent instruments were evaluated in populations that included participants with attention deficit hyperactivity disorder (ADHD), which is an important differential diagnosis in this age group.

The Child Mania Rating Scale – Parent (CMRS-P) brief version is a 10-item instrument with four possible answers per question and which showed accuracy comparable to the full scale. The Conner’s abbreviated Parent Questionnaire, is an instrument to assess ADHD in children and adolescents is also a 10-item instrument, each with four possible answers. None of these measures had satisfactory properties for identifying bipolar disorder in primary care.

5.2.4. Health economics evidence

Systematic literature review

The systematic search of the economic literature undertaken for the guideline identified one eligible study on case identification that was conducted in the US (Menzin et al., 2009). Full references and evidence tables for all economic evaluations included in the systematic literature review are provided in Appendix 32. Completed methodology checklists of the studies are provided in Appendix 31. Economic evidence profiles of studies considered during guideline development (that is, studies that fully or partly met the applicability and quality criteria) are presented in Appendix 33.

The study by Menzin and colleagues (2009) assessed the cost effectiveness of MDQ versus no screening in adults presenting for the first time with symptoms of major depressive disorder in primary care; people who screened positive were subsequently referred to psychiatrists. The study, which was based on decision analytic modelling, adopted a third-party payer perspective. Costs included the cost of administration of MDQ by a nurse or physician, the cost of referral to psychiatrists for adults that were screened positive, costs of inpatient and outpatient care, and medication costs. The primary measure of outcome was the number of people correctly diagnosed with bipolar disorder or unipolar depression. Cost data were taken from published literature. Clinical input parameters were based on a literature review and expert opinion. The time horizon of the analysis was 5 years.

According to the results of the analysis, the MDQ resulted in a higher number of correctly diagnosed people compared with no screening (440 versus 402 correct diagnoses per 1000 people screened, respectively) and also in a lower total cost per person (US$34,107 versus US$36,044, respectively, in 2006 prices). Consequently, screening with MDQ was the dominant option. Probabilistic analysis showed that the probability of screening with MDQ being cost-saving reached 76%. Results were robust under various alternative scenarios that considered a range of values for the prevalence of bipolar disorder, sensitivity/specificity of MDQ, costs of treatment, as well as a different time horizon.

The study is only partially applicable to the UK context because it was conducted in the US where clinical practice, resource use and unit costs differ from those in the NHS. Moreover, the study has potentially serious limitations because a number of clinical input parameters relating to no screening as well as to further assessment of people with a false positive MDQ result were based on expert opinion.

Economic evidence statement

There is some evidence indicating that the MDQ may be cost-saving in adults presenting for the first time with symptoms of major depression in primary care. This evidence is partially applicable to the UK, but has potentially serious limitations.

5.3. Assessment

5.3.1. Clinical review protocol

The review protocol summary, including the review questions, can be found in

Table 8 (a complete list of review questions and full review protocols can be found in Appendix 7; further information about the search strategy can be found in Appendix 8).

Table 8

Review protocol summary for the review of the assessment of bipolar disorder.

For the purposes of this review it was decided that a narrative synthesis of available evidence would be conducted, and in the absence of adequate data, a consensus-based approach to identify the key components of an effective assessment would be used.

5.3.2. Studies considered

The GDG was unable to identify any formal evaluations of the structure and content of the overall clinical assessment process for people with possible bipolar disorder other than the data on the various case identification instruments described above.

5.3.3. Clinical evidence review

As there was an absence of evidence the GDG drew up a list of the following components of an assessment to consider when making recommendations:

the person’s symptom profile, including a history of mood, episodes of overactivity, disinhibition or other episodic and sustained changes in behaviour, symptoms between episodes, triggers to previous episodes and patterns of relapse, and family history
social and personal functioning, and current psychosocial stressors
potential mental and physical comorbidities
general physical health and side effects of medication, including weight gain
involvement of a family member or carer to give a corroborative history
treatment history and interventions that have been effective or ineffective in the past
possible factors associated with changes in mood, including relationships, psychosocial factors and lifestyle changes
risk to self and to others.

The GDG also discussed the components of a long-term management plan in the context of assessment. They considered that the plan should cover possible triggers and early warning signs of relapse, a protocol for increasing medication for those at risk of onset of mania, agreements between primary and secondary care about how to respond to an increase in risk and how service users and carers can access help in a crisis, with a named professional.

The GDG also considered the service configuration best suited to provide assessment of people with suspected bipolar disorder (and also early management). The GDG reviewed the Psychosis and Schizophrenia in Adults guideline (NCCMH, 2014; NICE, 2014) and the evidence underpinning the use of early intervention services for people with suspected and early psychosis. These populations include people who later develop schizophrenia, bipolar disorder and other psychoses. All the trials included in the guideline review were with mixed populations. The GDG considered that early intervention services were therefore appropriate, and indeed important, for people with bipolar disorder. However, there were concerns, also raised by stakeholders during the consultation period, that early intervention in psychosis services might not be accessible to all people with bipolar disorder (either because of their age or because they did not have bipolar disorder with psychotic features), therefore the GDG considered the requirements of any team when providing assessment and further management for bipolar disorder. They judged that these teams, in common with Psychosis and Schizophrenia in Adults (NICE, 2014) guideline, should be able to provide the full range of recommended interventions, be competent to deliver these interventions, promote engagement rather than risk management, and offer treatment in the least restrictive and stigmatising environment possible. The GDG agreed by consensus that in addition to early intervention in psychosis teams, specialist bipolar disorder and specialist integrated community-based teams could offer these services.

5.3.4. Health economic evidence review

No studies assessing the cost effectiveness of assessment systems or instruments for people with bipolar disorder were identified by the systematic search of the economic literature.

5.4. Immediate Post-Assessment Period

In addition to conducting the reviews on identification and assessment, the GDG discussed the immediate post-assessment period, and the process and issues that would need to be considered when planning treatment and care for people across all phases of the disorder.

The GDG discussed this topic using informal consensus methods (see section 3.5.6) and their expert knowledge and experience. They considered that the following would need to be considered when making recommendations in this area:

experience of care
the care of certain groups of people, or ‘special populations’.

Regarding the experience of care, the GDG acknowledged the existing guideline on Service User Experience in Adult Mental Health (NICE, 2011a; NCCMH, 2012), which provides evidence-based recommendations for improving experience of mental health services in the following main areas: care and support across all points on the care pathway, access to care, assessment, community care, assessment and referral in a crisis, hospital care, discharge and transfer of care, and assessment and treatment under the Mental Health Act. The GDG identified specific areas not explicitly covered by the Service User Experience in Adult Mental Health guideline that they considered important to include in this current guideline on bipolar disorder. This included identifying any problems related to the service user’s education, employment or finances that may have resulted directly from features of their bipolar disorder, such as extravagant spending, and reckless behaviour and decision-making, during episodes of mania. Related to this topic, the GDG recognised the need for people with bipolar disorder to consider a lasting power of attorney and developing advance statements.

Bearing in mind the reviews undertaken earlier in this chapter and in Chapter 6, Chapter 7 and Chapter 8, the GDG also considered the care of special populations across all phases of the disorder. They judged that the following groups may need special attention:

older people
people with a learning disability
people with a coexisting disorders, such as personality disorder, anxiety disorders and substance use-disorders
people with rapid-cycling disorder
women of child-bearing potential.

The GDG recognised potential inequalities in the way older people with bipolar disorder could be treated, and saw the need to ensure that they are offered the same range of treatments and services as young people. Given that people with a learning disability may be at increased risk of developing comorbid serious mental illness, and due to the uncertainty around treatment options, the GDG was keen to ensure that they were also offered the same range of treatments and services as other people with bipolar disorder. Bipolar disorder also commonly coexists with anxiety disorders, substance-use disorders and personality disorder, therefore the GDG judged that any additional treatment for these disorders should be undertaken according to the related NICE guideline. The GDG bore in mind the reviews undertaken in this chapter on identification, and in subsequent chapters on interventions, and acknowledged that there was very little evidence that people who have sometimes been described as ‘rapid cycling’ can be reliably identified, and there was no evidence to suggest they respond differently to treatment, therefore the GDG determined that these people should also be offered the same treatment as people with other types of bipolar disorder. Finally, the GDG reviewed the recommendations on race, culture and ethnicity in the Psychosis and Schizophrenia in Adults guideline (NCCMH, 2014; NICE, 2014) and recognised that the principles conveyed by these recommendations were relevant to people with bipolar disorder.

The GDG also reviewed the Psychosis and Schizophrenia in Adults guideline in relation to care planning and considered that one recommendation was also relevant to people with bipolar disorder. The method of incorporation and adaptation (see section 3.7) was followed to ensure that the recommendations were appropriate for people with bipolar disorder. Further information about shared recommendations and the reason for incorporating or adapting each one can be found in Table 9.

Table 9

Recommendations incorporated or adapted from another NICE guideline.

5.5. Linking Evidence to Recommendations

5.5.1. Relative value placed on the outcomes considered

In considering case identification instruments, the primary outcome was the accurate detection of bipolar disorder. For assessment, no limits were initially placed on the outcomes that would be considered.

5.5.2. Trade-off between benefits and harms

A number of case identification instruments were identified, but the GDG determined that there was little evidence to support their use as screening instruments in primary care (both general practice and primary care based psychological therapy services) for those already diagnosed with depression. There is some rationale, but the GDG were not aware of evidence for use of the instruments to support provisional diagnosis in those already suspected of bipolar disorder. Through consensus, the GDG developed new recommendations about the identification of bipolar disorder in primary care and what should happen if it is suspected.

There was little evidence about case identification in children and young people (Waugh et al., 2013). The GDG noted that DSM-V has been revised in light of concerns about over-diagnosis of children. Bipolar disorder is extremely rare in children, and although it can begin in adolescence, this is also rare. The reviewed evidence evaluated two instruments with at least ten items in relatively small sample sizes. The GDG concluded that case identification instruments used in primary care would need to be much shorter to have clinical utility. Moreover, the instruments were evaluated in populations that included participants with attention deficit hyperactivity disorder (ADHD), which is an important differential diagnosis in this age group. Without robust evidence in children and young people, the GDG agreed that it should be recommended that questionnaires are not used for identifying children and young people with suspected bipolar disorder. Rather, the GDG developed recommendations based on a careful consideration of the available evidence and their expert consensus about the best way to manage children and young people with serious psychiatric symptoms that could be indicative of bipolar disorder.

The GDG wished to stress the importance of having specialist input in the diagnosis of bipolar disorder or another serious mental health problem in this population.

The GDG considered evidence for the MDQ and determined that its poor sensitivity in large samples suggests the MDQ is not appropriate for case identification and that it would be better to refer people with suspected bipolar disorder for a full assessment. The GDG wished to emphasise that health and social care professionals who are concerned that an adult may be exhibiting symptoms of mania or psychosis should refer the service user for assessment by a qualified professional.

The GDG also considered the comorbidity of bipolar disorder with other problems in children and young people, the risks associated with bipolar disorder and the impact of bipolar disorder on individuals and their families.

Regarding assessment, the GDG was unable to identify any high-quality evidence that related to the process of assessment for people with bipolar disorder. As a result the GDG drew on their expert knowledge and experience using informal consensus methods. During discussion, the GDG identified several key principles for assessing people with suspected bipolar disorder. In addition, and as a result of comments received as part of the stakeholder consultation, the GDG also considered that associated problems across the lifespan (childhood trauma, developmental disorder or later-life cognitive dysfunction) also need to be assessed and understood in the context of the development of the mood disorder. They also discussed risk assessment and the components of a risk management plan. The GDG noted that self-harm is common in bipolar disorder and that healthcare professionals should be aware that mental state and suicide risk can change quickly. Similarly, the disinhibited, changeable and impulsive nature of patients with bipolar disorder, particularly in a manic or a mixed state, means that healthcare professionals should exercise caution when there is a risk of harm to others. The GDG determined that there was very little evidence that people who have sometimes been described as ‘rapid cycling’ can be reliably identified, and there was no evidence to suggest they respond differently to treatment, so the GDG determined that this specifier is of little clinical utility at present.

Regarding the immediate post-treatment period, the GDG were concerned that certain groups of people with bipolar disorder received the most appropriate treatment and care from other NICE guidelines following assessment, including older people, women of childbearing potential and those with coexisting disorders, such as personality disorder, anxiety and substance misuse. People with a learning disability may be at increased risk of developing comorbid serious mental illness. However, coexisting conditions are often overlooked. Given the uncertainty around treatment options, the GDG argued that people with a learning disability should receive the same care as other people with bipolar disorder. A similar recommendation was issued for older people; while adjustments might need to be made to their medication regimes (see Chapter 7), they should be offered the same range of treatments and services as younger people with bipolar disorder. Finally, the GDG opted to cross-refer to the Psychosis and Schizophrenia in Adults guideline (NCCMH, 2014; NICE, 2014) regarding recommendations pertaining to working with people from black, Asian and minority ethnic groups.

As part of the discussions around the assessment and post-assessment period, the GDG also considered other aspects of care, and the support people should receive when first diagnosed and throughout treatment, including having the same high standard of care as set out in Service User Experience in Adult Mental Health (NICE, 2011a), and an approach that promotes a positive recovery message and builds supportive and empathic relationships. The GDG also wished to make sure that people with bipolar disorder receive help with problems related to their education, employment or finances that may have resulted from their bipolar disorder, that they are encouraged to make a lasting power of attorney (especially if they have experienced serious financial problems), and that they develop an advance statement, setting out their preferences, wishes, beliefs and values regarding their future care if, at any point, they are unable to make decisions.

When considering the service configuration best suited to provide assessment of people with suspected bipolar disorder (and also early management), the GDG considered the evidence reviewed in Psychosis and Schizophrenia in Adults (NCCMH, 2014) for early intervention in psychosis services in mixed populations, but also took into account the possible restricted access to these services for people with bipolar disorder without psychosis. They judged that specialist bipolar disorder and specialist integrated community-based teams could also undertake assessment of bipolar disorder if they had the required components (namely, they could provide the full range of recommended interventions, be competent to deliver these interventions, promote engagement rather than risk management, and offer treatment in the least restrictive and stigmatising environment possible).

With regards to children and young people, the GDG wished to make recommendations about diagnosis in this age group. The GDG for the 2014 guideline acknowledged the consensus conference undertaken for the previous guideline (NCCMH, 2006), which had international representation. The impact of the conference on the diagnosis of children and young people had lasting effects in the UK and the US on diagnostic practices, therefore some recommendations are retained.

The GDG further noted that bipolar disorder in children and young people is rare, and they considered that it should not be diagnosed by professionals who do not have specialist training in its assessment and management in young people. For these reasons, the GDG determined that children and young people with suspected bipolar disorder should be referred to appropriate services depending on their age. The GDG agreed by consensus that children under 14 years should be referred to CAMHS. When considering older age groups, the GDG bore in mind the evidence for early intervention in psychosis services in young adults (NCCMH, 2013), and judged that people aged 14 or over could be referred to either a specialist early intervention in psychosis service or to a CAMHS team (tiers 3 or 4). The GDG agreed that both the specialist early intervention in psychosis and CAMHS teams should be multidisciplinary (comprising professionals who are trained and competent in working with young people with bipolar disorder) and have access to structured psychological interventions and pharmacological interventions. Vocational and educational interventions should also be available. In addition family involvement and family intervention are particularly important to support the diagnosis and ongoing treatment. Engagement and assertive outreach approaches should also be employed to build trusting and supportive relationships, particularly in children and young people who might be difficult to engage (such as those from the looked-after care system).

The GDG also noted a few important differences between the diagnosis of bipolar disorder in adults and in children/young people (namely, that mania must be present, as should euphoria most days and for most of the time, but that irritability is not a core diagnostic criterion); failing to appreciate these differences might have contributed to the historical over-diagnosis of the condition in this population.

5.5.3. Trade-off between net health benefits and resource use

The GDG considered evidence from the US indicating that the MDQ may be cost-saving in adults presenting for the first time with symptoms of major depression in primary care. It also took into account the substantial costs associated with delayed diagnosis and management of unrecognised and/or misdiagnosed bipolar disorder, resulting from overuse of antidepressants and underuse of potentially effective medications. The GDG recognised that early diagnosis of bipolar disorder offers a benefit to the service users who receive appropriate treatment for their condition, and may also result in a considerable reduction in healthcare resource use. Regarding assessment, the GDG acknowledged that appropriate assessment of people with bipolar disorder enables them to receive suitable treatment according to their needs, thus ensuring efficient use of available healthcare resources.

5.5.4. Quality of the evidence

For case identification instruments, overall, the studies were assessed as having a low risk of bias. No formal evaluations were identified that examined the structure and content of the overall clinical assessment process for people with possible bipolar disorder.

5.6. Recommendations

5.6.1. Clinical practice recommendations

Recognising and managing bipolar disorder in adults in primary care

Recognising bipolar disorder in primary care and referral

5.6.1.1.: When adults present in primary care with depression, ask about previous periods of overactivity or disinhibited behaviour. If the overactivity or disinhibited behaviour lasted for 4 days or more, consider referral for a specialist mental health assessment.
5.6.1.2.: Refer people urgently for a specialist mental health assessment if mania or severe depression is suspected or they are a danger to themselves or others.
5.6.1.3.: Do not use questionnaires in primary care to identify bipolar disorder in adults.

Assessing suspected bipolar disorder in adults in secondary care

5.6.1.4.

Assessment of suspected bipolar disorder, and subsequent management, should be conducted in a service that can:

offer the full range of pharmacological, psychological, social, occupational and educational interventions for people with bipolar disorder consistent with this guideline
be competent to provide all interventions offered
place emphasis on engagement as well as risk management
provide treatment and care in the least restrictive and stigmatising environment possible, and in an atmosphere of hope and optimism in line with the NICE clinical guidance on Service User Experience in Adult Mental Health.

This might be an early intervention in psychosis service, a specialist bipolar disorder team, or a specialist integrated community-based team.

5.6.1.5.

When assessing suspected bipolar disorder:

undertake a full psychiatric assessment, documenting a detailed history of mood, episodes of overactivity and disinhibition or other episodic and sustained changes in behaviour, symptoms between episodes, triggers to previous episodes and patterns of relapse, and family history
assess the development and changing nature of the mood disorder and associated clinical problems throughout the person’s life (for example, early childhood trauma, developmental disorder or cognitive dysfunction in later life)
assess social and personal functioning and current psychosocial stressors
assess for potential mental and physical comorbidities
assess the person’s physical health and review medication and side effects, including weight gain
discuss treatment history and identify interventions that have been effective or ineffective in the past
encourage people to invite a family member or carer to give a corroborative history
discuss possible factors associated with changes in mood, including relationships, psychosocial factors and lifestyle changes
identify personal recovery goals.

5.6.1.6.

Take into account the possibility of differential diagnoses including schizophrenia spectrum disorders, personality disorders, drug misuse, alcohol-use disorders, attention deficit hyperactivity disorder and underlying physical disorders such as hypo- or hyperthyroidism.

5.6.1.7.

If bipolar disorder is diagnosed, develop a care plan in collaboration with the person with bipolar disorder based on the assessment carried out in 5.6.1.5, as soon as possible after assessment and, depending on their needs, using the care programme approach. Give the person and their GP a copy of the plan, and encourage the person to share it with their carers¹⁴.

5.6.1.8.

Carry out a risk assessment in conjunction with the person with bipolar disorder, and their carer if possible, focusing on areas that are likely to present possible danger or harm, such as self-neglect, self-harm, suicidal thoughts and intent, risks to others, including family members, driving, spending money excessively, financial or sexual exploitation, disruption in family and love relationships, disinhibited and sexualised behaviour, and risks of sexually transmitted diseases. For the management of risk, follow the recommendations 5.6.1.26, 6.6.1.21 and 6.6.1.22.

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

Improving the experience of care

5.6.1.9.

Use this guideline in conjunction with the NICE clinical guidance On Service User Experience in Adult Mental Health to improve the experience of care for adults with bipolar disorder using mental health services, and for adults, children and young people:

promote a positive recovery message from the point of diagnosis and throughout care
build supportive and empathic relationships as an essential part of care.

Treatment and support for specific populations

5.6.1.10.: Follow the recommendations in race, culture and ethnicity in the NICE clinical guideline on psychosis and schizophrenia in adults when working with people with bipolar disorder from black, Asian and minority ethnic groups.
5.6.1.11.: See the NICE clinical guideline on antenatal and postnatal mental health for guidance on the management of bipolar disorder during pregnancy and the postnatal period and in women and girls of childbearing potential.
5.6.1.12.: Ensure that people with bipolar disorder and a coexisting learning disability are offered the same range of treatments and services as other people with bipolar disorder.
5.6.1.13.: Ensure that older people with bipolar disorder are offered the same range of treatments and services as younger people with bipolar disorder.
5.6.1.14.: Offer people with bipolar disorder and coexisting disorders, such as personality disorder, attention deficit hyperactivity disorder, anxiety disorders or substance misuse, treatment in line with the relevant NICE clinical guideline, in addition to their treatment for bipolar disorder. See the NICE clinical guidelines on antisocial personality disorder, attention deficit hyperactivity disorder, borderline personality disorder, generalised anxiety disorder and psychosis with coexisting substance misuse, and be alert to the potential for drug interactions and use clinical judgement.
5.6.1.15.: Offer people with rapid cycling bipolar disorder the same interventions as people with other types of bipolar disorder because there is currently no strong evidence to suggest that people with rapid cycling bipolar disorder should be treated differently.

Information and support

5.6.1.16.: Consider identifying and offering assistance with education, financial and employment problems that may result from the behaviour associated with bipolar disorder, such as mania and hypomania. If the person with bipolar disorder agrees, this could include talking directly with education staff, creditors and employers about bipolar disorder and its possible effects, and how the person can be supported.
5.6.1.17.: Encourage people with bipolar disorder to develop advance statements while their condition is stable, in collaboration with their carers if possible.
5.6.1.18.: Explain and discuss making a lasting power of attorney with adults with bipolar disorder and their carers if there are financial problems resulting from mania or hypomania.

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

Recognition and referral

5.6.1.19.

Do not use questionnaires in primary care to identify bipolar disorder in children or young people.

5.6.1.20.

If bipolar disorder is suspected in primary care in children or young people aged under 14 years, refer them to child and adolescent mental health services (CAMHS).

5.6.1.21.

If bipolar disorder is suspected in primary care in young people aged 14 years or over, refer them to a specialist early intervention in psychosis service or a CAMHS team with expertise in the assessment and management of bipolar disorder in line with the recommendations in this guideline. The service should be multidisciplinary and have:

engagement or assertive outreach approaches
family involvement and family intervention
access to structured psychological interventions and psychologically informed care
vocational and educational interventions
access to pharmacological interventions
professionals who are trained and competent in working with young people with bipolar disorder.

Diagnosis and assessment

5.6.1.22.

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.

5.6.1.23.

When diagnosing bipolar disorder in children or young people take account of the following:

mania must be present
euphoria must be present on most days and for most of the time, for at least 7 days
irritability is not a core diagnostic criterion.

5.6.1.24.

Do not make a diagnosis of bipolar disorder in children or young people on the basis of depression with a family history of bipolar disorder but follow them up.

5.6.1.25.

When assessing suspected bipolar disorder in children or young people, follow recommendations 5.6.1.5-5.6.1.7 for adults, but involve parents or carers routinely and take into account the child or young person’s educational and social functioning.

Managing crisis, risk and behaviour that challenges in adults with bipolar disorder in secondary care

5.6.1.26.

Develop a risk management plan jointly with the person, and their carer if possible, covering:

identifiable personal, social, occupational, or environmental triggers and early warning signs and symptoms of relapse
a protocol for applying the person’s own coping strategies and increasing doses of medication or taking additional medication (which may be given to the person in advance) for people at risk of onset of mania or for whom early warning signs and symptoms can be identified
agreements between primary and secondary care about how to respond to an increase in risk or concern about possible risk
information about who to contact if the person with bipolar disorder and, if appropriate, their carer, is concerned or in a crisis, including the names of healthcare professionals in primary and secondary care who can be contacted.

Give the person and their GP a copy of the plan, and encourage the person to share it with their carers.

Footnotes

13: Here and elsewhere in the guideline, each study considered for review is referred to by a study ID in capital letters (primary author and date of study publication, except where a study is in press or only submitted for publication, then a date is not used).
14: Adapted from Psychosis and schizophrenia in adults (NICE clinical guideline 178).

All rights reserved. No part of this guideline may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, or in any information storage or retrieval system, without permission in writing from the National Collaborating Centre for Mental Health. Enquiries in this regard should be directed to the Centre Administrator: ku.ca.hcyspcr@nimdAHMCCN

Bookshelf ID: NBK545963

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