1. Bipolar disorder July 2006

2. 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

3. 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

4. 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

5. PresentationKey features ManiaElevated, expansive or irritable mood With or without psychotic symptoms Marked impairment in functioning HypomaniaElevated, expansive or irritable mood No psychotic symptoms Less impairment of functioning DepressionMild, moderate or severe With or without psychotic symptoms Rapid cyclingAt least four episodes in 1 year Mixed statesManic and depressive features present during same episode Look for key features

6. Incidence and prevalence Annual incidence 7 per 100,000 Estimated lifetime prevalence – bipolar I 4–16 per 1000 Peak onset between 15 and 19 years of age Suicide bipolar I – 17% attempt suicide bipolar disorder – 0.4% die annually by suicide

7. 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)

8. What this guideline covers Diagnosis 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

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. Take possible pregnancy into account Valproate should not be used routinely for women who may become pregnant. It may: cause foetal abnormalities affect the childs 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

24. 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

25. 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

26. 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

27. 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

28. Establish review systems Agree responsibility locally Establish monitoring and early warning systems Develop systems for responsibility and intervention Communicate results Follow up non attendance

29. 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

30. Costs and savings RecommendationCost £m Pharmacological management of women of child-bearing potential 3.6 Psychological management20.8 Weight management3.6 Annual review of physical health3.4 Estimated saving achieved through increased psychological management -11.4 National cost impact20.1

31. Access tools online Costing tools costing report costing template Implementation advice Available from: www.nice.org.uk/CG038

32. 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