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Bipolar Disorder Glos Care Pathway Overview

People with bipolar disorder experience episodes of extreme mood swings which range from mania to depression. These symptoms can be severe and are different from normal 'ups and downs' that many people go through day to day. Symptoms can impact severely upon an individual but with treatment people living with this illness can lead full and productive lives.

Symptoms can be difficult to spot on initial assessment. These symptoms may seem like separate problems which are not recognised as parts of a larger problem. People living with bipolar disorder may go years before they are properly diagnosed and treated. It is a long term illness that must be managed carefully and with proper diagnosis and treatment, the frequency and severity of episodes can be managed effectively.

The following pathway clarifies care and interventions throughout a patients pathway from assessment; initial management; treatments and medication.

Please click the relevant flowchart box to be taken directly to textual information.

                                

Red Flags
Urgent concern (if the patient) or partner/carer/parent reports that the patient:
  • is considered to be an immediate risk to themselves or others
  • is actively suicidal, has a current suicide plan, is at risk of self-harm
  • has psychotic symptoms, e.g. hallucinations, delusions
  • has severe agitation accompanying severe symptoms
  • presents with severe self-neglect
  • is pregnant or has recently given birth- please see Perinatal Mental Health pathway
  • has deteriorating personal circumstances exacerbating their mental illness

If any urgent concern consider GP led pharmacological intervention, discussion and referral. Referrer Information for Mental Health Services - Gloucestershire including the Contact Centre, Mental Health Acute Response Service (formerly Crisis Resolution and Home Treatment Teams) can be found here.

2gether- A Guide to Suicide Risk Assessment and Management in Primary Care can be found here

Presentation
  • bipolar disorder is characterised by recurrent episodes of elevated or irritable mood and depression, accompanied by changes in sleep and energy and associated with cognitive, physical, and behavioural symptoms.
  • bipolar I disorder is characterised by at least 1 episode of mania.
  • bipolar II disorder is characterised by history of major depressive episodes and hypomanic episodes only (not mania).
  • rapid cycling is 4 or more episodes of mania, hypomania, or depression over a period of 12 months with at least 2 months of partial or complete remission or a switch to episode of opposite polarity (such as major depressive episode to manic episode).
  • heritability is high and may share susceptibility genes and inheritance patterns with schizophrenia and major depressive disorder.
  • life events and chronic stress may precipitate and perpetuate mood episodes.
  • comorbid psychiatric disorders are common, especially generalised anxiety disorder, impulse control disorders, attention deficit hyperactivity disorders, and substance abuse

  • expansive, grandiose affect and inflated self-esteem
  • increased talkativeness
  • decreased need for sleep
  • increase in impulsive risk taking behaviour

  • milder version of mania that lasts for a short period (a few days)
  • happy, euphoric, with a sense of wellbeing
  • creative and full of ideas and plans
  • finding it difficult to sit still
  • more active than usual

  • depressed mood and profound loss of interest in activities
  • feelings of worthlessness and suicidal ideation
  • weight change

Bipolar should not be confused with mood instability.

The Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-V) provides diagnostic criteria for biploar disorder.

Differential Diagnosis

Other causes for manic or depressive symptoms include;

  • substance abuse (drugs, alcohol)
  • thyroid disorder
  • neurological disease
  • dementia (agitation, confusion)
  • metabolic disturbance (i.e. endocrine disturbances)
  • mood instability
  • physical symptoms

If a patient is psychotic please consider Gloucestershire Recovery in Psychosis (GRiP)

Comorbidity is common amongst bipolar patients. Regardless of the comorbidities that may exist the bipolar should be addressed and treated seperately.

Initial Primary Care Assessment

  • respectful probing and reflective listening
    • help the patient feel understood and valued
    • promote optimism and motivation while assessment, diagnosis, and strategies are negotiated and actioned
    • this in itself is therapeautic

Take a full psychiatric history including:

  • history of self-harm
  • history of suicide attempt/s
  • history of early childhood attachment
  • history of abuse/trauma
  • past history of mania or hypomania or mixed episodes
  • response to any treatment for depression in the past

It may also be useful to ask the patients partner/carer/parents for more information with their consent.

Enquire into past medical history.

Consider asking the following:

  • do you currently, or have you in the past, experienced mood that was higher than normal?
  • at the same time did you have an increase in your energy levels so that you were much more active or did not need as much sleep?
  • are you pregnant or just had a baby?
  • are you engaging in out of character impulsive risky behaviours e.g. spending lots of money, sexual promiscuity, alcohol/drug misuse?

Yes to any questions should prompt further evaluation. According to NICE guidance, questionnaires should not be used in Primary Care.

When to Refer

Refer all suspected cases for a specialist mental health assessment/ diagnostic confirmation if patient has experienced overactivity or disinhibited behaviour lasting four days or more. Refer urgently if they are a danger to themselves or others. Do not start selective serotonin re-uptake inhibitors (SSRI's) in the depressed phase as they are ineffective, and may be harmful. NICE also says do not start lithium, valproate, gabapentin or topirmate in Primary Care to treat bipolar disorder.

Consider talking to the Mental Health Intermediate Care (MH ICT) nurse for further advice/ assessment/ support and local services

Contact details and referral advice for the Contact Centre, Mental Health Acute Response Service (MHARS) (formerly Crisis Resolution and Home Treatment Teams) and other mental health services that accept direct referral are available here.

Ongoing Primary Care

Provide advice/refer/signpost patients to any of the following self-management services;

Consider referral to signpost patient to Change, Grow, Live, Gloucestershire's Community Drug & Alcohol Recovery Service

  • Substance misuse is in itself not an exclusion to other work, but it will likely impair it, so this may be the first step

Practice Point

The Contact Centre may be contacted for advice at any stage:
Tel: 0800 015 1499
Email: 2gnft.FPCC-Admin@nhs.net
Address: Tri Service Centre, Waterwells Police HQ, Waterwells Drive, Gloucester, GL2 2BP.

The Gloucestershire Council Social Care Helpdesk may also be contact for support:
Tel: 01452 426868
Email: socialcare.enq@gloucestershire.gov.uk

If bipolar disorder is managed solely in primary care, re-refer to secondary care if any one of the following applies:

  • there is a poor or partial response to treatment
  • the person's functioning declines significantly
  • treatment adherence is poor
  • the person develops intolerable or medically important side effects from medication
  • comorbid alcohol or drug misuse is suspected
  • the person is considering stopping any medication after a period of relatively stable mood
  • a woman with bipolar disorder is pregnant or planning a pregnancy
Notification of Serious Untoward Incidents (SUIs)

Recent reviews of serious incidents have identified potential system and process changes which could improve the quality and responsiveness of care for people who require secondary care mental health services.

It would be helpful if GPs could please share any information in relation to substance misuse with GHC, particularly when a patient is injecting, as this aids clinical risk assessment and management. It is also really helpful if referrals into mental health services contain an appropriate risk assessment.

In all instances when a patient dies unexpectedly, especially if the cause of death is suspected suicide, GPs should inform GHC as soon as possible. This will allow GHC to quickly put in place support for those bereaved and minimise the risk of appointment letters etc. being sent to the deceased.

Contact: gordonbenson@nhs.net (Assistant Director of Governance & Compliance, GHCNHSFT)

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