Dr Ewa Wisniewska Young (left), Professor Nicol Ferrier and Dr Peter Young explain how the new NICE guideline encourages better communication between primary and secondary care


 

   

In July 2006 NICE published a guideline on the management of bipolar disorder.1 This guideline aims to improve long-term outcomes by increasing recognition of bipolar disorder, and improving management where it is currently suboptimal.

NICE commissioned the National Collaborating Centre for Mental Health to develop this guideline. It is the first time NICE has reviewed this topic, although it did carry out a technology appraisal on drugs for bipolar disorder in 2003.2 The guideline is based on the guideline development group's (GDG) analysis of the best available evidence, and takes cost-effectiveness information into account where possible.

The GDG acknowledged that there has been an increase in the research of bipolar disorder over the past decade, however, they also emphasized the paucity of data in a number of areas (notably the management of bipolar depression), and the lack of long-term studies in naturalistic settings.

Despite these shortcomings, the guideline makes recommendations covering all aspects of the care of bipolar disorder, but it should be noted when reading it that the strength of the evidence varies, and according to the new policy of NICE, the degree of certainty (previously denoted by the A, B, C, etc. system) is no longer included (see www.nice.org.uk for more details).

Background to bipolar disorder

The management of bipolar disorder should be shared between primary care and secondary psychiatric services. Although much of the guideline is targeted at secondary services, primary care guidance is also included. Care should be patient-centred, taking into account individual needs and preferences. Carers and relatives should have the opportunity to be involved in decisions, unless their involvement is specifically excluded by the patient.

Bipolar disorder is potentially a lifelong illness characterized by episodes of depression and at least one manic or hypomanic episode.1 The key features of the condition are outlined in Table 1. Bipolar disorder can be categorized as type I or type II:

  • bipolar I – occurence of at least one manic episode or mixed episode (with or without depressive episodes) is required for diagnosis3
  • bipolar II – in which episodes of both depression and hypomania, but no evidence of mania, are required for diagnosis.

There is less evidence on treatments for bipolar II disorder than for bipolar I. Therefore, healthcare professionals should be cautious about applying the recommendations for treating bipolar I disorder to treating bipolar II disorder, except where specific recommendations for the treatment of bipolar II disorder have been made. There are also significant limitations to the evidence base for patients under 18 years of age and older adults (greater than 65 years of age).

Bipolar disorder is equally common in both sexes,4and the estimated lifetime prevalence for bipolar I disorder is 4–16 individuals per 1000.4 The first episode may occur at any age; however, in children, it is rare before puberty and is most common in the late teens.6 A diagnosis of bipolar disorder is usually made in the patient's twenties.7

New diagnoses of bipolar disorder are rare in old age,6 and if older patients present with symptoms suggestive of new onset bipolar disorder, possible organic causes should be excluded before the diagnosis is made.

Manic episodes usually begin abruptly, and last for between 2 weeks and 4–5 months. Depressive episodes tend to last longer, and have a median duration of about 6 months. Recovery may not be complete between episodes.1 Depressive episodes generally become more common and longer lasting as the illness progresses, and periods of remission tend to get shorter over time. Patients with bipolar disorder have a significantly increased risk of suicide – the suicide rate among patients with bipolar disorder is 10–15%.1

Table 1: Key features of bipolar disorder *
Presentation
Key features
Mania



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 in functioning
Depression


Mild, moderate or severe
With or without psychotic symptoms
Rapid cycling
At least four episodes in 1 years
Mixed state
Manic and depressive features present during same episode

*see www.nice.org.uk/page/aspx?o=345028
Reproduced by kind permission of the National Institute for Health and Care Excellence

Assessment, recognition and diagnosis

For patients already diagnosed with bipolar disorder who do not have secondary care follow-up, i.e. those managed solely in primary care, NICE recommends referral in the following circumstances:

  • refer urgently if there is an acute exacerbation of symptoms, or an increase in the risk, or change in nature of risk, to self or others
  • consider review in secondary care or increased contact in primary care if there is a significant decline in function, poor treatment adherence, suspected alcohol or drug misuse, or the patient wishes to stop prophylactic medication
  • consider referral to secondary care for any new patients who register and have existing bipolar disorder.

Patients with new or suspected bipolar disorder should be referred to secondary care for a specialist mental health assessment and development of a care plan. Patients with periods of overactive, disinhibited behaviour lasting at least 4 days, with or without periods of depression, and patients with a history of three or more recurrent depressive episodes, and a history of overactive disinhibited behaviour, should be referred.

Primary care clinicians should ask about hypomanic symptoms when assessing a patient with depression. An urgent referral should be made for patients with mania or severe depression who are a danger to themselves or others.

A risk assessment should be undertaken when:

  • bipolar disorder is first diagnosed
  • there is a significant change in mental state or personal circumstances
  • a patient with bipolar disorder is discharged, or on leave, from inpatient care.

NICE advocates the establishment of integrated care programmes that clearly define the roles of primary and secondary healthcare professionals in the management of people with bipolar disorder. For patients at risk of suicide, exploitation, severe neglect, risk to others, or who have a history of recurrent admissions, a specific crisis plan, developed in collaboration with the patient, should be drawn up as part of the care programme.1

Treatment

The medications licensed in the UK for the treatment of mania are lithium, olanzapine, quetiapine, risperidone, and valproate semisodium. These medications are usually initiated in secondary care. The choice of treatment for individual patients is guided by preferences for future prophylactic treatment and the side-effect profile. When a patient who is currently taking antidepressant medication presents to their GP with symptoms of hypomania or mania, the antidepressant should be stopped.

Patients with bipolar disorder who are suffering a depressive episode should be treated with antidepressant medication. Antidepressants should be avoided in patients with rapid cycling bipolar disorder, and those who have had a hypomanic episode or functionally impairing rapid mood fluctuations. There are risks of these patients switching from depression to mania when taking antidepressant medication, so an antimanic drug should be used at the same time.

Antidepressant treatment should be started at a low dose and increased gradually. When depressive symptoms have been significantly less, or in remission for 8 weeks, it is sensible to consider stopping the antidepressant by reducing the dose gradually.

Long-term antimanic treatment is generally required to reduce the occurrence of acute episodes. It is normally continued for at least 2 years. The medications currently recommended for this are lithium, olanzapine and valproate, although valproate is not recommended for treatment of women of child bearing potential.

Lithium requires close monitoring due to its potential toxicity. Serum lithium levels should be checked every 3 months (the desired level is 0.6–0.8 mmol/L), and creatinine, urea, and thyroid function should be checked every 6 months. Closer monitoring is needed if there is clinical deterioration, abnormal results, or initiation of angiotensin-converting enzyme inhibitors, non-steroidal antiinflammatory drugs or diuretics.

A shared-care protocol should be established between secondary care prescribers and the patient's GP for prescribing and monitoring of lithium. Lithium should not be stopped abruptly, unless due to urgent medical conditions, because of a significant risk of developing rebound mania.

Psychological therapy including psychoeducation, promotion of medication adherence, coping strategies, monitoring of mood, and detection of early warnings should be considered for those who are stable.

Annual review

People with bipolar disorder have higher levels of physical morbidity and mortality than the general population. NICE recommends an annual physical health review, normally in primary care, which should include the following:

  • blood pressure
  • weight
  • smoking status and alcohol use
  • lipid levels, including cholesterol, in all patients over 40
  • plasma glucose
  • thyroid function.

Patients who gain weight during treatment should have a review of their medication, and appropriate weight gain management.

Women of childbearing potential

Valproate should not be routinely prescribed to women of child bearing potential, and if it is prescribed, the woman should be using a reliable method of contraception.

The care of patients with bipolar disorder who are trying to conceive, are pregnant, or are in the post-natal period, is complex and needs special attention. The NICE guideline outlines a number of important issues that should be considered during this time including the potential teratogenicity of antimanic therapy and the increased risk of relapse during the puerperium.1

No psychotropic drug is specifically licensed for use during pregnancy or when breast feeding. If antimanic medication needs to be continued, antipsychotics are considered to be safer than lithium, valproate, carbamazepine, or lamotrigine.

Increased contact with specialist mental health services should be considered during this time, and a written plan for managing the woman's bipolar disorder should be developed and shared with her obstetrician, midwife, GP, and health visitor.

Children and adolescents

The diagnosis of bipolar disorder in children and adolescents is challenging because the current diagnostic criteria were developed for adults and have limitations when applied to younger people.1 Therefore, their assessment and management should be by a clinician with specialist training in child and adolescent mental health.

Lithium is the only medication licensed in the UK for use in bipolar disorder in children aged 12 years and over. Other medications may be used by specialist services. Medications should be started at lower doses than for adults, and closer monitoring is needed because children and adolescents may be more prone to adverse effects, including sedation, obesity, extrapyramidal symptoms, metabolic changes, and raised prolactin.

Summary

The recent NICE guideline on the management of bipolar disorder comprehensively outlines best practice in primary and secondary care for this relatively common illness.

It details the role of GPs and the importance of good communication between primary and secondary care. Guidance is given to improve recognition of bipolar disorder and accuracy of diagnosis.

Special consideration needs to be made when caring for women of childbearing potential, children and adolescents. Patients with bipolar disorder should have regular monitoring of their physical health.8

Implementation tools
NICE has developed the following tools to support implementation of its guideline on bipolar disorder in primary and secondary care.They are now available to download from the NICE website: www.nice.org.uk.
Implementation advice
The implementation advice document contains suggested actions for implementing the guideline. It aims to help implementers identify recommendations in the guideline that are not part of current practice and should be used alongside the costing report and template.
Slide set
The slides are aimed at supporting organizations to help implement the guideline recommendations at a local level. They do not try to cover all the recommendations from the guideline but contain key messages and should be used in conjunction with the quick reference guide.
Costing tools

National cost reports and local cost templates for the guideline have also been produced.

Costing reports are estimates of the national cost impact arising from implementation based on assumptions about current practice, and predictions of how it might change following implementation of the guideline.

Costing templates are spreadsheets that allow individual NHS organizations and local health economies to estimate the costs of implementation taking into account local variation from the national estimates and quickly assess the impact the guideline may have on local budgets.

 

Guidelines in Practice, November 2006, Volume 9( 11 )
© 2006 MGP Ltd
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  1. National Institute for Health and Care Excellence. Clinical guideline 38. Bipolar disorder: the management of bipolar disorder in adults, children and adolescents, in primary and secondary care. London: NICE, 2006.
  2. National Institute for Clinical Excellence. Technology appraisal 66. Olanzapine and valproate semisodium in the treatment of acute mania associated with bipolar I disorder. London: NICE, 2003.
  3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Washington, DC: American Psychiatric Association, 1994.
  4. World Health Organization. The ICD-10 Classification of Mental and Behavioural Disorders. Geneva: World Health Organization, 1992.
  5. www.nice.org.uk
  6. Bellivier F, Golmard J, Rietschel M et al. Age at onset in bipolar I affective disorder: further evidence for three subgroups. Am J Psychiatry 2003; 160 (5): 999–1001.
  7. ldessarini R, Tondo L, Hennen J. Treatment-latency and previous episodes: relationships to pretreatment morbidity and response to maintenance treatment in bipolar I and II disorders. Bipolar Disord 2003; 5 (3): 169–179.
  8. Kupfer D. The increasing medical burden in bipolar disorder. JAMA 2005: 293 (20): 2528–2530.