Bipolar disorder in children and young people: signs, diagnosis and treatment in the UK

The NHS describes bipolar disorder as a mental health condition where you have extreme mood changes, with high moods (mania or hypomania) and low moods (depression) that usually last a few days or weeks at a time, with stable periods in between. The same pattern applies to children and young people, but it can look different and is harder to recognise.

NICE guideline CG185 covers recognising, assessing and treating bipolar disorder in children, young people and adults. In its definitions, children are people aged 12 and under and young people are those aged 13 to 17. The guideline treats bipolar disorder in this age group as a distinct clinical problem because it is easy to confuse with other conditions that are far more common in childhood, and for that reason it sets stricter rules for diagnosis than for adults.

Ordinary childhood and teenage behaviour includes mood swings, irritability and big emotions. These are very common and are usually not bipolar disorder. The pattern that points to it is a distinct episode, lasting days, where mood and energy are clearly elevated and out of character.

The NHS lists the symptoms of high mood in bipolar disorder as feeling very happy and excited, feeling very irritable, having a lot of energy or not needing much sleep, racing thoughts, speaking fast, feeling overly confident, being impulsive and sometimes hearing or believing things that are not real. Low mood symptoms include feeling sad or hopeless, losing interest in things, low energy, sleeping or eating too much or too little, difficulty concentrating, withdrawing from people and thoughts of suicide or self-harm.

In a young person, signs that deserve a specialist assessment include several days of unusually high energy with much less need for sleep, extreme excitement or grandiose ideas that are out of character, rapid speech and racing thoughts, risky behaviour and then episodes of low mood. NICE is explicit that irritability on its own is not a core diagnostic criterion, because irritability is a feature of many childhood problems.

If a child or young person talks about suicide or self-harm, seems to have lost touch with reality, is not sleeping and is behaving dangerously, or you are worried about their immediate safety, do not wait for an appointment. The NHS directs people to find urgent help for mental health through NHS 111 and the mental health crisis pathway in their area, and to call 999 or go to A&E if there is an immediate risk to life.

For a worry that is not an emergency, see a GP. NICE says that suspected bipolar disorder in primary care should be referred rather than managed by the GP alone.

NICE sets out several safeguards. Questionnaires should not be used in primary care to identify bipolar disorder in children and young people. If it is suspected in a child under 14, the GP should refer to child and adolescent mental health services (CAMHS). For young people aged 14 or over, referral should go to a specialist early intervention in psychosis service or a CAMHS team with expertise in the assessment and management of bipolar disorder.

Diagnosis should be made only after a period of intensive, prospective longitudinal monitoring by a team trained and experienced in this age group, in collaboration with parents or carers. NICE says that mania must be present, with euphoria present on most days and for most of the time for at least 7 days, and that a diagnosis should not be made on the basis of depression with a family history of bipolar disorder, although such young people should be followed up. Assessment routinely involves parents or carers and takes account of educational and social functioning.

The NHS notes that bipolar disorder can take time to diagnose because it affects everyone differently and the symptoms are similar to those of other mental health conditions.

NICE asks teams to take into account a young person's cognitive ability, emotional maturity, developmental level, capacity to consent, the severity of the disorder and risk of suicide or self-harm. For bipolar depression it recommends a structured psychological intervention, individual cognitive behavioural therapy or interpersonal therapy, lasting at least 3 months, with a multidisciplinary review if there is no or limited response after 4 to 6 weeks.

For mania, NICE notes that aripiprazole is recommended as an option for moderate to severe manic episodes in young people with bipolar I disorder, and advises not to routinely continue antipsychotic treatment for longer than 12 weeks. It says valproate should not be offered to young people unless there is no other effective and tolerated treatment, following MHRA safety measures, and that some recommended treatments may be off-label in young people.

In the longer term, a structured individual or family psychological intervention may be considered. As the NHS stresses for bipolar disorder in general, it cannot be cured but treatment helps manage it, and medicines should not be stopped unless a doctor advises it.

Regular routines, enough sleep, a healthy diet and exercise, and avoiding recreational drugs and too much caffeine are among the things the NHS says can help keep moods stable. Sleep disruption is a common trigger for episodes, so protecting sleep at the weekend and during exams matters.

School and college need to know enough to make adjustments. Families can ask the CAMHS team about education support and can find advice and peer support from charities such as Bipolar UK, Mind and Rethink Mental Illness, which the NHS names as sources of information for people affected by bipolar disorder and their carers.

In the NHS, assessment and treatment are usually through CAMHS or an early intervention service following GP referral, and NICE emphasises that the diagnosis needs a team with specific experience. Private child and adolescent psychiatrists can provide assessment and second opinions, but monitoring over time, school liaison and any prescribing under shared care are usually coordinated with the local CAMHS team, so it is worth keeping the GP and NHS team informed.