Bipolar disorder: mood episodes, diagnosis and long-term treatment

The NHS describes bipolar disorder as a condition whose main symptom is extreme changes to mood: sometimes high moods (mania or hypomania), sometimes low moods (depression). These usually last a few days or weeks at a time, with stable periods between. NICE guideline CG185 covers children, young people and adults, and applies to bipolar I, bipolar II, mixed affective and rapid cycling disorders.

The NHS says highs can be severe (mania) or mild (hypomania). Symptoms include feeling very happy and excited or very irritable or aggressive, having lots of energy or needing little sleep, racing thoughts or poor concentration, speaking fast, a high sex drive, being overly confident, impulsive or extravagant, for example spending lots of money, saying or doing things that are rude or unusual for you, and in some people hallucinations, delusions or paranoia.

Low episodes, as the NHS describes them, include feeling sad or upset, loss of interest in usual activities, low energy, sleeping too little or too much, eating too much or too little, low confidence, feeling worthless or hopeless, difficulty concentrating, avoiding other people and having suicidal thoughts or thoughts of harming yourself. If you are thinking of harming yourself, contact NHS 111 or your mental health team urgently, and call 999 if you are in immediate danger.

The NHS says it is not known exactly what causes bipolar disorder. Factors that increase the chance of it include childhood trauma or abuse, a stressful event such as relationship problems, abuse, the death of someone close or money problems, recreational drugs such as cannabis or cocaine, and a parasite called toxoplasma gondii. It notes that episodes can be triggered by stress, too little sleep or being too busy.

The NHS says a GP who suspects bipolar disorder will refer you to a psychiatrist, who asks about moods, behaviour, health and family history, and that diagnosis can take time because it affects everyone differently and symptoms resemble other conditions. NICE says that when an adult presents in primary care with depression, the GP should ask about previous periods of overactivity or disinhibited behaviour; if it lasted 4 days or more, specialist assessment should be considered. It advises urgent specialist assessment if mania or severe depression is suspected or the person is a danger to themselves or others, and says not to use questionnaires in primary care to identify bipolar disorder.

NICE says a full psychiatric assessment should document mood history, episodes of overactivity, symptoms between episodes, triggers, patterns of relapse and family history.

The NHS says treatment is built around medicines to stabilise moods and talking therapy such as CBT, planned with a mental health specialist. Some medicines are taken all the time and others only when symptoms worsen; all can cause side effects, which vary by medicine. Some bipolar medicines are not safe in pregnancy, so tell your doctor if you are pregnant or planning a pregnancy.

NICE says people with bipolar depression should be offered a psychological intervention developed specifically for bipolar disorder, or a choice of CBT, interpersonal therapy or behavioural couples therapy. It says lithium and valproate should not be started in primary care, and that valproate is subject to MHRA safety measures: it should not be started for the first time in people under 55 unless two specialists independently agree there is no other effective and tolerated treatment, and in women and girls able to have children only if other options are not effective or tolerated and the risks, including to an unborn child, have been fully discussed.

For preventing relapse, NICE recommends a structured psychological intervention designed for bipolar disorder, with self-monitoring of mood, thoughts and behaviour and plans for relapse management. NICE says a risk management plan should cover triggers, early warning signs and a protocol for coping strategies and medicine adjustments. The NHS advises a regular routine, plenty of sleep, a healthy diet, regular exercise and managing stress, and advises avoiding recreational drugs, smoking, heavy drinking, shift work or very long hours where possible, night flights or flying across time zones, and lots of caffeinated drinks.

NICE says physical health should be monitored at least annually in primary care, including weight or BMI, diet and physical activity, pulse and blood pressure, fasting glucose or HbA1c and lipids, and for people taking long-term lithium, kidney and thyroid function and calcium levels, with liver function also included. It says treatment and care, including medication, should be reviewed at least annually and more often if concerns arise.

NICE says carers should be offered written and verbal information, and a carer-focused education and support programme. It also says clinicians should consider helping with education, financial and employment problems that result from mania or hypomania, and discuss lasting power of attorney when finances are affected. The NHS names Bipolar UK, Mind and Rethink Mental Illness for information and peer support. If doctors are worried about risk of self-harm, suicide or harm to someone else, the NHS says a stay in hospital or support from a crisis team at home may be needed.

NHS care involves a GP and a community mental health team, with crisis services when needed. A private psychiatrist can offer faster assessment, but the same principles apply: a diagnosis should rest on a full history over time, medicine decisions should be shared and monitored with the blood tests above, and your GP should be informed so the annual physical checks continue.