Psychosis in bipolar disorder: symptoms, causes and treatment in the UK

Bipolar disorder is a mental health condition in which mood swings between very high states (mania or milder hypomania) and low states (depression), with stable periods in between. The NHS describes the main symptom as extreme changes in mood. NICE Clinical Knowledge Summaries add that a manic episode is one that is severe enough to cause marked impairment in everyday functioning, or to need hospital admission, or that includes psychotic features.

Psychosis is a term for losing some contact with reality. The NHS explains that this may involve seeing or hearing things other people cannot (hallucinations), believing things that are not true (delusions), and confused or disordered thinking and speech. In bipolar disorder these experiences usually appear when mood is at one of its extremes, and they tend to ease as the mood episode is treated and settles.

Having psychotic symptoms does not mean someone has schizophrenia, and it does not mean the bipolar diagnosis is wrong. The NHS lists bipolar disorder, schizophrenia and severe depression as separate conditions that can each lead to psychosis. A specialist assessment looks at the whole pattern of mood and symptoms over time before a diagnosis is made.

During a high mood episode the NHS lists feeling very happy and excited, being very irritable, having a lot of energy and not needing much sleep, racing thoughts, speaking fast, being impulsive or extravagant, and in some people hearing things that are not real, believing things that are not true or feeling paranoid. Rethink gives examples of how psychotic beliefs often follow the mood: believing you have special powers or are being monitored by the government in mania, or feeling very guilty or worse than everyone else in depression.

It can be hard for the person themselves to see what is happening. NHS inform notes that during a psychotic episode most people do not realise they are ill, and that friends and family may not understand why the person is reacting so strongly to things they cannot see or hear. That is why relatives and close friends often notice first.

• Hearing voices or sounds that other people cannot hear, or seeing, feeling, smelling or tasting things that are not there.

• Strong beliefs that are not shared by others, such as being followed, being specially chosen or being under surveillance.

• Thoughts and speech that come very fast and are hard for others to follow.

• Very little need for sleep, high energy and risky or out-of-character behaviour alongside the above.

• In the low phase, intense guilt, worthlessness or hopelessness, sometimes with thoughts of suicide or self-harm.

The NHS advises seeing a GP immediately if you are experiencing symptoms of psychosis. If you are worried about someone else, you can contact a GP on their behalf or, if they already have a mental health worker or team, contact that team. Where a person has been under a home treatment or crisis resolution team before, the NHS suggests trying to contact them first.

If symptoms are severe enough to need urgent treatment and could place the person at risk, the NHS says you can take them to the nearest A&E if they agree, call their GP or the out-of-hours GP service, or call 999 and ask for an ambulance. NHS 111 can advise if you do not have a crisis team number. If someone is thinking about ending their life, the NHS says to call 999 or go to A&E, and the Samaritans offer free support at any time.

The NHS also states that you should not drive during an episode of psychosis and that it is a legal obligation to tell the DVLA about any medical condition that could affect your driving. Rethink gives the same message for severe depression, hypomania, mania or psychosis in bipolar disorder.

The NHS says it is not known exactly what causes bipolar disorder. You are more likely to have it if a parent, brother or sister has it. Rethink puts the chance for someone with a close relative with bipolar disorder at 13 in 100, and says the risk is higher if both parents or a twin have the condition.

Episodes, including psychotic ones, can be set off by things such as childhood trauma, stressful events, relationship problems, bereavement or money worries, and by recreational drugs such as cannabis or cocaine, according to the NHS. Poor sleep and being too busy are also listed by the NHS as triggers for mood changes. For general psychosis the NHS adds physical conditions, head injury, childbirth and side effects of some prescribed medicines as possible contributors, which is one reason doctors ask about medicines and substance use at the first assessment.

There is no single test that confirms psychosis. The NHS explains that a GP will ask about symptoms, medicines, alcohol and drug use, mood, day-to-day functioning, family history and any thoughts of self-harm. Because the evidence supports early treatment, a referral to a specialist is likely to be urgent.

Depending on the situation the referral may go to a community mental health team, a crisis resolution team or, for a first episode, an early intervention team. Rethink says that if you may be having an episode of psychosis for the first time, your GP should refer you to your local NHS early intervention team. A psychiatrist then carries out a full assessment of mood, behaviour, physical health and family history. NICE Clinical Knowledge Summaries say that anyone with suspected bipolar disorder should be referred for specialist assessment and that a risk assessment determines how urgent that referral is, with urgent admission arranged if a person is a danger to themselves or others.

The NHS notes that bipolar disorder can take time to diagnose because it affects everyone differently and the symptoms resemble other mental health conditions. Keeping a record of mood and sleep, and bringing someone who has seen the symptoms, can help the assessment.

Treatment for psychosis in bipolar disorder combines treating the mood episode and the psychotic symptoms. Rethink summarises the NICE approach for mania as offering a mood-stabilising medicine, usually starting with an antipsychotic; the antipsychotics it names for bipolar disorder are haloperidol, olanzapine, quetiapine and risperidone. If the first does not work, a different antipsychotic may be tried, then lithium alongside it, and then sodium valproate. Sodium valproate should not be taken by people who can get pregnant, because of the risk of developmental disorder or birth defects, and Rethink says people assigned male at birth should use contraception when taking it.

Rethink describes bipolar disorder as a long-term, often recurring condition, and says lithium usually works better than other medicines for long-term treatment. Your team should offer physical health checks at least once a year, a psychological therapy designed for bipolar disorder, and support to write a recovery plan that lists early warning signs, triggers and who to call.

The NHS suggests a regular routine, plenty of sleep, regular exercise and managing stress, and avoiding recreational drugs, smoking, heavy drinking, very long working hours and shift work where you can. Rethink says you can also make an advance statement describing how you would want to be treated if you ever lose capacity to make decisions. The NHS adds that people with a severe mental illness can have a physical check-up at their GP surgery once a year.

Charities including Bipolar UK, Mind and Rethink Mental Illness offer information and peer support groups for people affected and for carers, which the NHS points to alongside its own pages.

In the NHS, assessment and treatment for psychosis run through the GP, community mental health or early intervention teams and crisis services, and are free at the point of use. In an emergency the route is A&E, 999 or NHS 111 rather than waiting for a routine appointment.

Some people also see a private psychiatrist, mainly to shorten the wait for a first assessment or to seek a second opinion. The medicines and therapies are the same and a private psychiatrist will usually work with the GP and communicate with any NHS team. Rethink notes you do not have a right to a second opinion on the NHS but that a doctor should listen to your reasons for wanting one. Anyone at immediate risk should use the emergency routes described above.