_ RCGP Learning

World Bipolar Day takes place every year on 30^th March and is organised by various international charity organisations, who support people with bipolar disorder. The aim of the awareness day is to inform people about bipolar disorder and to improve attitudes towards the condition by eliminating the social stigma around it¹. Bipolar disorder (previously known as manic depression) is a lifelong mental health condition, consisting of recurring episodes of depression and mania or hypomania². Whilst bipolar disorder is usually diagnosed in secondary care, patients are likely to present in primary care first. Therefore, it is important for GPs to be able to recognise the signs and symptoms in order to refer to secondary care for formal diagnosis.

The National Institute for Health and Care Excellence (NICE) estimate that the peak age of onset is 15-19 years old. As bipolar disorder can often be difficult to detect initially, there is usually a significant delay between onset and first contact with mental health services^3,4.

The Adult Psychiatric Morbidity Survey, conducted in 2014, found that 2% of the English population screened positive for bipolar spectrum disorders².

The elevated mood in bipolar may be hypomania or mania, the definitions of which are as follows⁶:

Mania – Abnormally and persistently elevated or irritable mood for a distinct period of at least one week (with or without psychotic symptoms).

Hypomania – Mild mood elevation with increased energy and irritability, that lasts for 4 or more continuous days.

Depressive symptoms are the most common initial presentation in primary care, which makes it difficult to recognise them as being part of bipolar disorder. Patients may present with symptoms such as depression, anxiety, mood swings, sleep disturbance, irritability, fatigue and difficulty in focus and concentration⁴. To make a distinction between depression and bipolar disorder, ask the patient about periods of elated, excited or irritable mood lasting four days or more. It is also recommended that GPs take a family history of mania and depression⁷.

Patients who have been diagnosed and treated in secondary care should return to primary care with a mutually agreed care plan in place. This includes their recovery goals, a crisis plan which indicates early warning symptoms of a relapse and what do in this instance, an assessment of their mental state, and a medication plan with a date for review³. Both the patient and their GP should have a copy of this plan so that the GP can begin monitoring their condition in primary care.

Following diagnosis and stabilisation, the primary care team’s role is to optimise physical health, check mental state and review the patient’s medication (as would happen in any chronic disease management). Unwell patients will need help from their mental health teams if destabilisation occurs which cannot be managed in primary care.

Medication

From the care plan provided, the GP should have all the details concerning the patient’s medication and when it should be reviewed. However, NICE states that the secondary care team should be responsible for monitoring the efficacy of the patient’s antipsychotic medication for at least the first 12 months, or until the patient’s condition has stabilised, whichever is longer³. Following this, the responsibility for this monitoring may transfer to primary care under shared-care agreements.

If the patient is on lithium, the psychiatry team should provide a target lithium level (typically 0.6-0.8 mmol/L, depending on the patient). It is recommended that GPs check the levels every three months and monitor and adjust accordingly⁷, but if the patient becomes unstable they should be referred back to secondary care, in line with local shared care guidelines. The NICE guideline on ‘Bipolar disorder: assessment and management’ includes more specific information about the different pharmacological options for bipolar disorder and their use.

Physical health checks

As well as monitoring medication, it is recommended that GPs perform a physical health check on patients with bipolar disorder at least annually. According to NICE, these checks should include³:

• Weight, BMI, diet and nutrition and levels of exercise
• Pulse and blood pressure
• Fasting blood glucose, glycosylated haemoglobin (HbA1c) and blood lipid profile
• Liver function
• Renal and thyroid function
• Calcium levels (for people taking long-term lithium)

It is estimated that the life expectancy for people living with severe mental illness is 15-20 years lower than the general population⁸. This statistic highlights the importance of carrying out the checks above and managing any potential comorbidities alongside treatment for bipolar disorder.

Support

As part of their regular reviews, GPs should provide holistic support to bipolar disorder patients and their families/carers. This includes preparing for major life events: for example, all patients planning a pregnancy or who have become pregnant should be immediately referred to the perinatal mental health service to advise the patient on the management of their medication in relation to their pregnancy. A good social history during visits will reveal important life changes that might be detrimental to the patient’s health such as changes in social or family situations or their general wellbeing⁴.  As well as building relationships with the patient and their families/carers, the GP can help carrying out the care plans from secondary care and help with recovery goals.

For more information about the diagnosis and management of bipolar disorder, RCGP members can access the following eLearning resources for free:

EKU15: Assessment & Management of Bipolar Disorder in Adults, Children & Young People

EKU13 (Briefing): Bipolar Disorder – Diagnosis & Current Treatment Options

References

¹ World Bipolar Day, 2019. About World Bipolar Day. [Online] Available at: http://www.worldbipolarday.org/about-wbd.html

² Marwaha S, Sal N, Bebbington P, 2016. ‘Chapter 9: Bipolar disorder’ in McManus S, Bebbington P, Jenkins R, Brugha T. (eds) Mental health and wellbeing in England: Adult Psychiatric Morbidity Survey 2014. Leeds: NHS Digital. Available at:

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/556596/apms-2014-full-rpt.pdf

³ NICE, 2014. Bipolar disorder: assessment and management (CG185). [Online] Available at: https://www.nice.org.uk/guidance/cg185/resources/bipolar-disorder-assessment-and-management-pdf-35109814379461

⁴ Culpepper L, 2010. ‘The role of primary care clinicians in diagnosing and treating bipolar disorder’. Primary care companion to the Journal of clinical psychiatry vol. 12, Suppl 1 (2010): 4-9. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2902189/

⁵ Merikangas, Kathleen R et al. “Prevalence and correlates of bipolar spectrum disorder in the world mental health survey initiative” Archives of general psychiatry vol. 68,3 (2011): 241-51. Available at: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3486639/

⁶ Mind, 2018. What types of bipolar are there? [Online]. Available at: https://www.mind.org.uk/information-support/types-of-mental-health-problems/bipolar-disorder/types-of-bipolar/#.XFgoXFz7S70

⁷ Goodwin GM et al, 2016. Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendation from the British Association for Psychopharmacology. Journal of Pharmacology 2016, Vol 30(6) 495-553. Available at: https://www.bap.org.uk/pdfs/BAP_Guidelines-Bipolar.pdf

⁸ NHS England, 2018. Improving physical healthcare for people living with severe mental illness (SMI) in primary care: Guidance for CCGs. [Online] Available at: https://www.england.nhs.uk/publication/improving-physical-healthcare-for-people-living-with-severe-mental-illness-smi-in-primary-care-guidance-for-ccgs/