How should I approach the management of a patient experiencing a manic episode in primary care?

When a patient presents in primary care experiencing a manic episode, the primary approach should be urgent referral for specialist mental health assessment ².

• Urgent Referral: Refer the person urgently for a specialist mental health assessment if mania is suspected, or if they pose a danger to themselves or others ².
• Risk Assessment: Conduct a risk assessment focusing on potential dangers such as self-neglect, self-harm, suicidal thoughts, risks to others, excessive spending, and disinhibited behaviour ².
• Supportive Environment: Advise ensuring the person has access to calming environments and reduced stimulation ². Encourage them not to make important decisions until they have recovered and to maintain relationships with their carers ².
• Carer Involvement: Involve family or carers where possible, offering them an initial assessment of their own needs and a focused education and support programme ¹. Ensure they know where to obtain help during a crisis ¹. Provide carers with written and verbal information about bipolar disorder, support available, and how to get help in a crisis ².

• Do Not Initiate: Do not start lithium or valproate to treat bipolar disorder in primary care for people who have not taken these medications before, except under shared-care arrangements for lithium ².
• Antidepressants: If the person develops mania while taking an antidepressant, the antidepressant medication is usually tapered and discontinued by secondary care ¹.

If a person with bipolar disorder is being managed solely in primary care, re-refer them to secondary care if there is a poor or partial response to treatment, significant decline in functioning, poor treatment adherence, intolerable or medically important side effects from medication, suspected comorbid alcohol or drug misuse, or if they are considering stopping medication after a period of stable mood ¹,². Additionally, re-refer if a female of reproductive potential is taking sodium valproate without two specialists independently documenting no other effective treatment, or if a woman is pregnant or planning a pregnancy ¹,².

For people with confirmed bipolar disorder whose symptoms have responded effectively and remained stable following secondary care treatment, primary care may undertake ongoing management ¹. This includes supporting them to carry out care plans developed in secondary care, following crisis plans, and liaising with secondary care specialists if necessary ¹,². Review their treatment and care, including medication, at least annually or more often if there are concerns ¹,². Monitor physical health, including weight/BMI, cardiovascular status, metabolic status, liver function, and renal/thyroid function (for those on lithium) ².