Bipolar Disorder
NICE clinical guideline [CG185] Bipolar disorder: assessment and management. Last updated: Dec 2023.
NICE CKS Bipolar disorder. Last revised: May 2025.
Guidelines
Primary Care Management
All suspected cases:
- Refer to a specialist mental health service to confirm the diagnosis and start treatment
- Children (<14 yrs) → Child and Adolescent Mental Health Services (CAMHS)
- Refer for urgent mental health assessment if the patient presents with mania or severe depression or is a danger to themselves or others
Do not start lithium in primary care for people who have not taken lithium before, except under shared‑care arrangements
Do not start antipsychotic medication unless advised by a consultant psychiatrist
Consider tapering/discontinuation of antidepressant medication on specialist advice if mania develops
Secondary Care Management
Acute Management
Mania / Hypomania
Mania / hypomania should NOT be managed solely in primary care.
Where to treat:
- Mania (all cases) → refer urgently to secondary care mental health services (community mental health team or crisis team)
- Hypomania with low risk → refer to secondary mental health services for assessment (urgency depends on severity and risk to person/others)
How to treat:
- Step 1: offer an antipsychotic (haloperidol / olanzapine / quetiapine / risperidone), and stop any antidepressants (if patient is taking one)
- Step-up accordingly if there is inadequate response:
- Step 2: offer an alternative antipsychotic
- Step 3: add lithium
- Step 4: add sodium valproate
If the patient is already on mood stabilisers (e.g. lithium, sodium valproate):
- 1st line: optimise medication dose
- If that fails, then add drugs as outlined above
NB if taking lithium, measure plasma lithium levels to guide treatment optimisation based on lithium targets
Bipolar Depression
Offer all patients psychological intervention
Pharmacological interventions are indicated if there is moderate / severe bipolar depression:
- 1st line: olanzapine +/- fluoxetine or quetiapine alone
- 2nd line: lamotrigine alone (stop the 1st line drugs)
If the patient is already on mood stabilisers (e.g. lithium, sodium valproate):
- 1st line: optimise medication dose
- If that fails, then add drugs as outlined above
NB if taking lithium, measure plasma lithium levels to guide dose optimisation based on lithium targets
The core concept of treating bipolar depression is NOT to offer an antidepressant alone. Either give an antidepressant with an antipsychotic, or don’t at all.
Long Term Management (Preventive Treatment)
Offer psychological interventions and family intervention
Choice of pharmacological treatment (i.e. mood stabilisers):
- 1st line: lithium monotherapy
- 2nd line: antipsychotic monotherapy (e.g. risperidone, quetiapine, olanzapine, aripiprazole, asenapine)
- 3rd line (combination therapy): lithium / antipsychotic + sodium valproate
Due to the risk of fetal malformations and neurodevelopmental outcomes, strict MHRA safety advice must be followed when using valproate, especially for women and girls of childbearing potential, and for people (male or female) younger than 55 years.
References
Original Guideline