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Bipolar disorder

About

What is covered

Bipolar disorder is a potentially lifelong and disabling condition characterised by episodes of mania (abnormally elevated mood or irritability and related symptoms with severe functional impairment or psychotic symptoms for 7 days or more) or hypomania (abnormally elevated mood or irritability and related symptoms with decreased or increased function for 4 days or more) and episodes of depressed mood. It is often comorbid with other disorders such as anxiety disorders, substance misuse, personality disorders and attention deficit hyperactivity disorder.
The peak age of onset is 15–19 years, and there is often a substantial delay between onset and first contact with mental health services. The lifetime prevalence of bipolar I disorder (mania and depression) is estimated at 1% of the adult population, and bipolar II disorder (hypomania and depression) affects approximately 0.4% of adults. Bipolar disorder in children under 12 years is very rare.
This pathway covers the recognition, assessment and management of bipolar disorder in children, young people and adults. It includes specific recommendations for diagnosis in children and young people because presentation in these age groups can be complicated by other conditions such as attention deficit hyperactivity disorder. The recommendations apply to people with bipolar I, bipolar II, mixed affective and rapid cycling disorders. Non-bipolar affective disorders are not covered because these are addressed by other pathways, and this pathway does not make specific recommendations about other mental disorders that commonly coexist with bipolar disorder.
In this pathway children are defined as people aged 12 years and younger, young people as people aged 13–17 years, and older people as people aged 65 years and over.

Updates

Updates to this pathway

14 October 2015 Bipolar disorder, psychosis and schizophrenia in children and young people (NICE quality standard 102) added to this pathway.
22 July 2015 Bipolar disorder in adults (NICE quality standard 95) added to this pathway.
29 May 2015 Minor maintenance updates.
9 April 2015 Recommendations in starting, monitoring and stopping valproate treatment updated in line with strengthened Medicines and Healthcare Products Regulatory Agency warnings on the use of valproate in women of childbearing potential.
2 April 2015 Minor maintenance updates.

Your responsibility

Guidelines

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this pathway is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the pathway to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Technology appraisals

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this pathway is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the pathway does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Bipolar disorder: the assessment and management of bipolar disorder in adults, children and young people in primary and secondary care

What is covered

Bipolar disorder is a potentially lifelong and disabling condition characterised by episodes of mania (abnormally elevated mood or irritability and related symptoms with severe functional impairment or psychotic symptoms for 7 days or more) or hypomania (abnormally elevated mood or irritability and related symptoms with decreased or increased function for 4 days or more) and episodes of depressed mood. It is often comorbid with other disorders such as anxiety disorders, substance misuse, personality disorders and attention deficit hyperactivity disorder.
The peak age of onset is 15–19 years, and there is often a substantial delay between onset and first contact with mental health services. The lifetime prevalence of bipolar I disorder (mania and depression) is estimated at 1% of the adult population, and bipolar II disorder (hypomania and depression) affects approximately 0.4% of adults. Bipolar disorder in children under 12 years is very rare.
This pathway covers the recognition, assessment and management of bipolar disorder in children, young people and adults. It includes specific recommendations for diagnosis in children and young people because presentation in these age groups can be complicated by other conditions such as attention deficit hyperactivity disorder. The recommendations apply to people with bipolar I, bipolar II, mixed affective and rapid cycling disorders. Non-bipolar affective disorders are not covered because these are addressed by other pathways, and this pathway does not make specific recommendations about other mental disorders that commonly coexist with bipolar disorder.
In this pathway children are defined as people aged 12 years and younger, young people as people aged 13–17 years, and older people as people aged 65 years and over.

Updates

Updates to this pathway

14 October 2015 Bipolar disorder, psychosis and schizophrenia in children and young people (NICE quality standard 102) added to this pathway.
22 July 2015 Bipolar disorder in adults (NICE quality standard 95) added to this pathway.
29 May 2015 Minor maintenance updates.
9 April 2015 Recommendations in starting, monitoring and stopping valproate treatment updated in line with strengthened Medicines and Healthcare Products Regulatory Agency warnings on the use of valproate in women of childbearing potential.
2 April 2015 Minor maintenance updates.

Sources

The NICE guidance that was used to create the pathway.
Bipolar disorder (2014) NICE guideline CG185
Guidance on the use of electroconvulsive therapy (2003) NICE technology appraisal guidance 59
Bipolar disorder in adults (2015) NICE quality standard 95

Quality standards

Bipolar disorder, psychosis and schizophrenia in children and young people

These quality statements are taken from the bipolar disorder, psychosis and schizophrenia in children and young people quality standard. The quality standard defines clinical best practice for bipolar disorder, psychosis and schizophrenia in children and young people and should be read in full.

Bipolar disorder in adults

These quality statements are taken from the bipolar disorder in adults quality standard. The quality standard defines clinical best practice for bipolar disorder in adults care and should be read in full.

Quality statements

Assessment for a first episode of psychosis

This quality statement is taken from the bipolar disorder, psychosis and schizophrenia in children and young people quality standard. The quality standard defines clinical best practice in bipolar disorder, psychosis and schizophrenia in children and young people and should be read in full.

Quality statement

Children and young people who are referred to a specialist mental health service with a first episode of psychosis start assessment within 2 weeks.

Rationale

Starting assessment for a first episode of psychosis within 2 weeks can improve outcomes by reducing the duration of untreated psychosis, as longer periods of untreated psychosis are linked to worse outcomes. Specialist mental health services can improve symptoms and clinical outcomes such as admission and relapse rates.

Quality measures

Structure
Evidence of local arrangements to ensure that systems are in place for children and young people who are referred to a specialist mental health service with a first episode of psychosis to start assessment within 2 weeks.
Data source: Local data collection.
Process
Proportion of children and young people who are referred to a specialist mental health service with a first episode of psychosis who start assessment within 2 weeks.
Numerator – the number in the denominator who start assessment within 2 weeks of referral.
Denominator – the number of children and young people who are referred to a specialist mental health service with a first episode of psychosis.
Data source: Local data collection. National data are collected in the Health and Social Care Information Centre Child and Adolescent Mental Health Services Data Set.
Outcome
a) Mental health admission rates for children and young people.
Data source: Local data collection. National data are collected in the Health and Social Care Information Centre Child and Adolescent Mental Health Services Data Set.
b) Duration of untreated psychosis.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers (such as child and adolescent mental health services and early intervention in psychosis services) ensure that systems and protocols are in place for children and young people who are referred to a specialist mental health service with a first episode of psychosis to start assessment within 2 weeks.
Healthcare professionals (such as psychologists and psychiatrists) start assessment of children and young people who are referred with a first episode of psychosis within 2 weeks of referral.
Commissioners (such as clinical commissioning groups and NHS England) commission specialist mental health services that start assessment within 2 weeks for children and young people who are referred with a first episode of psychosis.

What the quality statement means for children, young people, parents and carers

Children and young people who have been having hallucinations or delusions (believing things that aren’t true) for 4 weeks or more for the first time start an assessment within 2 weeks of being referred to a specialist mental health service (such as a child and adolescent mental health service or an early intervention in psychosis service). These services find out why the child or young person is having hallucinations or delusions, and will provide support and treatment to prevent them from coming back. This will reduce the chance that the child or young person needs to be admitted to hospital.

Source guidance

Definitions of terms used in this quality statement

A first episode of psychosis
A first presentation of sustained psychotic symptoms (lasting 4 weeks or more). Symptoms may include ‘positive symptoms’ such as hallucinations (perception in the absence of any stimulus) and ‘negative symptoms’ such as emotional apathy, lack of drive, poverty of speech, social withdrawal and self-neglect.
[Psychosis and schizophrenia in children and young people (NICE guideline CG155) recommendation 1.3.1 (key priority for implementation) and Introduction]
Specialist mental health service
An age-appropriate multidisciplinary service such as a child and adolescent mental health service or an early intervention in psychosis service.

Equality and diversity considerations

Assessments should be adjusted if necessary to take account of any learning disabilities, autism or cognitive impairment, and healthcare professionals should consider consulting a relevant specialist.

Family intervention

This quality statement is taken from the bipolar disorder, psychosis and schizophrenia in children and young people quality standard. The quality standard defines clinical best practice in bipolar disorder, psychosis and schizophrenia in children and young people and should be read in full.

Quality statement

Children and young people with a first episode of psychosis and their family members are offered family intervention.

Rationale

Families play an important part in providing care and support to children and young people with a first episode of psychosis. When family intervention forms part of a broad-based approach that combines different treatment options tailored to the needs of the individual and their family, it can improve coping skills and relapse rates for children and young people with a first episode of psychosis.

Quality measures

Structure
Evidence of local arrangements to ensure that family intervention is an available treatment option for children and young people with a first episode of psychosis and their family members.
Data source: Local data collection.
Process
a) Proportion of children and young people with a first episode of psychosis whose family members receive family intervention.
Numerator – the number in the denominator whose family members receive family intervention.
Denominator – the number of children and young people with a first episode of psychosis.
Data source: Local data collection.
b) Proportion of children and young people with a first episode of psychosis who receive family intervention.
Numerator – the number in the denominator who receive family intervention.
Denominator – the number of children and young people with a first episode of psychosis.
Data source: Local data collection.
Outcome
Relapse rates for children and young people with psychosis.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as child and adolescent mental health services and early intervention in psychosis services) ensure that family intervention is an available treatment option for children and young people with a first episode of psychosis and their family members. They should ensure that practitioners are trained and have the appropriate competencies to deliver it.
Healthcare professionals (such as psychologists and psychiatrists) offer family intervention to children and young people with a first episode of psychosis and their family members.
Commissioners (such as clinical commissioning groups and NHS England) commission family intervention services and ensure that referral pathways are in place for children and young people with a first episode of psychosis and their family members to be referred for family intervention.

What the quality statement means for children, young people, parents and carers

Children and young people with a first episode of psychosis and their family members are offered a psychological therapy called family intervention. This helps support families or carers to work together to help children and young people with psychosis cope and to reduce stress.

Source guidance

Definitions of terms used in this quality statement

Family members
Family members include parents and carers, siblings and other family members who the child or young person with a first episode of psychosis lives with or is in close contact with.
A first episode of psychosis
A first presentation of sustained psychotic symptoms (lasting 4 weeks or more). Symptoms may include ‘positive symptoms’ such as hallucinations (perception in the absence of any stimulus) and ‘negative symptoms’ such as emotional apathy, lack of drive, poverty of speech, social withdrawal and self-neglect.
[Psychosis and schizophrenia in children and young people (NICE guideline CG155) recommendation 1.3.1 (key priority for implementation) and Introduction]
Family intervention
Family intervention is a psychological therapy that should:
  • include the child or young person with psychosis, if practical
  • be carried out for between 3 months and 1 year
  • include at least 10 planned sessions
  • take account of the whole family’s preference for either single-family intervention or multi-family group intervention
  • take account of the relationship between the parents or carers and the child or young person with psychosis
  • have a specific supportive, educational or treatment function and include negotiated problem solving or crisis management work.
[Psychosis and schizophrenia in children and young people (NICE guideline CG155) recommendation 1.3.27]

Equality and diversity considerations

The delivery and duration of family intervention should be adjusted if necessary to take account of any learning disabilities, autism or cognitive impairment in the child or young person with psychosis or their family members, and healthcare professionals should consider consulting a relevant specialist.
The workforce across agencies should, as far as possible, reflect the local community. Practitioners should have training to ensure that they have a good understanding of the culture of families they are working with. Interpreters should be provided if no practitioner is available who speaks a language in which the family members can communicate easily.

Psychological intervention

This quality statement is taken from the bipolar disorder, psychosis and schizophrenia in children and young people quality standard. The quality standard defines clinical best practice in bipolar disorder, psychosis and schizophrenia in children and young people and should be read in full.

Quality statement

Children and young people newly diagnosed with bipolar depression or a first episode of psychosis are offered a psychological intervention.

Rationale

Psychological interventions (in conjunction with antipsychotic medication, or on their own if medication is declined or not needed) can improve outcomes for bipolar depression and psychosis. The psychological intervention will be based on a psychological assessment and formulation, and will aim to reduce distress, promote social and educational recovery, reduce social anxiety and depression, and prevent relapse in children and young people.

Quality measures

Structure
Evidence of local arrangements to ensure that children and young people newly diagnosed with bipolar depression or a first episode of psychosis are offered a psychological intervention.
Data source: Local data collection.
Process
a) Proportion of children and young people newly diagnosed with bipolar depression who receive cognitive behavioural therapy or interpersonal therapy.
Numerator – the number in the denominator who receive cognitive behavioural therapy or interpersonal therapy.
Denominator – the number of children and young people newly diagnosed with bipolar depression.
Data source: Local data collection.
b) Proportion of children and young people newly diagnosed with a first episode of psychosis who receive cognitive behavioural therapy.
Numerator – the number in the denominator who receive cognitive behavioural therapy.
Denominator – the number of children and young people newly diagnosed with a first episode of psychosis.
Data source: Local data collection.
Outcomes
a) Relapse rates for children and young people with bipolar depression.
Data source: Local data collection.
b) Relapse rates for children and young people with psychosis.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as child and adolescent mental health services and early intervention in psychosis services) ensure that a psychological intervention is available as a treatment option for children and young people newly diagnosed with bipolar depression or a first episode of psychosis. They should ensure that practitioners are trained and have the appropriate competencies to deliver psychological interventions.
Healthcare professionals (such as psychologists, psychiatrists and psychotherapists) offer a psychological intervention to children and young people newly diagnosed with bipolar depression or a first episode of psychosis.
Commissioners (such as clinical commissioning groups and NHS England) commission services that offer a psychological intervention to children and young people newly diagnosed with bipolar depression or a first episode of psychosis.

What the quality statement means for children, young people, parents and carers

Children and young people who are diagnosed with bipolar depression or a first episode of psychosis are offered a psychological therapy. This involves meeting a healthcare professional on their own or with a parent or carer to talk about their feelings and thoughts, which can help them to find ways to cope with their symptoms. For children and young people with psychosis, psychological therapy works better when they also take antipsychotic medication (medicine to help with psychosis).

Source guidance

Definitions of terms used in this quality statement

Psychological intervention
Children and young people with a first episode of psychosis should be offered cognitive behavioural therapy. It should be delivered in at least 16 planned sessions, follow a treatment manual and include at least 1 of the following:
  • normalising
  • personal monitoring
  • promoting alternative ways of coping
  • reducing distress
  • improving functioning.
Children and young people newly diagnosed with bipolar depression should be offered cognitive behavioural therapy or interpersonal therapy. The intervention should be delivered over at least 3 months and have a published evidence-based manual describing how it should be delivered.
[Adapted from Psychosis and schizophrenia in children and young people (NICE guideline CG155) recommendation 1.3.28 and Bipolar disorder (NICE guideline CG185) recommendation 1.11.11 (key priority for implementation)]

Equality and diversity considerations

The delivery and duration of a psychological intervention should be adjusted if necessary to take account of any learning disabilities, autism or cognitive impairment a child or young person with bipolar depression or psychosis has, and healthcare professionals should consider consulting a relevant specialist.
Specialist mental health services should provide children and young people from diverse ethnic and cultural backgrounds with culturally appropriate psychological and psychosocial treatment, and address cultural and ethnic differences in beliefs about biological, social and family influences on mental states.

Support for carers

This quality statement is taken from the bipolar disorder, psychosis and schizophrenia in children and young people quality standard. The quality standard defines clinical best practice in bipolar disorder, psychosis and schizophrenia in children and young people and should be read in full.

Quality statement

Parents and carers of children and young people newly diagnosed with bipolar disorder, psychosis or schizophrenia are given information about carer-focused education and support.

Rationale

Carer-focused education and support enhances engagement and reduces carer burden and psychological distress, and may improve the carer’s quality of life. As part of the initial process of assessment and engagement, carer-focused education and support can also help carers of children and young people with bipolar disorder, psychosis or schizophrenia to be able to identify and monitor symptoms of concern.

Quality measures

Structure
Evidence of local arrangements to ensure that parents and carers of children and young people newly diagnosed with bipolar disorder, psychosis or schizophrenia are given information about carer-focused education and support.
Data source: Local data collection.
Process
Proportion of children and young people newly diagnosed with bipolar disorder, psychosis or schizophrenia whose parents or carers receive information about carer-focused education and support.
Numerator – the number in the denominator whose parents or carers receive information about carer-focused education and support.
Denominator – the number of children and young people newly diagnosed with bipolar disorder, psychosis or schizophrenia.
Data source: Local data collection.
Outcome
a) Satisfaction of parents and carers of children and young people newly diagnosed with bipolar disorder, psychosis or schizophrenia with the information and support provided to meet their own needs.
Data source: Local data collection.
b) Quality of life for parents and carers of children and young people with bipolar disorder, psychosis or schizophrenia.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (such as GP surgeries, community health services, child and adolescent mental health services and early intervention in psychosis services) ensure that processes are in place for parents or carers of children and young people newly diagnosed with bipolar disorder, psychosis or schizophrenia to be given information and encouragement to participate in carer-focused education and support.
Health and social care practitioners (such as psychologists, social workers and GPs) give parents or carers of children and young people newly diagnosed with bipolar disorder, psychosis or schizophrenia information about carer-focused education and support, and encourage them to participate.
Commissioners (clinical commissioning groups and NHS England) ensure that carer-focused education and support is available, and that appropriate referral pathways are in place for parents or carers of children and young people newly diagnosed with bipolar disorder, psychosis or schizophrenia.

What the quality statement means for children, young people, parents and carers

Parents or carers of children and young people newly diagnosed with bipolar disorder, psychosis or schizophrenia are given information about education and support. This can help carers to cope by improving their understanding of the condition and treatments for it, and giving them the opportunity to discuss their experiences with others.

Source guidance

Definitions of terms used in this quality statement

Carer-focused education and support
This will include information about support groups and education programmes available locally, including those provided by the third sector. Support groups and education programmes will provide information, mutual support and open discussion to carers through voluntary participation. Support groups and education programmes should be available as needed and offer a positive message about recovery.
[Adapted from Bipolar disorder (NICE guideline CG185) recommendation 1.1.18 and Psychosis and schizophrenia in children and young people (NICE guideline CG155) recommendation 1.1.14]

Equality and diversity considerations

If a person does not have access to specialist training or support near their home, and has difficulty travelling long distances (because of the financial cost or other reasons), they may need additional support.
Equality of language and capability in training carers needs to be considered.

Healthy lifestyle advice

This quality statement is taken from the bipolar disorder, psychosis and schizophrenia in children and young people quality standard. The quality standard defines clinical best practice in bipolar disorder, psychosis and schizophrenia in children and young people and should be read in full.

Quality statement

Children and young people with bipolar disorder, psychosis or schizophrenia are given healthy lifestyle advice at diagnosis and at annual review.

Rationale

As they get older, children and young people with bipolar disorder, psychosis or schizophrenia have poorer physical health than the general population and a reduced life expectancy. Health problems may sometimes be linked to lifestyle factors and risky behaviours, and are exacerbated by the use of antipsychotic drugs. It is important that primary care and specialist mental health services take a proactive approach to promoting positive health behaviours from a young age by giving age-appropriate healthy lifestyle advice at diagnosis and at annual review.

Quality measures

Structure
a) Evidence of local arrangements to ensure that children and young people with bipolar disorder, psychosis or schizophrenia are given healthy lifestyle advice at diagnosis.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that children and young people with bipolar disorder, psychosis or schizophrenia being supported in primary care or specialist mental health services are given healthy lifestyle advice at their annual review.
Data source: Local data collection.
Process
a) Proportion of children and young people with bipolar disorder, psychosis or schizophrenia who receive healthy lifestyle advice at diagnosis.
Numerator – the number in the denominator who receive healthy lifestyle advice at diagnosis.
Denominator – the number of children and young people with a new diagnosis of bipolar disorder, psychosis or schizophrenia.
Data source: Local data collection.
b) Proportion of children and young people with bipolar disorder, psychosis or schizophrenia who receive healthy lifestyle advice at their annual review.
Numerator – the number in the denominator who receive healthy lifestyle advice at their annual review.
Denominator – the number of children and young people with bipolar disorder, psychosis or schizophrenia who are supported in primary care or specialist mental health services.
Data source: Local data collection.
Outcomes
a) Obesity rates in children and young people with bipolar disorder, psychosis or schizophrenia.
Data source: Local data collection. Data on BMI values are included in the ‘care.data’ extract for the Health and Social Care Information Centre (not specific to children and young people with bipolar disorder, psychosis or schizophrenia).
b) Physical activity in children and young people with bipolar disorder, psychosis or schizophrenia.
Data source: Local data collection.
c) Drug use in children and young people with bipolar disorder, psychosis or schizophrenia.
Data source: Local data collection.
d) Alcohol consumption in children and young people with bipolar disorder, psychosis or schizophrenia.
Data source: Local data collection. Data on alcohol consumption are included in the ‘care.data’ extract for the Health and Social Care Information Centre (not specific to children and young people with bipolar disorder, psychosis or schizophrenia).
e) Smoking rates in children and young people with bipolar disorder, psychosis or schizophrenia.
Data source: Local data collection. Data on smoking status are included in the ‘care.data’ extract for the Health and Social Care Information Centre (not specific to children and young people with bipolar disorder, psychosis or schizophrenia).
f) Infection rates for sexually transmitted diseases in children and young people with bipolar disorder, psychosis or schizophrenia.
Data source: Local data collection.
g) Premature mortality of people with bipolar disorder, psychosis or schizophrenia.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GP surgeries, community health services, child and adolescent mental health services and early intervention in psychosis services) ensure that processes are place for children and young people with bipolar disorder, psychosis or schizophrenia to receive age-appropriate healthy lifestyle advice at diagnosis and at annual review.
Healthcare professionals (such as GPs, psychologists and mental health nurses) offer age-appropriate healthy lifestyle advice to children and young people with bipolar disorder, psychosis or schizophrenia at diagnosis and at annual review.
Commissioners (such as clinical commissioning groups and NHS England) commission services that offer age-appropriate healthy lifestyle advice to children and young people with bipolar disorder, psychosis or schizophrenia at diagnosis and at annual review.

What the quality statement means for children, young people, parents and carers

Children and young people with bipolar disorder, psychosis or schizophrenia should be offered advice that is suitable for their age at diagnosis and at annual review on healthy eating, how to make sure they get enough exercise, practising safe sex and the importance of avoiding drug and alcohol misuse and smoking. If they smoke, they should be given advice on how to stop.

Source guidance

Definitions of terms used in this quality statement

Healthy lifestyle advice
Age-appropriate advice on healthy eating, physical activity, drug and alcohol use, smoking and sexual health.
[Adapted from Bipolar disorder (NICE guideline CG185), recommendation 1.8.2 and Psychosis and schizophrenia in children and young people (NICE guideline CG155), recommendations 1.3.4 and 1.5.13.]

Equality and diversity considerations

Healthcare professionals should be aware of the impact of social factors (such as inadequate housing, lack of access to affordable physical activity, poor cooking skills and limited budgets for food) on continued healthy eating and physical activity.
Healthcare professionals should take into account cultural and communication needs when giving healthy lifestyle advice to a child or young person.

Monitoring for side effects of antipsychotic medication

This quality statement is taken from the bipolar disorder, psychosis and schizophrenia in children and young people quality standard. The quality standard defines clinical best practice in bipolar disorder, psychosis and schizophrenia in children and young people and should be read in full.

Quality statement

Children and young people with bipolar disorder, psychosis or schizophrenia prescribed antipsychotic medication have their treatment monitored for side effects.

Rationale

Children and young people with bipolar disorder, psychosis or schizophrenia are particularly vulnerable to the adverse side effects of antipsychotic medication, including rapid weight gain and metabolic disturbances. This, combined with higher rates of smoking, leads to a higher risk of cardiovascular disease and metabolic disorders than the general population. Regular monitoring will allow antipsychotic medication to be adjusted so that side effects are minimised, and so that physical health interventions can be offered if needed.

Quality measures

Structure
Evidence of local arrangements to ensure that children and young people with bipolar disorder, psychosis or schizophrenia prescribed antipsychotic medication have their treatment monitored for side effects.
Data source: Local data collection.
Process
a) Proportion of children and young people newly diagnosed with bipolar disorder, psychosis or schizophrenia prescribed antipsychotic medication who have a record of baseline physical health investigations.
Numerator – the number in the denominator who have a record of baseline physical health investigations.
Denominator – the number of children and young people newly diagnosed with bipolar disorder, psychosis or schizophrenia prescribed antipsychotic medication.
Data source: Local data collection. The Prescribing Observatory for Mental Health (POMH-UK) audit-based quality improvement programme on prescribing antipsychotics for children and adolescents includes data (for participating trusts) on documented tests and measures taken before starting antipsychotic treatment.
b) Proportion of children and young people with bipolar disorder, psychosis or schizophrenia newly prescribed antipsychotic medication who have a record of side-effect monitoring 12 weeks after starting treatment.
Numerator – the number in the denominator who have a record of side-effect monitoring 12 weeks after starting treatment.
Denominator – the number of children and young people with bipolar disorder, psychosis or schizophrenia newly prescribed antipsychotic medication.
Data source: Local data collection.
c) Proportion of children and young people with bipolar disorder, psychosis or schizophrenia prescribed antipsychotic medication for more than a year with a record of side-effect monitoring within the last 6 months.
Numerator – the number in the denominator with a record of side-effect monitoring within the last 6 months.
Denominator – the number of children and young people with bipolar disorder, psychosis or schizophrenia prescribed antipsychotic medication for more than a year.
Data source: Local data collection. The (POMH-UK) audit-based quality improvement programme on prescribing antipsychotics for children and adolescents includes data (for participating trusts) on a documented review of therapeutic response and side effects of antipsychotic medication at least once every 6 months.
Outcome
a) Obesity rates in children and young people with bipolar disorder, psychosis or schizophrenia.
Data source: Local data collection. Data on BMI values are included in the ‘care.data’ extract for the Health and Social Care Information Centre (not specific to children and young people with bipolar disorder, psychosis or schizophrenia).
b) Incidence of cardiovascular disease in people with bipolar disorder, psychosis or schizophrenia.
Data source: Local data collection. Data can be collected for adults with schizophrenia using the Royal College of Psychiatrists’ National audit of schizophrenia Audit of practice tool, question 30.
c) Incidence of type 2 diabetes in people with bipolar disorder, psychosis or schizophrenia.
Data source: Local data collection. Data can be collected for adults with schizophrenia using the Royal College of Psychiatrists’ National audit of schizophrenia Audit of practice tool, question 30.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GP surgeries, community health services, child and adolescent mental health services and early intervention in psychosis services) ensure that systems and protocols are in place to monitor the side effects of antipsychotic medication for children and young people with bipolar disorder, psychosis or schizophrenia, and to share the results when the child or young person is in the care of primary and secondary care services.
Healthcare professionals (such as GPs, mental health nurses, and psychiatrists) monitor the side effects of antipsychotic medication for children and young people with bipolar disorder, psychosis or schizophrenia, and share the results when the child or young person is in the care of primary and secondary care services.
Commissioners (such as clinical commissioning groups and NHS England) commission services that monitor the side effects of antipsychotic medication for children and young people with bipolar disorder, psychosis or schizophrenia. They should also ensure that arrangements are in place to share the results of monitoring when the child or young person is in the care of primary and secondary services.

What the quality statement means for children, young people, parents and carers

Children and young people with bipolar disorder, psychosis or schizophrenia who are taking antipsychotic medication (medicine to help with psychosis) should see their healthcare professional regularly to check for side effects. This will include regular checks such as blood tests and measurements of their weight, height, waist, hip, pulse and blood pressure, to check for problems that may be caused by their medication (such as weight gain, diabetes, and heart, lung and breathing problems). The results of all health checks should be discussed with the child or young person and their parents or carers and shared between their GP surgery and mental health team.

Source guidance

Definitions of terms used in this quality statement

Baseline physical health investigations
Before starting antipsychotic medication, the following baseline investigations should be undertaken and recorded:
  • weight and height (both plotted on a growth chart)
  • waist and hip circumference
  • pulse and blood pressure
  • fasting blood glucose, glycosylated haemoglobin (HbA1c), blood lipid profile and prolactin levels
  • assessment of any movement disorders
  • assessment of nutritional status, diet and level of physical activity.
[Psychosis and schizophrenia in children and young people (NICE guideline CG155) recommendation 1.3.16 and Bipolar disorder (NICE guideline CG185) recommendation 1.10.5]
Monitoring for side effects of antipsychotic medication
Side effects of antipsychotic medication can be:
  • metabolic (including weight gain and diabetes)
  • extrapyramidal (including akathisia, dyskinesia and dystonia)
  • cardiovascular (including prolonging the QT interval)
  • hormonal (including increasing plasma prolactin)
  • other (including unpleasant subjective experiences).
The following should be monitored and recorded regularly and systematically throughout treatment with antipsychotic medication, but especially during titration:
  • efficacy, including changes in symptoms and behaviour
  • side effects of treatment, taking into account overlap between certain side effects and clinical features of schizophrenia (for example, the overlap between akathisia and agitation or anxiety)
  • the emergence of movement disorders
  • weight, weekly for the first 6 weeks, then at 12 weeks and then every 6 months (plotted on a growth chart)
  • height every 6 months (plotted on a growth chart)
  • waist and hip circumference every 6 months (plotted on a percentile chart)
  • pulse and blood pressure (plotted on a percentile chart) at 12 weeks and then every 6 months
  • fasting blood glucose, HbA1c, blood lipid and prolactin levels at 12 weeks and then every 6 months
  • adherence
  • physical health.
[Psychosis and schizophrenia in children and young people (NICE guideline CG155) recommendation 1.3.19 (key priority for implementation) and Bipolar disorder (NICE guideline CG185) recommendation 1.10.8]

Equality and diversity considerations

Healthcare professionals should take into account cultural and communication needs when explaining how the side effects of antipsychotic medication will be monitored.

Home treatment in crisis (developmental)

This quality statement is taken from the bipolar disorder, psychosis and schizophrenia in children and young people quality standard. The quality standard defines clinical best practice in bipolar disorder, psychosis and schizophrenia in children and young people and should be read in full.
Developmental quality statements set out an emergent area of cutting-edge service delivery or technology currently found in a minority of providers and indicating outstanding performance. They will need specific, significant changes to be put in place, such as redesign of services or new equipment.

Quality statement

Children and young people with bipolar disorder, psychosis or schizophrenia who are in crisis are offered home treatment if it is suitable.

Rationale

Hospital admissions can be disruptive for a child or young person and their family or carers. It may be possible to avoid hospital admission if treatment and support can be provided at home. A crisis assessment will determine whether home treatment is a suitable option, based on the child or young person’s needs, risks and circumstances.

Quality measures

Structure
Evidence of local arrangements to ensure that children and young people with bipolar disorder, psychosis or schizophrenia who are in crisis are offered home treatment if it is suitable.
Data source: Local data collection.
Process
a) Proportion of crisis episodes in children and young people with bipolar disorder, psychosis or schizophrenia that are assessed for the suitability of home treatment.
Numerator – the number in the denominator that are assessed for the suitability of home treatment.
Denominator – the number of crisis episodes in children and young people with bipolar disorder, psychosis or schizophrenia.
Data source: Local data collection.
b) Proportion of crisis episodes in children and young people with bipolar disorder, psychosis or schizophrenia that are assessed as suitable for home treatment and result in home treatment.
Numerator – the number in the denominator that result in home treatment.
Denominator – the number of crisis episodes in children and young people with bipolar disorder, psychosis or schizophrenia that are assessed as suitable for home treatment.
Data source: Local data collection.
Outcome
Mental health admission rates for children and young people.
Data source: Local data collection. National data are collected in the Health and Social Care Information Centre Child and Adolescent Mental Health Services Data Set.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (such as child and adolescent mental health services and early intervention in psychosis services) ensure that home treatment is available for children and young people with bipolar disorder, psychosis or schizophrenia who are in crisis.
Health and social care practitioners (such as psychologists and social workers) assess the suitability of home treatment for children and young people with bipolar disorder, psychosis or schizophrenia who are in crisis.
Commissioners (clinical commissioning groups and NHS England) commission home treatment services for children and young people with bipolar disorder, psychosis or schizophrenia who are in crisis.

What the quality statement means for children, young people, parents and carers

Children and young people with bipolar disorder, psychosis or schizophrenia who have a crisis should have a discussion with their mental health professional to agree if treatment at home would be better for them than treatment in hospital. Treatment in hospital can be very disruptive (for example, they may miss time in school).

Source guidance

Definitions of terms used in this quality statement

Crisis
A crisis may be suicidal behaviour or intention, panic attacks or extreme anxiety, psychotic episodes, or behaviour that seems out of control or irrational and likely to endanger the person or others.
[Mental health crisis care concordat, Department of Health (2014) and expert opinion]
Assessment for suitability for home treatment
A crisis assessment should be carried out by health and social care professionals who are experienced and competent in crisis working. The decision to start home treatment should depend not on the diagnosis, but on:
  • the level of distress
  • the severity of the problems
  • the vulnerability of the child or young person and issues of safety and support at home
  • the child or young person’s ability to adhere to treatment.
[Service user experience in adult mental health (NICE guideline CG136) recommendation 1.5.3 and Psychosis and schizophrenia in children and young people (NICE guideline CG155) recommendation 1.5.3]
Home treatment
A service that assesses, supports and provides treatment at home to promote engagement and avoid admission to hospital. The service should be available 24 hours a day, 7 days a week.
[Service user experience in adult mental health (NICE guideline CG136) full guideline and recommendation 1.5.7]

Equality and diversity considerations

Home treatment should be available to all children and young people with bipolar disorder, psychosis or schizophrenia in crisis, regardless of their age, if it is assessed as suitable.
Children and young people with psychosis from black and minority ethnic backgrounds are more frequently subject to compulsory admissions. It is therefore important that health and social care practitioners take into consideration ethnic and cultural backgrounds when making assessments for suitability for home treatment, so that compulsory admission is avoided whenever possible.

Referral for specialist mental health assessment

This quality statement is taken from the bipolar disorder in adults quality standard. The quality standard defines clinical best practice in bipolar disorder in adults care and should be read in full.

Quality statement

Adults presenting in primary care with symptoms of depression are offered a referral for a specialist mental health assessment if they have experienced overactivity or disinhibited behaviour lasting 4 days or more.

Rationale

The initial presentation in primary care for adults with bipolar disorder is usually with symptoms of depression. If the adult with bipolar disorder receives treatment for depression only, the intervention is ineffective and potentially harmful. If the adult presenting with depression has also experienced overactivity or disinhibited behaviour recently or in the past, depression may be a symptom of an underlying bipolar disorder. It indicates a need for further specialist mental health assessment.

Quality measures

Structure
Evidence of practice arrangements and written clinical protocols to ensure that adults presenting with symptoms of depression are referred for a specialist mental health assessment if they have experienced overactivity or disinhibited behaviour lasting 4 days or more.
Data source: Local data collection.
Process
a) Proportion of adults presenting in primary care with symptoms of depression who are asked if they have experienced overactivity or disinhibited behaviour lasting 4 days or more.
Numerator – the number in the denominator asked if they have experienced overactivity or disinhibited behaviour lasting 4 days or more.
Denominator – the number of adults presenting in primary care with symptoms of depression.
Data source: Local data collection.
b) Proportion of adults presenting in primary care with symptoms of depression who have experienced overactivity or disinhibited behaviour lasting 4 days or more who were referred for a specialist mental health assessment.
Numerator – the number in the denominator referred for a specialist mental health assessment.
Denominator – the number of adults presenting in primary care with symptoms of depression who have experienced overactivity or disinhibited behaviour lasting 4 days or more.
Data source: Local data collection.
Outcome
a) Referral rates for specialist mental health assessment.
Data source: Local data collection.
b) Recognition of bipolar disorder within the community.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GP practices, community health services and drug and alcohol misuse services) ensure that systems and protocols are in place for adults who present in primary care with symptoms of depression to be asked about experiences of overactivity or disinhibited behaviour lasting 4 days or more and referred for a specialist mental health assessment if needed.
Healthcare professionals ask adults who present in primary care with symptoms of depression about experiences of overactivity or disinhibited behaviour lasting 4 days or more, and follow local pathways and criteria for adults who need to be referred for a specialist mental health assessment.
Commissioners (such as clinical commissioning groups and NHS England local area teams) commission services that carry out specialist mental health assessments and ensure that local referral pathways are in place for adults who present in primary care with symptoms of depression who have also experienced overactivity or disinhibited behaviour lasting 4 days or more to receive a specialist mental health assessment.

What the quality statement means for service users and carers

Adults who see their GP with symptoms of depression are referred for a specialist mental health assessment if they have not been in control of their mood and behaviour for 4 days in a row or longer.

Source guidance

Definitions of terms used in this quality statement

Symptoms of depression
Key symptoms:
  • persistent sadness or low mood; and/or
  • marked loss of interests or pleasure.
Associated symptoms:
  • disturbed sleep (decreased or increased compared to usual)
  • decreased or increased appetite and/or weight
  • fatigue or loss of energy
  • agitation or slowing of movements
  • poor concentration or indecisiveness
  • feelings of worthlessness or excessive or inappropriate guilt
  • suicidal thoughts or acts.
[Depression in adults (NICE guideline CG90) appendix C: Assessing depression and its severity]
Referral for specialist mental health assessment
Adults with symptoms of depression presenting in primary care should be offered a referral for specialist mental health assessment if overactivity or disinhibited behaviour has lasted for 4 days or more. Overactivity or disinhibited behaviour may include:
  • elated, expansive or irritable mood
  • increased activity
  • decreased need for sleep
  • increased talkativeness
  • fast or racing thinking
  • inflated self-esteem or self-importance
  • increased sexual activity
  • attention easily drawn to irrelevant stimuli
  • excessive involvement in activities with high potential for undesired consequences, such as overspending or risky behaviours.
[Bipolar disorder (NICE guideline CG185) recommendations 1.2.5 and expert opinion]

Personalised care plan

This quality statement is taken from the bipolar disorder in adults quality standard. The quality standard defines clinical best practice in bipolar disorder in adults care and should be read in full.

Quality statement

Adults with bipolar disorder have their early warning symptoms and triggers of relapse, preferred response during relapse and personal recovery goals specified in their care plan.

Rationale

Bipolar disorder is a long-term condition that involves periods of wellbeing that may end abruptly because of relapse into mania, hypomania or bipolar depression. It is important for adults with bipolar disorder to have a personalised care plan in which they specify the care they want to receive, particularly in a crisis. It is also important that their care plan is focused on maintaining wellbeing, preventing relapse and achieving recovery goals. Specifying early warning symptoms and triggers in the care plan allows health and social care practitioners and carers to be alert to these and to intervene early to prevent or prepare for a crisis.

Quality measures

Structure
Evidence of practice arrangements and written clinical protocols to ensure that care plans specify early warning symptoms and triggers of mania and depression relapse, preferred response during relapse and personal recovery goals.
Data source: Local data collection.
Process
a) Proportion of adults with bipolar disorder who have a care plan that specifies early warning symptoms of mania and depression relapse.
Numerator – the number in the denominator who have a care plan that specifies early warning symptoms of mania and depression relapse.
Denominator – the number of adults with bipolar disorder who have a care plan.
Data source: Local data collection.
b) Proportion of adults with bipolar disorder who have a care plan that specifies triggers of mania and depression relapse.
Numerator – the number in the denominator who have a care plan that specifies triggers of mania and depression relapse.
Denominator – the number of adults with bipolar disorder who have a care plan.
Data source: Local data collection.
c) Proportion of adults with bipolar disorder who have a care plan that specifies preferred response during mania and depression relapse.
Numerator – the number in the denominator who have a care plan that specifies preferred response during mania and depression relapse.
Denominator – the number of adults with bipolar disorder who have a care plan.
Data source: Local data collection.
d) Proportion of adults with bipolar disorder who have a care plan that specifies personal recovery goals.
Numerator – the number in the denominator who have a care plan that specifies personal recovery goals.
Denominator – the number of adults with bipolar disorder who have a care plan.
Data source: Local data collection.
Outcome
a) Adults with bipolar disorder who feel enabled to self manage their condition.
Data source: Health and Social Care Information Centre GP patient survey and local data collection.
b) Health related quality of life for adults with a long-term mental health condition.
Data source: Health and Social Care Information Centre GP patient survey and local data collection.
c) Frequency of relapse rates among adults with bipolar disorder.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as secondary care services, GP practices and community mental health services) ensure that systems are in place for adults with bipolar disorder to specify in their care plan early warning symptoms and triggers of mania and depression relapse, preferred response during relapse and personal recovery goals.
Healthcare professionals collaborate with adults with bipolar disorder to develop a care plan that specifies early warning symptoms and triggers of mania and depression relapse, preferred response during relapse and personal recovery goals.
Commissioners (such as clinical commissioning groups, NHS England local area teams and local authorities) commission services that ensure that adults with bipolar disorder have a care plan that specifies early warning symptoms and triggers of mania and depression relapse, preferred response during relapse and personal recovery goals.

What the quality statement means for service users and carers

Adults with bipolar disorder have a care plan that specifies what to look out for that might mean they are becoming unwell again or things that might act as a ‘trigger’ to becoming unwell, what the person would prefer to happen if they become unwell again and their personal recovery goals.

Source guidance

Equality and diversity considerations

Some adults with bipolar disorder may find it difficult to express their needs and aspirations. They may also find it difficult to understand bipolar disorder and what options they have for living well with the condition. Healthcare professionals who develop care plans with adults who have bipolar disorder should ensure that they support these adults to understand the condition and the options available, using carers, interpreters or advocates if needed.

Involving carers in care planning

This quality statement is taken from the bipolar disorder in adults quality standard. The quality standard defines clinical best practice in bipolar disorder in adults care and should be read in full.

Quality statement

Carers of adults with bipolar disorder are involved in care planning, decision-making and information sharing about the person as agreed in the care plan.

Rationale

Carers of people with bipolar disorder should be involved at every stage of care provision if the person with bipolar disorder agrees to it. It is particularly important for adults with bipolar disorder and their carers to plan for periods of crisis during times of wellbeing. Adults with bipolar disorder should be encouraged to make advance statements specifying who should receive information and who should make decisions on their behalf if they are unable to.

Quality measures

Structure
Evidence of local arrangements to ensure that carers are involved in care planning, decision-making and information sharing about the adult with bipolar disorder as agreed in the care plan.
Data source: Local data collection.
Process
a) Proportion of adults with bipolar disorder whose care plan includes statements on information sharing with carers.
Numerator – the number in the denominator whose care plan includes statements on information sharing with carers.
Denominator – the number of adults with bipolar disorder with an identified carer.
Data source: Local data collection.
b) Proportion of adults with bipolar disorder whose care plan includes statements on decision-making by carers.
Numerator – the number in the denominator whose care plan includes statements on decision-making by carers.
Denominator – the number of adults with bipolar disorder with an identified carer.
Data source: Local data collection.
Outcome
Carers’ satisfaction with services.
Data source: Health and Social Care Information Centre Personal Social Services Adult Social Care Survey and local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (such as community health services and mental health services) ensure that systems are in place for carers of adults with bipolar disorder to be involved in care planning, decision-making and information sharing about the adult with bipolar disorder as agreed within the care plan.
Health and social care practitioners ensure that they are aware of the role of carers and involve them in care planning, decision-making and information sharing about the adult with bipolar disorder as agreed within the care plan.
Commissioners (such as clinical commissioning groups and NHS England local area teams) ensure that local arrangements are in place to encourage adults with bipolar disorder to make advanced statements within their care plans on involving carers in care planning, decision-making and information sharing about them.

What the quality statement means for service users and carers

Carers of adults with bipolar disorder (who may be family members, partners or friends) are involved in care planning, decision-making and information sharing about the adult with bipolar disorder, which should be agreed with the person and included in their care plan. This is particularly important at the time of crisis when information should be given to carers who may need to make decisions on behalf of the adult with bipolar disorder if they are unable to.

Source guidance

  • Bipolar disorder (2014) NICE guideline CG185 recommendations 1.1.15 and 1.1.17.

Definitions of terms used in this quality statement

Carers
People who provide unpaid support to a partner, family member, friend or neighbour who is ill, struggling or disabled. [Bipolar disorder (NICE guideline CG185)]

Equality and diversity considerations

The workforce across agencies should, as far as possible, reflect the local community. Health and social care practitioners should have training to ensure that they have a good understanding of the culture of families they are working with. Interpreters should be provided if no practitioner is available who speaks a language in which the carers can communicate easily.

Psychological interventions: developmental

This quality statement is taken from the bipolar disorder in adults quality standard. The quality standard defines clinical best practice in bipolar disorder in adults care and should be read in full.
Developmental quality statements set out an emergent area of cutting-edge service delivery or technology currently found in a minority of providers and indicating outstanding performance. They will need specific, significant changes to be put in place, such as redesign of services or new equipment.

Quality statement

Adults with bipolar disorder are offered psychological interventions.

Rationale

Currently very few adults with bipolar disorder can access appropriate psychological interventions because of capacity and training issues within mental health services. Psychological interventions specifically developed for adults with bipolar disorder (such as enhanced relapse prevention/individual psychoeducation or cognitive behavioural therapy for bipolar disorder) have been shown to improve symptoms and prevent relapses and hospitalisation. Adults with bipolar disorder can be offered psychological intervention as individual, group or family intervention depending on accessibility and suitability to them.

Quality measures

Structure
a) Evidence of local arrangements for the provision of psychological intervention programmes.
Data source: Local data collection.
b) Evidence of practice arrangements and written clinical protocols to ensure that adults with bipolar disorder are offered psychological interventions.
Data source: Local data collection.
Process
Proportion of adults with bipolar disorder who receive a psychological intervention.
Numerator – the number in the denominator who receive a psychological intervention.
Denominator – the number of adults with bipolar disorder.
Data source: Local data collection.
Outcome
a) Relapse rates for adults with bipolar disorder.
Data source: Health and Social Care Information Centre Improving Access to Psychological Therapies dataset (IAPT) and local data collection.
b) Hospital admission rates for adults with bipolar disorder.
Data source: Health and Social Care Information Centre Hospital Episode Statistics and local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GP practices, community health services and mental health services) ensure that systems are in place for adults with bipolar disorder to be offered psychological interventions.
Healthcare professionals offer adults with bipolar disorder psychological interventions.
Commissioners (such as clinical commissioning groups, NHS England local area teams and local authorities) commission services that deliver psychological interventions and ensure that adults with bipolar disorder are offered a referral to these services.

What the quality statement means for service users and carers

Adults with bipolar disorder are offered psychological treatment for bipolar disorder to help them manage their symptoms and stay well in the future.

Source guidance

  • Bipolar disorder (2014) NICE guideline CG185 recommendations 1.2.5, 1.6.1 and 1.7.3 (key priority for implementation).

Definitions of terms used in this quality statement

Psychological interventions
Psychological interventions recommended specifically for adults with bipolar disorder include:
  • a psychological intervention that has been developed specifically for bipolar disorder and has a published, evidence-based manualA manual based on at least 1 randomised controlled trial published in a peer‑reviewed journal showing effectiveness of the intervention in reducing depression symptoms in bipolar depression or, when used as long‑term treatment, reducing relapse in people with bipolar disorder. describing how it should be delivered or
  • a high-intensity psychological intervention (cognitive behavioural therapy, interpersonal therapy or behavioural couples therapy) in line with recommendations 1.5.3.1–1.5.3.5 in the NICE clinical guideline on depression.
Psychological interventions can be delivered as a one-to-one, group or family therapy and should address the presentation of adults with bipolar disorder.
[Bipolar disorder (NICE guideline CG185) recommendations 1.2.5, 1.6.1 and expert opinion]

Equality and diversity considerations

Specialist mental health services should provide person-centred psychological interventions that are appropriate for different ethnic and cultural backgrounds and that take into account differences in beliefs about biological, social, psychological and family influences on mental states.

Maintaining plasma lithium levels

This quality statement is taken from the bipolar disorder in adults quality standard. The quality standard defines clinical best practice in bipolar disorder in adults care and should be read in full.

Quality statement

Adults with bipolar disorder prescribed lithium have their dosage adjusted if their plasma lithium levels are outside the optimum range.

Rationale

Lithium is effective in treating mania, recurrent depression, and preventing further mood episodes and suicide in adults with bipolar disorder. It has a narrow optimum range, with plasma lithium levels below 0.6 mmol per litre ineffective and plasma lithium levels above 0.8 mmol per litre linked to increased toxicity.

Quality measures

Structure
Evidence of practice arrangements and written clinical protocols to ensure that adults with bipolar disorder who are prescribed lithium have their dosage adjusted if their plasma lithium levels are outside the optimum range.
Data source: Local data collection.
Process
Proportion of adults with bipolar disorder prescribed lithium who had their dosage adjusted if their plasma lithium levels were outside the optimum range.
Numerator – the number in the denominator who had their dosage adjusted if their plasma lithium levels were outside the optimum range.
Denominator – the number of adults with bipolar disorder prescribed lithium.
Data source: Local data collection. Data can be collected using the NICE Quality and Outcomes Framework menu indicator NM22 (QOF indicator MH010).
Outcome
a) Adults with bipolar disorder prescribed lithium who have their plasma lithium levels maintained within the optimum range.
Data source: Local data collection.
b) Kidney function among adults with bipolar disorder prescribed lithium.
Data source: Local data collection.
c) Thyroid function among adults with bipolar disorder prescribed lithium.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GP practices, community health services, mental health services and hospitals) ensure that shared care arrangements, procedures and protocols are in place to adjust lithium dosage and maintain plasma lithium levels within the optimum range for adults with bipolar disorder prescribed lithium.
Healthcare professionals ensure that adults with bipolar disorder prescribed lithium have their dosage adjusted if their plasma lithium levels are outside the optimum range.
Commissioners (such as NHS England area teams and clinical commissioning groups) specify in their contracts that there are shared care arrangements to ensure that adults with bipolar disorder prescribed lithium have their plasma lithium levels maintained within the optimum range.

What the quality statement means for service users and carers

Adults with bipolar disorder who are prescribed lithium have regular blood tests to check the amount of lithium in their blood and have their dose changed if they are not getting the right amount to ensure that it is both effective and non-toxic.

Source guidance

  • Bipolar disorder (2014) NICE guideline CG185, recommendations 1.10.15 and 1.10.19.

Definitions of terms used in this quality statement

Plasma lithium levels within the optimum range
Plasma lithium levels below 0.6 mmol per litre are ineffective and plasma lithium levels above 0.8 mmol per litre are linked to increased toxicity. Once lithium has been started and stabilised, plasma lithium levels need to be maintained within the range of 0.6–0.8 mmol per litre.
If the adult with bipolar disorder needs plasma lithium levels maintained at above 0.8 mmol per litre, they should have their lithium levels monitored at least every 3 months.
[Bipolar disorder (NICE guideline CG185) adapted from recommendations 1.10.15 and 1.10.20]

Valproate

This statement has been removed and is replaced by statement 1: valproate in the quality standard for antenatal and postnatal mental health (QS115).

Assessing physical health

This quality statement is taken from the bipolar disorder in adults quality standard. The quality standard defines clinical best practice in bipolar disorder in adults care and should be read in full.

Quality statement

Adults with bipolar disorder have a physical health assessment at least annually.

Rationale

Life expectancy among adults with bipolar disorder is estimated to be 15–20 years lower than for the general population. Causes contributing to high morbidity and premature mortality among adults with bipolar disorder include cardiovascular disease, respiratory disease, diabetes and obesity. Assessing physical health allows healthcare professionals to identify early signs and symptoms of poor health and take action to address them.

Quality measures

Structure
a) Evidence of local arrangements to ensure that adults with bipolar disorder receive a physical health assessment at least annually.
Data source: Local data collection.
b) Evidence of local arrangements to ensure that symptoms of poor physical health identified during the physical health assessment of adults with bipolar disorder are addressed.
Data source: Local data collection.
Process
a) Proportion of adults with bipolar disorder who receive an annual physical health assessment.
Numerator – the number in the denominator who received an annual physical health assessment within the last 12 months.
Denominator – the number of adults with bipolar disorder.
Data source: Local data collection. Some of the information can be collected using NICE Quality and Outcomes Framework menu indicators NM15 (QOF indicator MH007), NM16, NM17 (QOF indicator MH003), NM18 and NM42.
b) Proportion of adults with bipolar disorder who receive treatment or intervention for symptoms of poor physical health identified during the physical health assessment.
Numerator – the number in the denominator who receive treatment or intervention for symptoms of poor physical health identified during the physical health assessment.
Denominator – the number of adults with bipolar disorder who receive an annual physical health assessment that identified symptoms of poor physical health.
Data source: Local data collection.
Outcome
Premature mortality among adults with bipolar disorder.
Data source: Local data collection.

What the quality statement means for service providers, healthcare professionals and commissioners

Service providers (such as GP practices, community health services and mental health services) ensure that protocols are in place to carry out physical health assessment in adults with bipolar disorder at least annually, and that the assessment results are acted on.
Healthcare professionals carry out a physical health assessment at least annually in adults with bipolar disorder, take appropriate actions based on assessment results and share the results (under shared care arrangements) if the adult is in the care of primary and secondary services.
Commissioners (such as clinical commissioning groups, NHS England local area teams and local authorities) ensure that they commission services that carry out an annual physical health assessment in adults with bipolar disorder at least annually, and take appropriate actions based on assessment results. They include this requirement in continuous training programmes and service specifications.

What the quality statement means for service users and carers

Adults with bipolar disorder have a physical health assessment at least once a year and receive support if any health problems are identified. A copy of the results should be sent to their care coordinator and psychiatrist, and put in their records.

Source guidance

  • Bipolar disorder (2014) NICE guideline CG185 recommendations 1.2.11 and 1.2.12.

Definitions of terms used in this quality statement

Physical health assessment
A physical health assessment for adults with bipolar disorder should include:
  • weight or BMI, diet, nutritional status and level of physical activity
  • cardiovascular status, including pulse and blood pressure
  • metabolic status, including fasting blood glucose, glycosylated haemoglobin (HbA1c) and blood lipid profile
  • liver function
  • renal and thyroid function, and calcium levels, for adults taking long-term lithium.
Hypertension, abnormal lipid levels, obesity or risk of obesity, diabetes or risk of diabetes, or physical inactivity among adults with bipolar disorder should be identified at the earliest opportunity and treated in line with the NICE guidelines on hypertension, lipid modification, prevention of cardiovascular disease, obesity (prevention, identification, assessment and management, weight management services), physical activity and preventing type 2 diabetes.
[Adapted from Bipolar disorder (NICE guideline CG185) recommendations 1.2.11, 1.2.12, 1.2.13 and 1.2.14]

Supported employment programmes

This quality statement is taken from the bipolar disorder in adults quality standard. The quality standard defines clinical best practice in bipolar disorder in adults care and should be read in full.

Quality statement

Adults with bipolar disorder who currently work, and those who wish to find or return to work, receive supported employment programmes.

Rationale

Although employment rates for adults with bipolar disorder are higher than for people with other severe mental health problems, bipolar disorder frequently leads to workplace underperformance, absenteeism and decline in occupational status. There are also particular risks for some people with bipolar disorder when they undertake shift work. Supported employment programmes can help adults with bipolar disorder stay in employment or move to another job, and identify employment opportunities for those who wish to find work.

Quality measures

Structure
Evidence of local arrangements to ensure that adults with bipolar disorder who currently work, and those who wish to find or return to work, receive supported employment programmes.
Data source: Local data collection.
Process
a) Proportion of adults with bipolar disorder who currently work who receive supported employment programmes.
Numerator – the number in the denominator who receive a supported employment programme.
Denominator – the number of adults with bipolar disorder who currently work.
Data source: Local data collection.
b) Proportion of adults with bipolar disorder who wish to find or return to work who receive supported employment programmes.
Numerator – the number in the denominator who receive a supported employment programme.
Denominator – the number of adults with bipolar disorder who wish to find or return to work.
Data source: Local data collection.
Outcome
Employment rates among adults with bipolar disorder.
Data source: Local data collection. National data are collected in the Health and Social Care Information Centre Mental health and learning disabilities data set.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers (such as GP practices, community health services and mental health services) ensure that systems are in place for adults with bipolar disorder who currently work, and those who wish to find or return to work, to be offered supported employment programmes.
Health and social care practitioners ensure that they are aware of local referral pathways for supported employment programmes, and offer these to adults with bipolar disorder who currently work or who wish to find or return to work.
Commissioners (such as NHS England area teams and clinical commissioning groups) ensure that they commission services that offer supported employment programmes, and referral pathways for these programmes, for adults with bipolar disorder who currently work or who wish to find or return to work.

What the quality statement means for service users and carers

Adults with bipolar disorder who work or wish to find or return to work receive a place on an employment scheme (also called a supported employment programme) that helps them to stay in their current job, or to find or return to work quickly.

Source guidance

Definitions of terms used in this quality statement

Supported employment programmes
Supported employment programmes provide support to people with disabilities or other disadvantaged groups to secure and maintain paid employment in the open labour market.

Equality and diversity considerations

Services should work in partnership with local stakeholders, including those representing minority ethnic groups, to enable adults with bipolar disorder to stay in work or education or find new employment, volunteering and educational opportunities.
Services should make reasonable adjustments (see the Health and Safety Executive’s Health and safety for disabled people) to help adults with bipolar disorder stay in work or education, or find new employment, volunteering and educational opportunities.
Some adults may be unable to work or unsuccessful in finding employment. Other occupational or education activities should be considered for these adults, including pre-vocational training.

Effective interventions library

Effective interventions library

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Implementation

These resources include support for commissioners to plan for costs and savings of guidance implementation and meeting quality standards where they apply.
These resources will help to inform discussions with providers about the development of services and may include measurement and action planning tools.
These resources provide help with planning ahead for NICE guidance, understanding where you are now, and conducting improvement initiatives.

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Your responsibility

Guidelines

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this pathway is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the pathway to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Technology appraisals

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this pathway is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this pathway represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the pathway does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this pathway should be interpreted in a way that would be inconsistent with compliance with those duties.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Monitor the physical health of people with bipolar disorder when responsibility for monitoring is transferred from secondary care, and then at least annually. The health check should be comprehensive, including all the checks recommended below and focusing on physical health problems such as cardiovascular disease, diabetes, obesity and respiratory disease. A copy of the results should be sent to the care coordinator and psychiatrist, and put in the secondary care records.
Ensure that the physical health check for people with bipolar disorder, performed at least annually, includes:
  • weight or BMI, diet, nutritional status and level of physical activity
  • cardiovascular status, including pulse and blood pressure
  • metabolic status, including fasting blood glucose, glycosylated haemoglobin (HbA1c) and blood lipid profile
  • liver function
  • renal and thyroid function, and calcium levels, for people taking long-term lithium.
Identify people with bipolar disorder who have hypertension, have abnormal lipid levels, are obese or at risk of obesity, have diabetes or are at risk of diabetes (as indicated by abnormal blood glucose levels), or are physically inactive, at the earliest opportunity. Follow the NICE pathways on hypertension, cardiovascular disease prevention, obesity, physical activity and preventing type 2 diabetes.
Offer treatment to people with bipolar disorder who have diabetes and/or cardiovascular disease in primary care in line with the NICE pathways on diabetes and cardiovascular disease prevention.
  • undertake a full psychiatric assessment, documenting a detailed history of mood, episodes of overactivity and disinhibition or other episodic and sustained changes in behaviour, symptoms between episodes, triggers to previous episodes and patterns of relapse, and family history
  • assess the development and changing nature of the mood disorder and associated clinical problems throughout the person's life (for example, early childhood trauma, developmental disorder or cognitive dysfunction in later life)
  • assess social and personal functioning and current psychosocial stressors
  • assess for potential mental and physical comorbidities
  • assess the person's physical health and review medication and side effects, including weight gain
  • discuss treatment history and identify interventions that have been effective or ineffective in the past
  • encourage people to invite a family member or carer to give a corroborative history
  • discuss possible factors associated with changes in mood, including relationships, psychosocial factors and lifestyle changes
  • identify personal recovery goals.
Take into account the possibility of differential diagnoses including schizophrenia spectrum disorders, personality disorders, drug misuse, alcohol-use disorders, attention deficit hyperactivity disorder and underlying physical disorders such as hypo- or hyperthyroidism. For more information see the NICE pathways on:
Carry out a risk assessment in conjunction with the person with bipolar disorder, and their carer if possible, focusing on areas that are likely to present possible danger or harm, such as self-neglect, self-harm, suicidal thoughts and intent, risks to others, including family members, driving, spending money excessively, financial or sexual exploitation, disruption in family and love relationships, disinhibited and sexualised behaviour, and risks of sexually transmitted diseases. For the management of risk follow the recommendations in managing crisis, risk and behaviour that challenges in this pathway.
When offering psychotropic medication to older people, take into account its impact on cognitive functioning in older people and:
  • use medication at lower doses
  • take into account the increased risk of drug interactions
  • take into account the negative impact that anticholinergic medication, or drugs with anticholinergic activity, can have on cognitive function and mobility
  • ensure that medical comorbidities have been recognised and treated.
  • a psychological intervention that has been developed specifically for bipolar disorder and has a published evidence-based manual describing how it should be delivered or
  • a high-intensity psychological intervention (cognitive behavioural therapy, interpersonal therapy or behavioural couples therapy) in line with the NICE pathway on depression.
Discuss the use of alcohol, tobacco, prescription and non-prescription medication and illicit drugs with the person, and their carer if appropriate. Explain the possible interference of these substances with the therapeutic effects of prescribed medication and psychological interventions.
Do not offer gabapentin or topiramate to treat bipolar disorder.

Glossary

A person who provides unpaid support to a partner, family member, friend or neighbour who is ill, struggling or disabled.
The severity of bipolar depression is defined in line with the NICE pathway on depression as follows: mild depression – few, if any, symptoms in excess of the 5 required to make the diagnosis, with symptoms resulting in minor functional impairment; moderate depression – symptoms or functional impairment that are between mild and severe; severe depression – most symptoms, with symptoms markedly interfering with functioning. Can occur with or without psychotic symptoms.
Based on at least 1 randomised controlled trial published in a peer-reviewed journal showing effectiveness in reducing depression symptoms in bipolar depression or preventing relapse when used as long-term treatment in people with bipolar disorder.
As required.
Refers to 3 formulations of valproate available in the UK: sodium valproate, valproic acid and semi-sodium valproate. At the time of publication (September 2014), sodium valproate and valproic acid had UK marketing authorisation for the treatment of epilepsy. Semi-sodium valproate had a UK marketing authorisation for the treatment of acute mania and for continuation treatment in people who have had mania that has responded to treatment with semi-sodium valproate. Both semi-sodium and sodium valproate are metabolised to valproic acid (also known as valproate), which is the pharmacologically active component.

Paths in this pathway

Pathway created: September 2014 Last updated: February 2016

© NICE 2016

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