When should I consider referring a patient with bipolar disorder to secondary mental health services?

You should consider referring a patient with bipolar disorder to secondary mental health services in several key situations:

• Suspected Diagnosis: Refer all people with suspected bipolar disorder (from age 14 years onwards) to a specialist mental health service to confirm the diagnosis, treat the acute episode, and establish a care plan ¹. If an adult presents with depression, ask about previous periods of overactivity or disinhibited behaviour; if such behaviour lasted for four days or more, consider referral for a specialist mental health assessment ².
• Urgent Assessment: Refer people urgently for a specialist mental health assessment if mania or severe depression is suspected, or if they are a danger to themselves or others ¹,². If the person exhibits mania or severe depression and is judged to be at immediate risk of harm to themselves or others, arrange a same-day specialist assessment by the local Crisis Resolution and Home Treatment Team (CRHT) ³. If they exhibit mania or severe depression but are not judged to be at immediate risk of harm, urgently refer them for a specialist assessment by the community mental health service ³.
• Deterioration or Specific Issues (for patients managed in primary care): If a person with bipolar disorder is being managed solely in primary care, re-refer them to secondary care if any of the following apply:
  • There is a poor or partial response to treatment or treatment adherence is poor ¹,².
  • The person's functioning declines significantly ¹,².
  • They develop intolerable or medically important side effects from medication ¹,².
  • Comorbid alcohol or drug misuse is suspected ¹,².
  • The person is considering stopping any medication after a period of relatively stable mood ¹,².
  • A female of reproductive potential with bipolar disorder is taking sodium valproate without two specialists having independently considered and documented that there is no other effective or tolerated treatment ¹.
  • A woman with bipolar disorder is pregnant or planning a pregnancy ¹,².
  • They exhibit signs of hypomania or deterioration of depressive symptoms ²,³.