What criteria should I use to determine when to refer a patient with suspected bipolar disorder to a psychiatrist?

Refer a patient with suspected bipolar disorder to a psychiatrist if any of the following criteria are met:

• There is suspicion of mania or severe depression.
• The patient poses a danger to themselves or others.
• There is a history or current presentation of overactivity or disinhibited behaviour lasting 4 days or more.
• The patient shows poor or partial response to treatment, significant decline in functioning, poor treatment adherence, or intolerable/medically important side effects from medication.
• Comorbid alcohol or drug misuse is suspected.
• The patient is considering stopping any medication after a period of relatively stable mood.
• A woman with bipolar disorder is pregnant or planning a pregnancy.

Urgent referral is recommended if mania or severe depression is suspected or if there is immediate risk to self or others. Routine referral should be considered when overactivity or disinhibited behaviour has lasted 4 days or more, or when any of the above clinical concerns arise during management in primary care.

Do not use questionnaires in primary care to identify bipolar disorder; instead, base referral decisions on clinical assessment and risk factors.