Bipolar Disorder

NICE clinical guideline [CG185] Bipolar disorder: assessment and management. Last updated: Dec 2023. NICE CKS Bipolar disorder. Last revised: May 2025.

Guidelines

Refer all suspected bipolar disorder to specialist mental health service to confirm the diagnosis and subsequent treatment plan.

Refer for urgent mental health assessment if the patient presents with mania or severe depression or is a danger to themselves or others.

 

Do not start lithium in primary care for people who have not taken lithium before, except under shared‑care arrangements

Do not start antipsychotic medication unless advised by a consultant psychiatrist

Consider tapering antidepressant medication on specialist advice if mania develops

Mania / hypomania should NOT be managed solely in primary care.

Where to treat:
  • Mania (all cases) → refer urgently to secondary care mental health services (community mental health team or crisis team)
  • Hypomania with low risk → refer to secondary mental health services for assessment (urgency depends on severity and risk)


How to treat:
  • Step 1: offer an antipsychotic (haloperidol / olanzapine / quetiapine / risperidone), and stop any antidepressants (if patient is taking one)
  • Step 2: offer an alternative antipsychotic
  • Step 3: add lithium
  • Step 4: add sodium valproate

 

If the patient is already on mood stabilisers (e.g. lithium, sodium valproate):

  • 1st line: increase the dose of the medication 
  • If that fails, then add drugs as outlined above


NB if taking lithium, measure plasma lithium levels to guide dose increase.

Offer all patients psychological intervention

Pharmacological interventions are indicated if there is moderate / severe bipolar depression:
  • 1st line: olanzapine +/- fluoxetine or quetiapine alone
  • 2nd line: lamotrigine alone (stop the 1st line drugs)

 

If the patient is already on mood stabilisers (e.g. lithium, sodium valproate):

  • 1st line: increase the dose of the medication 
  • If that fails, then add drugs as outlined above


NB if taking lithium, measure plasma lithium levels to guide dose increase.

The core concept of treating bipolar depression is NOT to offer an antidepressant alone. Either give an antidepressant with an antipsychotic, or don't at all.

Offer psychological interventions and family intervention

Choice of pharmacological treatment (i.e. mood stabilisers):
  • 1st line: lithium
  • 2nd line: antipsychotic (e.g. risperidone, quetiapine, olanzapine, aripiprazole, asenapine)
  • 3rd line: sodium valproate + lithium / antipsychotic
Author: Adams Lau
Reviewer:
Last edited : 25/07/25