Updated NICE Guideline CG185 – ‘Bipolar disorder: assessment and management’
This NICE guideline CG185 was updated recently and provides new information on Bipolar disorder: assessment and management.
The most recent update of NICE clinical guideline CG185 was December 2023 it specifies that valproate should not be initiated in individuals under 55 years of age without careful consideration by two specialists unless no other effective or tolerated treatment options are available or there are compelling reasons why the reproductive risks do not apply.
Advice on the assessment and management of bipolar disorder
If a person develops mania or hypomania and is taking an antidepressant (as defined by the British National Formulary [BNF]) as monotherapy:
- consider stopping the antidepressant and
- offer an antipsychotic (haloperidol, olanzapine, quetiapine or risperidone), regardless of whether the antidepressant is stopped.
If a person develops mania or hypomania and is not taking an antipsychotic or mood stabiliser, offer haloperidol, olanzapine, quetiapine or risperidone, taking into account any advance statements, the person’s preference and clinical context (including physical comorbidity, previous response to treatment and side effects).
If the first antipsychotic is poorly tolerated at any dose (including rapid weight gain) or ineffective at the maximum licensed dose, offer an alternative antipsychotic (haloperidol, olanzapine, quetiapine or risperidone), taking into account any advance statements, the person’s preference and clinical context (including physical comorbidity, previous response to treatment and side effects).
If an alternative antipsychotic is not sufficiently effective at the maximum licensed dose, consider adding lithium.
Do not start valproate for the first time in people (male or female) younger than 55 years, unless 2 specialists independently agree and document that there is no other effective and tolerated treatment, or there are compelling reasons that the reproductive risks do not apply.
A summary of NICE clinical guideline CG185
This guideline offers comprehensive recommendations for assessing and managing bipolar disorder. Here are the key points:
Assessment: Conduct a thorough assessment, including medical and psychiatric history, physical examination, and mental state evaluation. Screen for substance use and consider referral to specialist services if necessary.
Initial management: Provide psychoeducation and support for patients and their families or carers. Discuss the diagnosis, prognosis, and available treatment options, outlining potential benefits and risks.
Pharmacological interventions: Consider mood stabilisers (such as lithium, valproate, or carbamazepine) as first-line treatments for acute mania or hypomania. Use antipsychotic medication (such as olanzapine, quetiapine, or risperidone) if mood stabilisers are ineffective or not tolerated.
Monitoring: Regularly monitor patients on mood stabilisers for adverse effects and therapeutic levels. Monitor physical health, including weight, blood pressure, and renal function, especially for those on lithium.
Psychological interventions: Offer psychological therapies such as cognitive-behavioral therapy (CBT), family-focused therapy (FFT), or interpersonal and social rhythm therapy (IPSRT) as adjuncts to pharmacotherapy, particularly for preventing relapse.
Long-term management: Develop a personalised treatment plan that includes ongoing monitoring, relapse prevention strategies, and support for managing comorbidities.
Pregnancy and breastfeeding: Provide information and support for women with bipolar disorder who are planning pregnancy or who are pregnant or breastfeeding, considering the potential risks and benefits of medication.
Special considerations: Tailor treatment plans to meet the needs of specific populations, such as children and young people, older adults, and those with comorbidities like substance misuse or personality disorder.
These recommendations aim to ensure that individuals with bipolar disorder receive holistic and personalised care, addressing both acute symptoms and long-term management while considering individual preferences and circumstances.
Find more about this guideline: Overview | Bipolar disorder: assessment and management | Guidance | NICE
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