Recognising Bipolar Disorders in Primary Care.

Bipolar disorder, previously called 'Manic-depression', is a complex group of conditions characterised by recurrent changes in mood and energy. Crucially, the intensity and duration of these changes go beyond normal fluctuations and personality traits. Bipolar Disorder is a mental health disorder, but physical health manifestations (Smith 2013, Westman 2013, Fagiolini 2008, Young 2013) and complications are just as important. GPs have a key role in the recognition and management, in conjunction with secondary care colleagues. Diagnosis is often difficult and may take several years (Smith 2011, Angst 2005, Manning 2010), because patients usually seek help for anxiety, depression or fatigue, not hypomania/mania, which they may not recognise. Individuals with a first episode of mania are more likely to present directly to secondary care, sometimes via a third party alerting the emergency services. There is also debate around the classification, diagnosis and treatment of individuals with brief and milder mood changes ('bipolar spectrum disorder') (Faravelli 2009, Spence 2011). In the UK, the recent NICE Guidelines (2014) 1 only included Bipolar I and Bipolar II for these reasons. A particular challenge for GPs is that whilst most people who have Bipolar Disorder (and especially Bipolar II) are depressed, most people with depression within a Primary Care setting do not have Bipolar Disorder. Thus, a brief pragmatic screen is recommended in Primary care: ask about a family history of Bipolar Disorder and screen for a history of mania/hypomania in individuals with anxiety, depression or irritability, especially if there are recurrent episodes, suicidal thoughts or a previous suicide attempt. For suspected cases, formal diagnosis should not be made within Primary Care but individuals should be referred for Psychiatric assessment, ideally to a Mood Disorders specialist.