Setting

This audit was carried out in a learning disability service but would be equally relevant to any psychiatrists managing bipolar disorder within their community or in-patient population.

Background

According to the National Institute for Health and Clinical Excellence (2006):

ᐅ cases of bipolar disorder often remain unrecognised, resulting in suboptimal treatment and an increase in the total healthcare costs

ᐅ the annual societal cost of bipolar disorder in the UK is about £2 billion.

Standards

Standards were obtained from Bipolar Disorder: The Management of Bipolar Disorder in Adults, Children and Adolescents, in Primary and Secondary Care (National Institute for Health and Clinical Excellence, 2006).

ᐅ Risk assessment should be undertaken when bipolar disorder is first diagnosed, after a change in the patient's mental state and at discharge.

ᐅ In the management of acute episodes, antidepressants should be stopped and antipsychotics should be considered, taking into account side-effects and future prophylaxis. Lithium or valproate should be considered if symptoms previously responded to these medications, but they should not be prescribed routinely for women of child-bearing potential.

ᐅ Patients should not routinely continue on long-term antidepressant treatment. In the long term, lithium, olanzapine and valproate should be considered.

ᐅ For frequent relapses or severe functional impairment, an alternative monotherapy or the addition of a second prophylactic agent should be considered.

ᐅ A brief assessment of cognitive state should be carried out if there is evidence of memory impairment or suspected lithium toxicity.

ᐅ If a combination of prophylactic agents is ineffective, consideration should be given to referring the patient to a specialist, and to the prescription of lamotrigine or carbamazepine.

ᐅ Clinical state, side-effects, blood levels and early warning signs should be monitored.

ᐅ Discussions regarding reasons for the choice of agent and potential benefits and risks should be documented.

ᐅ Physical monitoring should be done after initial presentation and at annual check-up.

ᐅ Trusts should ensure that all clinicians have access to advice from designated specialists and the opportunity to refer to tertiary centres.

The target was that these standards were being met for all patients.

Method

Data collection

The target population included all community learning disability patients with bipolar disorder in the trust.