GPAtlas🧭 When to suspect
Bipolar disorder is a recurrent, long-term disorder of mood and energy in which episodes of mania or hypomania alternate with episodes of depression, usually with periods of relative stability in between. Bipolar I requires at least one manic episode; bipolar II is defined by hypomania plus major depression, without full mania. Most people are well between episodes, but the condition is relapsing and remitting across a lifetime.
The single most useful insight in primary care is that most people with bipolar disorder first present with depression, and the underlying bipolarity is easily missed. The diagnostic distinction that matters is therefore mania versus hypomania, set out below.
| Feature | Hypomania | Mania |
|---|---|---|
| Duration | ≥ 4 days | ≥ 7 days (or any length if admission is needed) |
| Function | Noticeable change, but not markedly impaired | Marked impairment of social or occupational function |
| Psychosis | Absent | May be present (delusions, hallucinations) |
| Admission | Not required | Often required |
Raise suspicion in anyone with recurrent depression – especially with early onset (symptoms often emerge in the late teens to mid-twenties), a family history of bipolar disorder, postpartum episodes, treatment resistance, or an elevated mood triggered by an antidepressant. Ask directly about past periods of overactivity or disinhibition lasting four days or more; if present, refer for specialist assessment. Diagnosis and treatment initiation are a secondary-care responsibility – the GP's enduring role is recognising possible bipolarity, supporting shared-care monitoring, and spotting relapse early.
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⚠️ Common pitfall Treating bipolar depression as ordinary treatment-resistant unipolar depression. Someone returning repeatedly for “depression that won’t respond” may have an undiagnosed bipolar illness, and starting an antidepressant alone can precipitate a switch to mania or rapid cycling. Before escalating antidepressants, ask explicitly about previous highs – a few days of reduced need for sleep with sustained overactivity is the clue that is so often not volunteered. |
Source: NICE CG185
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