Quality standard

Quality statement 1: Referral for specialist mental health assessment

Quality statement 1: Referral for specialist mental health assessment

Quality statement

Adults presenting in primary care with symptoms of depression are offered a referral for a specialist mental health assessment if they have experienced overactivity or disinhibited behaviour lasting 4 days or more.

Rationale

The initial presentation in primary care for adults with bipolar disorder is usually with symptoms of depression. If the adult with bipolar disorder receives treatment for depression only, the intervention is ineffective and potentially harmful. If the adult presenting with depression has also experienced overactivity or disinhibited behaviour recently or in the past, depression may be a symptom of an underlying bipolar disorder. It indicates a need for further specialist mental health assessment.

Quality measures

The following measures can be used to assess the quality of care or service provision specified in the statement. They are examples of how the statement can be measured and can be adapted and used flexibly.

Structure

Evidence of practice arrangements and written clinical protocols to ensure that adults presenting with symptoms of depression are referred for a specialist mental health assessment if they have experienced overactivity or disinhibited behaviour lasting 4 days or more.

Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from service specifications.

Process

a) Proportion of adults presenting in primary care with symptoms of depression who are asked if they have experienced overactivity or disinhibited behaviour lasting 4 days or more.

Numerator – the number in the denominator asked if they have experienced overactivity or disinhibited behaviour lasting 4 days or more.

Denominator – the number of adults presenting in primary care with symptoms of depression.

Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.

b) Proportion of adults presenting in primary care with symptoms of depression who have experienced overactivity or disinhibited behaviour lasting 4 days or more who were referred for a specialist mental health assessment.

Numerator – the number in the denominator referred for a specialist mental health assessment.

Denominator – the number of adults presenting in primary care with symptoms of depression who have experienced overactivity or disinhibited behaviour lasting 4 days or more.

Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.

Outcome

a) Referral rates for specialist mental health assessment.

Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.

b) Recognition of bipolar disorder within the community.

Data source: No routinely collected national data for this measure has been identified. Data can be collected from information recorded locally by healthcare professionals and provider organisations, for example from patient records.

What the quality statement means for different audiences

Service providers (such as GP practices, community health services and drug and alcohol misuse services) ensure that systems and protocols are in place for adults who present in primary care with symptoms of depression to be asked about experiences of overactivity or disinhibited behaviour lasting 4 days or more and referred for a specialist mental health assessment if needed.

Healthcare professionals ask adults who present in primary care with symptoms of depression about experiences of overactivity or disinhibited behaviour lasting 4 days or more, and follow local pathways and criteria for adults who need to be referred for a specialist mental health assessment.

Commissioners commission services that carry out specialist mental health assessments and ensure that local referral pathways are in place for adults who present in primary care with symptoms of depression who have also experienced overactivity or disinhibited behaviour lasting 4 days or more to receive a specialist mental health assessment.

Adults who see their GP with symptoms of depression are referred for a specialist mental health assessment if they have not been in control of their mood and behaviour for 4 days in a row or longer.

Source guidance

Bipolar disorder: assessment and management. NICE guideline CG185 (2014, updated 2023), recommendation 1.2.1

Definitions of terms used in this quality statement

Symptoms of depression

Symptoms of depression include:

  • depressed mood

  • diminished interest or pleasure in all, or almost all, activities

  • significant changes in appetite or weight

  • slowing down of thoughts and reduction in physical movement

  • fatigue or loss of energy

  • beliefs of low self-worth or inappropriate guilt

  • reduced ability to concentrate and sustain attention or marked indecisiveness

  • hopelessness about the future

  • significantly disrupted sleep or excessive sleep

  • recurrent thoughts of death or suicidal ideation or evidence of attempted suicide.

[Adapted from NICE's guideline on depression in adults, terms used in this guideline; depression]

Referral for specialist mental health assessment

Adults with symptoms of depression presenting in primary care should be offered a referral for specialist mental health assessment if overactivity or disinhibited behaviour has lasted for 4 days or more. Overactivity or disinhibited behaviour may include:

  • elated, expansive or irritable mood

  • increased activity

  • decreased need for sleep

  • increased talkativeness

  • fast or racing thinking

  • inflated self‑esteem or self‑importance

  • increased sexual activity

  • attention easily drawn to irrelevant stimuli

  • excessive involvement in activities with high potential for undesired consequences, such as overspending or risky behaviours.

[NICE's guideline on bipolar disorder, recommendations 1.2.5 and expert opinion]