Risk assessment and management in bipolar disorders

Darryl L Bassett
Med J Aust 2010; 193 (4): S21. || doi: 10.5694/j.1326-5377.2010.tb03893.x
Published online: 16 August 2010
Risk assessment
Risk management
Fundamental clinical approach to risk management

Communication is the key intervention for managing risk. The clinician should advise the patient (and significant others, as appropriate) of the nature of the problem, and emphasise the level of concern. The clinician should also express confidence in being able to help and, where feasible, agree to a mutually satisfactory risk-management plan. Specific treatment interventions, such as medications, are fundamental. Appropriate authorities should be notified of risk, as should those directly involved in the risk if it includes others. This is essential if the patient has specifically divulged homicidal plans. If the patient is suicidal, the guidelines provided in Box 3 should be considered.

It is appropriate to explore simple measures of risk reduction such as asking a spouse to take charge of the patient’s credit card, to remove the risk of overspending during mania, and removing access to easy means of suicide (notably firearms and potentially lethal medications). For many patients there will be a history of previous illness episodes, and patients can be encouraged to take their own protective strategies. For example, patients may arrange for access to money to be voluntarily restricted or for medication supplies to be kept in a secure place. They should be encouraged to determine the “personal signature” of their early signs of relapse, so that help can be sought before risks become significant.

During instances of homicidal thoughts and impulses, close support and supervision is essential. Treatment in hospital is usually most appropriate.

In either phase of bipolar illness, concerted treatment is required, with regular review. The patient and significant others need to know how to access help in an emergency. Referral to a public mental health service or private psychiatrist may often be appropriate.

Hospital treatment is appropriate if the risk is high or if psychosocial supports are suboptimal. Compulsory hospital treatment might be required if the risk to self or others is high, if insight and judgement are poor, or if adherence to treatment is inadequate. If compulsory hospitalisation is required, the appropriate forms defined by the local Mental Health Act will be required and contact should be made with a hospital recognised under that Act. Police and ambulance services may also need to be involved. After the patient has recovered sufficiently from an episode which required compulsory treatment, it is good practice to arrange an opportunity to discuss and review — with both the patient and his or her family — the need for compulsory treatment and its impact.


Bipolar affective disorders carry significant risks for patients and those around them. These risks must be kept in mind and addressed conscientiously.

  • Darryl L Bassett

  • Hollywood Specialist Centre, Perth, WA.


Competing interests:

I have received fees from Pfizer and AstraZeneca for advisory board membership, from MDA National for consultancy, from the Medical Board of Western Australia and various legal firms in WA for expert testimony, honoraria from Pfizer, Wyeth, Eli Lilly, AstraZeneca, Servier and Janssen-Cilag, fees from Pfizer for development of educational presentations, funding for travel and accommodation from Pfizer, Wyeth, Eli Lilly, Servier and AstraZeneca, and lecture fees from the Churchill Clinic. I have also received royalties from several books.

  • 1. Goodwin F, Jamison K. Manic-depressive illness. Bipolar disorders and recurrent depression. New York: Oxford University Press, 2007.
  • 2. Joyce P, Mitchell P, editors. Mood disorders: recognition and treatment. Sydney: University of New South Wales Press, 2004.
  • 3. Petit J. Management of the acutely violent patient. Psychiatr Clin North Am 2005; 28: 701-712.
  • 4. Rihmer Z, Pestality P. Bipolar II disorder and suicidal behaviour. Psychiatr Clin North Am 1999; 22: 667-673.
  • 5. Castle D, Bassett D. A primer of clinical psychiatry. Sydney: Churchill Livingstone, 2009.


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