THE COMPETENT CANDIDATE

The competent candidate should be able to:

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Task 1: Take an appropriate psychiatric history, focusing on mood fluctuations, manic symptoms, and depressive episodes.

The competent candidate should:

• Establish rapport and create a non-judgmental environment to encourage disclosure of sensitive mental health symptoms.
• Use open-ended questions to explore the nature, onset, and duration of mood episodes.
• Identify manic symptoms, including:
  • Elevated mood, grandiosity, or irritability.
  • Reduced need for sleep but still feeling energetic.
  • Racing thoughts, pressured speech, and impulsivity (e.g., excessive spending).
  • Risk-taking behaviours (substance use, reckless decisions).
• Identify depressive symptoms, such as:
  • Low mood, fatigue, hopelessness, anhedonia.
  • Poor concentration, sleep disturbance, appetite changes.
  • Feelings of worthlessness or suicidal ideation.
• Assess psychosocial stressors (work issues, relationships, substance use).
• Conduct a risk assessment, including suicidal thoughts, self-harm, aggression, or psychosis.

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Task 2: Discuss your differential diagnosis, explaining how bipolar disorder is distinguished from depression, ADHD, or other mental health conditions.

The competent candidate should:

• Explain that bipolar disorder is characterised by distinct mood episodes, including both mania/hypomania and depression.
• Differentiate from:
  • Major Depressive Disorder (MDD): Persistent low mood without manic episodes.
  • ADHD: Overlapping symptoms such as impulsivity and inattention, but no distinct mood episodes.
  • Borderline Personality Disorder (BPD): Mood swings occur within hours, often triggered by interpersonal conflicts, whereas bipolar episodes last days to weeks.
  • Substance-Induced Mood Disorder: Rule out drug use as the sole cause of mood symptoms.
• Explain the importance of the DSM-5 criteria for Bipolar I and Bipolar II Disorder:
  • Bipolar I: At least one manic episode, may or may not have depressive episodes.
  • Bipolar II: Hypomania (less severe manic symptoms) plus major depressive episodes.
• Highlight diagnostic challenges and the importance of longitudinal assessment.

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Task 3: Outline a management plan, including medication, lifestyle interventions, and support services.

The competent candidate should:

• Educate the patient about bipolar disorder, explaining that it is a manageable but lifelong condition.
• Discuss pharmacological options:
  • Mood stabilisers (e.g., lithium, valproate) as first-line.
  • Atypical antipsychotics (e.g., quetiapine, olanzapine) if needed for acute mania.
  • Antidepressants should be used cautiously to avoid triggering mania.
• Non-pharmacological management:
  • Psychotherapy (CBT, psychoeducation, interpersonal therapy).
  • Sleep hygiene and routine stabilisation.
  • Substance use reduction (alcohol and drugs worsen mood instability).
• Crisis planning and risk management:
  • Provide a safety net for suicidal ideation.
  • Create a relapse prevention plan.
• Encourage family and social support, including involving the patient’s partner if appropriate.

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Task 4: Discuss referral options and follow-up to ensure appropriate long-term care.

The competent candidate should:

• Refer to a psychiatrist for diagnostic confirmation and medication initiation.
• Engage a psychologist for cognitive behavioural therapy (CBT) and mood monitoring.
• Discuss GP follow-up every 2-4 weeks initially, then adjust as needed.
• Monitor medication adherence and side effects (e.g., lithium toxicity, metabolic effects of antipsychotics).
• Address long-term considerations, such as employment support, disability support (if needed), and reproductive health considerations (if using mood stabilisers).

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SUMMARY OF A COMPETENT ANSWER

• Uses a structured psychiatric history, identifying bipolar symptoms, risk factors, and social impact.
• Explains the differential diagnosis clearly, distinguishing bipolar disorder from MDD, ADHD, and personality disorders.
• Provides a comprehensive management plan, including medications, psychotherapy, and lifestyle strategies.
• Refers appropriately to psychiatrists and psychologists, while ensuring regular GP follow-up.
• Communicates sensitively and reduces stigma, addressing the patient’s fears about diagnosis and treatment.

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PITFALLS

• Failing to establish rapport, leading to incomplete history-taking.
• Overlooking risk factors, such as suicidality, impulsivity, or substance use.
• Misdiagnosing as major depression, without screening for manic symptoms.
• Over-reliance on medication, without discussing psychotherapy and lifestyle interventions.
• Not involving specialist mental health services, delaying appropriate management.
• Using stigmatising language, which may make the patient reluctant to engage in treatment.

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REFERENCES

• RACGP Guidelines – Mental Health
• GP Exams – Bipolar Disorder

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MARKING

Each competency area is assessed on the following scale:

☐ Competency NOT demonstrated
☐ Competency NOT CLEARLY demonstrated
☐ Competency SATISFACTORILY demonstrated
☐ Competency FULLY demonstrated

1. Communication and Consultation Skills

1.1 Uses appropriate communication, ensuring a safe and comfortable discussion about mental health.
1.3 Engages the patient using a patient-centred approach, addressing concerns about bipolar disorder.
1.5 Explains medical information in an understandable and non-stigmatising manner.

2. Clinical Information Gathering and Interpretation

2.1 Takes a structured psychiatric history, identifying key symptoms of bipolar disorder.
2.2 Conducts a risk assessment, including suicidality, substance use, and impulsive behaviours.

3. Diagnosis, Decision-Making and Reasoning

3.1 Recognises the characteristic features of bipolar disorder, distinguishing it from other mood disorders.
3.4 Considers alternative or comorbid diagnoses, such as anxiety, ADHD, or personality disorders.

4. Clinical Management and Therapeutic Reasoning

4.2 Develops an evidence-based management plan, including medication, lifestyle modifications, and psychoeducation.
4.4 Incorporates a multidisciplinary approach, involving psychiatrists, psychologists, and support services.

5. Preventive and Population Health

5.2 Educates the patient on triggers, lifestyle modifications, and relapse prevention.

6. Professionalism

6.2 Demonstrates empathy and avoids stigmatising language when discussing mental health conditions.

7. General Practice Systems and Regulatory Requirements

7.2 Uses appropriate referral pathways (e.g., psychiatrist, crisis support services).

9. Managing Uncertainty

9.1 Addresses diagnostic uncertainty, ensuring close monitoring in undifferentiated mood disorders.

10. Identifying and Managing the Patient with Significant Illness

10.1 Identifies manic and depressive episodes, assessing for immediate risk factors such as suicidality or psychosis.

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Competency at Fellowship Level

☐ CLEARLY BELOW STANDARD
☐ BELOW EXPECTED STANDARD
☐ BORDERLINE
☐ AT EXPECTED STANDARD
☐ ABOVE STANDARD

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