Bipolar Disorder: A Guide for Support Workers

A worker arrives for an afternoon shift and the person they support has been up since four in the morning by their own account, has talked over them twice already, and mentions starting a business this week. It is easy to write this down as "in great form" and leave it there, or to get firm and argue, and both of those responses send a worker the wrong way. A change in state is not a change in character, and what it needs is the same thing every change needs: noticing, describing plainly, and reporting.

This page touches on suicide risk. If any of it lands close to home, Lifeline is on 13 11 14, any time, and 13YARN is on 13 92 76, any time, for Aboriginal and Torres Strait Islander people.

What is bipolar disorder, in plain terms?

Bipolar disorder involves episodes, sustained states that last days or weeks rather than hours, with time between them where many people are well and live whole ordinary years. Bipolar I involves at least one episode of mania, an elevated or irritable state severe enough to seriously disrupt a person's life. Bipolar II involves hypomania, a milder elevated state, together with depressive episodes.

Bipolar II is not "the mild one". People with bipolar II often spend a great deal of time depressed, and the impact of that can be just as heavy as bipolar I. Neither label is something a worker needs to apply. The person has usually lived with this for years and knows their own pattern far better than a worker does.

Why does the low matter more than the high?

This is the fact most workers get backwards. For most people with bipolar disorder, depression accounts for far more days, far more distress and far more disability than the elevated phase does. In bipolar I, people spend roughly three to four times more of their time depressed than elevated, and in bipolar II the gap is wider again.

The low also often follows the high, and carries what the high cost: debt, a missed shift at work, a damaged friendship, shame about things said. That shame is its own weight, separate from the low mood itself, and it is not a worker's place to moralise about it or say "I told you so". The practical response is a referral, to financial counselling, a support coordinator or an advocate, not a worker trying to fix it personally.

What does the elevated pole actually look like?

Not a checklist, and often not what people expect. Up most of the night and not tired. Talking fast, jumping topics, hard to interrupt. Big plans delivered with total certainty, parcels arriving, money given away. And often tense and quick to anger, especially when slowed down, because an elevated episode is often irritable rather than euphoric.

Some episodes carry both poles at once, a mixed state: restless and talking fast, while what the person is saying is genuinely bleak. It is one of the hardest states to read, because the energy is what a worker's eye catches first and the content of what is being said matters more. It is also widely recognised as one of the highest-risk times for suicide in bipolar disorder, alongside the depressive phase. Distress together with agitation is a same-shift report, whatever seems to be causing it, not something to leave for handover. Lifeline is on 13 11 14, any time, and 13YARN is on 13 92 76, any time, for Aboriginal and Torres Strait Islander people.

Why does the same word mean something different for Aboriginal and Torres Strait Islander people?

Aboriginal and Torres Strait Islander people often do not use the words "mental health" at all. The term is social and emotional wellbeing, and it is not a softer version of the same idea. It holds a person's wellbeing across several connections: to body, mind and emotions; to family and kinship; to community; and to culture, Country, spirituality and ancestors. A change can sit in one of those connections rather than in anything that looks like a symptom, and a person cut off from family or unable to get to Country can show real distress that no symptom checklist will explain. There is no single Aboriginal or Torres Strait Islander culture, and what is true for one person may not be true for the next. Ask what wellbeing means to this person, and record their own words, not a worker's.

What is the one thing that actually helps?

Most workers have exactly two instincts when someone is elevated, and both are wrong. One is to collude: "good on you" to the big plans. The other is to control: arguing, or shutting it down. There is a third move. Stay steady, lower your own pace and drop the optional parts of the shift. Stay honest, and never promise to keep something quiet. And pass it on, the same shift, telling the person exactly what you are passing on and to whom.

Sleep deserves particular attention, because it is one of the best recognised contributors to an elevated episode and often the earliest thing anyone notices. Keep shift times predictable, and never ring late at night or arrive early and wake someone. At the same time, sleep is the person's own business: a worker never enforces a bedtime, imposes a curfew, takes a device, or offers anything to help someone sleep.

Three sentences do real damage and are worth losing from a worker's vocabulary entirely: "that is just the bipolar talking", which dismisses everything the person says at once; "she has no insight", which is often the sentence that comes right before someone's rights get taken away; and "have you taken your medication?", which turns a feeling into a compliance question. Describe what happened. Do not describe a mood as "bipolar".

What happens when money is involved?

This is the hardest part to get right, because both harms are real at once. An adult has the same right to decide about their own money as anyone else, including decisions others would not make, and that right does not switch off because someone's mood is elevated. At the same time, people genuinely do get targeted during elevated periods, and someone offering to "look after the money" is abuse, escalated as abuse, not treated as a judgement call. Staff also sometimes restrict money to protect people, holding a card or setting a daily limit, and neither of those is a safeguard unless it is lawfully authorised.

Capacity is presumed, decision-specific and time-specific, and elevated mood is not incapacity. A worker never assesses capacity, formally or informally, including in a team meeting. A simple test is useful here: could the person get their own money, phone, keys, or out their own front door right now, without asking a worker? If not, someone is restricting them, and that needs to be reported, not decided on alone.

What should a worker do if lithium toxicity is suspected?

Many people take lithium for years and do very well on it, and blood tests are run because the helpful amount and the harmful amount sit close together. A person can be unwell even with a test result inside the usual range, which is exactly why a worker's job is to watch for signs, not numbers: vomiting, diarrhoea or stomach pain, new or worse shaking or muscle weakness, confusion or severe drowsiness, trouble walking or slurred speech, being very thirsty, or blurred vision. Severe cases can involve seizures, coma or death, and this is not a section to be gentle about.

Dehydration, fever, vomiting, a gastro bug, heat, and some other medicines (anti-inflammatories like ibuprofen, and some blood pressure tablets) can all raise the risk. Offer fluids and keep them in reach, never force them, never restrict them, and never advise on salt. Describe what you see plainly and report it the same shift. If toxicity is suspected, ring Poisons Information on 13 11 26 straight away, and 000 as well if the person is unwell. Never decide the next dose yourself, in either direction: get direction from a health professional or your organisation, follow it, and record who gave it.

One more medicine deserves its own mention. Any new rash in someone taking lamotrigine is urgent and needs reporting the same day, with 000 for blistering, mouth or eye involvement, facial swelling, fever or trouble breathing. Do not wait to see.

Sodium valproate is a separate case again. It carries significant risks in pregnancy, and that is the whole of what a worker needs to know about it. If someone asks a worker about pregnancy or contraception while taking it, that question goes straight to the person's own doctor, privately, the same day. It never goes to the team, the family, or the communication book. A worker does not answer it and does not repeat it. The job is only to make sure it reaches a doctor.

Who does a worker ring, and in what order?

Ring 000 first, always, for a life-threatening emergency, and do not wait to check policy. Then the organisation's own escalation contact, and the named clinical contact in the person's plan, whose job is to decide what the clinical response should be. Poisons Information on 13 11 26 covers anything taken, including a suspected lithium problem, with 000 as well if the person is unwell. Healthdirect on 1800 022 222 is there for health advice that is not an emergency. A support line is not the same thing as an escalation, and working down that list in order is what stops a genuine emergency waiting while someone rings a supervisor first.

When does this go beyond what a support worker can manage?

A mood stabiliser prescribed to treat a diagnosed condition, and given for that purpose, is treatment, not restraint, and supporting someone to take it is ordinary support. A sedating medicine given at nine at night because staff want the house quiet, using the same drug, is restraint. The test is what it was prescribed for, never the drug or the dose, and a worker never decides which one applies. Notice, record and report.

How CORA's course fits into this

CORA's course Understanding: Bipolar Disorder, part of the Mental Health & Wellbeing stream in the course library, covers the two poles and the one nobody talks about, how to stay steady, honest and pass things on without colluding or controlling, and the medicines, restrictions and escalation order a worker needs to know, including lithium and lamotrigine. It builds understanding and judgement. It is not clinical training, it is not a substitute for treatment, and CORA does not certify a worker's competence, that assessment sits with your organisation.

If you are mapping this alongside the rest of the Mental Health & Wellbeing stream for your whole team, the Free tools page has a free tool that maps it out, no sign-up required. Or enquire if you would rather talk it through.

Sources and further reading

• Bipolar disorder, SANE Australia
• Lithium, Healthdirect Australia
• Behaviour support and restrictive practices, NDIS Quality and Safeguards Commission
• What a capable NDIS workforce actually looks like, CORA Workforce

This page is general information for support workers and providers, not clinical or mental health advice. Always follow the person's individual support plan, their treating team, and your organisation's policies.