Next Steps After a Positive or Borderline RMS Score

1. Get more information

If a patient has an RMS score that is positive (4+) or borderline (3), it is not an official diagnosis and further clinical assessment is warranted. 

The Canadian Network for Mood and Anxiety Treatments (CANMAT) and the International Society for Bipolar Disorders (ISBD) recommend that primary care physicians collect additional clinical information to help differentiate bipolar disorder from major depressive disorder. For example, if your patient has a score of 3 or higher, you may consider asking about the following before making a referral:

  • A family history of bipolar disorder;

  • Post-partum depression or psychosis (that starts soon after delivery of a baby);

  • Increased sleep, craving for carbohydrates or increased appetite and weight gain; and

  • Irritability or racing thoughts during an episode of depression.

In addition, CAMH recommends that steps be taken to rule out other conditions, including: 

  • Secondary causes of mania; and

  • Substance use disorder by taking a history and, if necessary, conducting toxicology screening.

2. Consider a psychiatry referral

According to CAMH, primary care physicians can diagnose and treat bipolar disorder; however, referral to a specialist may be appropriate when:

  • Hospital admission is required;

  • Questions arise about a patient's capacity to make treatment decisions;

  • You are unfamiliar with the use of bipolar medications;

  • The clinical presentation is complex or uncertain;

  • Diagnostic uncertainty exists;

  • The patient has treatment-resistant mania;

  • Problematic adverse effects or safety concerns with medication arise; or

  • Electroconvulsive therapy is being considered.

The RMS can help you make more informed and consistent psychiatric referrals.

What should be included in the referral to psychiatry?

Include the RMS score, description of symptoms, any relevant clinical information from reviewing the responses to the RMS, and responses to follow-questions to support the psychiatrist’s assessment of the patient.

Psychiatrist e-consults in Ontario

If you require a non-urgent consult with a psychiatrist regarding your patient, consider submitting an eConsult through OTNhub.ca. Specialists are expected to respond within 7 days.

3. Support your patient while referral is pending

While your patients are waiting to see a psychiatrist, you may find it helpful to:

  • Share CAMH resources with patients, including an information guide on bipolar disorder.

  • In Ontario, connect patients with Hope + Me, which provides peer support groups, workshops, and counseling services for people living with bipolar disorder. A formal diagnosis may not be needed to access some of these services.

  • In Ontario, inform patients of ConnexOntario, which can help the patients navigate local mental health services while waiting to see a psychiatrist.

4. Support your patient after a positive BD diagnosis

Primary care physicians play a critical role in supporting a patient manage their BD diagnosis. For more information on the management of patients with BD, please refer to the CANMAT/ISBD guidelines.

Once the patient has been diagnosed with bipolar disorder, they can:

  • Be provided psychoeducation and offered psychosocial/behavioural strategies*; and

  • Begin treatment with antimanic pharmacotherapy.

*In Ontario, physicians can refer patients who have been diagnosed with bipolar disorder, or those awaiting a diagnostic assessment, to Hope + Me for peer support.