What is bipolar disorder and why is it so difficult to diagnose?
Takeaways
- Bipolar disorder (BD) frequently is misdiagnosed as depression.
- Indicators of BD include hypomanic symptoms, family history of BD, age of symptom onset, and poor response to antidepressants in the past.
Bipolar disorder (BD) is characterized by extreme mood swings—from emotional highs (mania) to lows (depression). (See BD facts and figures.) Unfortunately, BD frequently is misdiagnosed, which can lead to delays in treatment with mood stabilizers and harmful exposure to antidepressants as monotherapy. Before initiating antidepressant monotherapy, which can induce rapid cycling in people with undiagnosed BD (suggesting the presence of the disorder), patients should be screened to determine if they’re at risk for BD.
A retrospective study by McCormick and colleagues found that over 60% of depressed patients were incorrectly diagnosed and treated for depression rather than BD. In a survey of 600 patients diagnosed with BD by Hirschfeld and colleagues (2003), 69% reported they were misdiagnosed. Among misdiagnosed patients, 70% said they were misdiagnosed three times or less and 30% were misdiagnosed four times or more. Given these daunting statistics, one might wonder why BD is so difficult to recognize and diagnose. Part of the problem is that the same criteria are used to define the depressive episodes of BD and major depressive disorder (MDD). Clinicians need to know that what distinguishes BD from MDD is the presence or history of manic or hypomanic symptoms. A clearly cyclical pattern of episodes is more diagnostic of BD than MDD.
Bipolar disorder (BD) is a Diagnostic and Statistical Manual of Mental Disorders 5th edition (DSM-5) diagnosis that includes BD I and BD II.
Patients with BD I often present with recurrent mood episodes following a single manic event; they are more likely to experience hypomanic than depressive episodes. BD II usually begins with an episode of major depression followed by a hypomanic event. It’s associated with greater chronicity, with longer and more frequent episodes than BD I. The mean age of onset for BD I is 18 years and mid-20s for BD II. Both forms of BD result in serious impairments in work and social functioning. Cyclothymic disorder is a mild mood disorder with symptoms much like BD II, but it doesn’t meet the DSM-5 criteria for BD II.
Patients with BD experience significant changes in energy levels that are most notable in sleep fluctuations. In mania, sleep frequently decreases or is nonexistent. This differs from the hypersomnia experienced by patients with depression.
According to the National Comorbidity Study:
- The past-year prevalence of U.S. adults (those who identified symptoms in the 12 months preceding the survey) with BD is 2.8%.
- 4.4% of the population will experience BD at some point in their lives.
- BD occurs equally among woman and men.
- BD can occur in all age groups, but the average age of onset is between 18 and 29 years, with 50% of all cases occurring before age 25.
The exact cause of BD isn’t known, but we do know that a combination of genetics, environment, and altered brain structure and chemistry play a role. Family history of BD is one of the most reliable and consistent risk factors. According to studies by Ayano in 2016 and McCormick and colleagues in 2015, adult relatives of individuals with BD have a ten-fold increased risk for the disorder.
Differences between BD and depression
After ruling out organic causes when assessing a patient with acute depressive symptoms, determine whether a history of mania or hypomania exists. If the patient has no history of either, they most likely have depression. Other factors that suggest BD include family history, course of illness, treatment response, associated features, and manic/hypomanic symptoms.
Mood disorder screening tools, such as the Mood Disorder Questionnaire (MDQ), are effectively used in primary care and psychiatric settings to identify patients likely to have BD. The MDQ, a 13-item self-report questionnaire that takes about 5 minutes to complete, can be downloaded for free here. Most psychiatrists and psychiatric nurse practitioners use the MDQ before prescribing antidepressant medication. (See Ask the right questions.)
To meet the Diagnostic and Statistical Manual of Mental Disorders 5th edition criteria for BD, the patient must have three or more (four if the mood is only irritable, as irritability presents in many psychiatric conditions) symptoms of mania for more than 1 week and symptoms of hypomania for more than 4 days (less than 1 week). Symptoms of mania typically are more severe than hypomania and may require hospitalization. (See Mania symptoms.)
Your ability to recognize BD will improve when you understand the symptoms and diagnostic criteria for BD I, BD II, and MDD; obtain the patient’s history of mania or hypomania and family history of BD; and can identify a manic switch, rapid cycling, or suboptimal outcome in a patient receiving antidepressant medication.
Use the Mood Disorder Questionnaire to quickly and accurately screen patients for bipolar disorder. Additional medical assessment is recommended for patients who meet all of the following criteria: answered “yes” to seven or more events in the first question, answered “yes” to the second question, and answered “moderate problem” or “serious problem” to the third question.
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1. Has there ever been a period of time when you were not your usual self and… |
Yes | No |
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…you felt so good or so hyper that other people thought you were not your normal self, or you were so hyper that you got into trouble? …you were so irritable that you shouted at people or started fights or arguments? …you felt much more self-confident than usual? …thoughts raced through your head or you couldn’t slow your mind down? …you were so easily distracted by things around you that you had trouble concentrating or staying on track? …you had much more energy than usual? …you were much more active or did many more things than usual? …you were much more social or outgoing than usual, for example, you telephoned friends in the middle of the night? …you were much more interested in sex than usual? …you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky? …spending money got you or your family in trouble? |
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2. If you checked YES to more than one of the above, have several of these ever happened during the same period of time? |
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3. How much of a problem did any of these cause you—such as being able to work; having family, money, or legal troubles; getting into arguments or fights? |
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4. Have any of your blood relatives (children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder? |
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5. Has a health professional ever told you that you have manic-depressive illness or bipolar disorder? |
Adapted from Hirschfeld et al, 2000. Download here.
Managing BD
A combination of pharmacologic therapies and psychosocial interventions are recommended to successfully manage BD.
Pharmacologic therapies
Medications used to manage BD include mood stabilizers, second-generation atypical antipsychotics, antidepressants, benzodiazepines, and anticonvulsants. Patients with BD typically will require therapy with at least two medications. (See Pharmacologic treatment of bipolar disorder.)
Mood stabilizers (for example, lithium, lamotrigine, and carbamazepine) are the mainstay of bipolar treatment, and lithium remains the gold standard 6 decades after its discovery. It’s the most effective and widely studied medication in BD treatment. Many providers are reluctant to prescribe lithium because of its high toxicity potential, risk of renal failure, and need for periodic blood lithium levels, but studies have shown the drug to be safe when used judiciously. Lithium also lowers suicide risk among patients with BD and depression. Lithium decreases the level of thyroid hormone, so thyroid replacement medication may sometimes be needed.
Mania and hypomania symptoms of bipolar disorder are the same, but mania is more severe and causes more noticeable problems at work, school, and social activities, as well as in relationships.
- agitation (e.g., pacing, handwringing)
- decreased need for sleep (frequently the first sign of BD)
- distractibility
- excessive risky behavior (e.g., impulsive or excessive shopping, sexual acting out, gambling)
- flight of ideas or racing thoughts/feelings
- increased goal-directed activity
- inflated self-esteem or grandiosity
- irritability
- more talkative than usual
- pressured speech (rapid, frenetic speech; doesn’t allow others to speak)
Several second-generation atypical antipsychotics (for example, aripiprazole, cariprazine, quetiapine, ziprasidone, and aripiprazole) are effective at treating acute BD, but they have several metabolic (weight gain, hyperglycemia, and dyslipidemia) and extrapyramidal side effects. Some newer agents, such as lurasidone, claim to have fewer metabolic side effects. Long-acting injectable antipsychotics frequently are used for BD I maintenance therapy.
Antidepressants (for example, sertraline, fluoxetine, venlafaxine, escitalopram, and duloxetine) aren’t approved for treating BD and should be used only in combination with a mood stabilizer or atypical antipsychotic. Antidepressants can induce rapid cycling and cause a manic or hypomanic episode in some patients. Some debate exists about whether they should be used at all because of concern that some patients may become suicidal when taking them. Antidepressants carry a Black Box warning for children and adolescents up to age 25 years.
Venlafaxine is the most likely antidepressant to induce mania. Do not use tricyclic antidepressants or monoamine oxidase inhibitors (MAOI).
Sometimes benzodiazepines (for example, lorazepam and alprazolam) are used to treat insomnia and anxiety in patients with BD. However, they’re highly addictive and should be used only for short-term treatment. In addition, anticonvulsants (for example, valproic acid, divalproex, and topiramate) may be used to treat manic episodes. They work by calming hyperactivity in the brain.
Mania episodes
Atypical antipsychotics
• aripiprazole*
• asenapine*
• cariprazine
• olanzapine*
• risperidone*
• quetiapine*
• ziprasidone
Anticonvulsants
• carbamazepine
• valporic acid
Anticonvulsants
• lithium
Depression episodes
Atypical antipsychotics
• cariprazine
• olanzapine/fluoxetine*
• lurasidone*
• quetiapine XR
Maintenance therapy
Atypical antipsychotics
• aripiprazole*
• olanzapine
• quetiapine XR
• risperidone LAI
• ziprasidone**
Anticonvulsants
• lamotrigine
Mood stabilizers
• lithium
Mixed mania and depression
Atypical antipsychotics
• aripiprazole
• asenapine
• olanzapine
• risperidone
• ziprasidone
Anticonvulsants
• carbamazepine
*adjunct and monotherapy **adjunct only
Psychosocial interventions
BD management is most successful when medications are combined with psychosocial interventions. Individual psychotherapy, cognitive behavioral therapy, and interpersonal and social rhythm therapy (IPSRT) explore psychological issues that may be preventing treatment adherence and focus on self-care. IPSRT also views BD as a circadian rhythm disturbance and uses sleep/wake regulation and daily activities as a treatment strategy. Peer support and education that includes family members and significant others also have been shown to significantly reduce relapse rates. (See Patient education and self-care.)
Barriers to BD treatment
Medication nonadherence is one of the significant barriers to effective BD management. Many patients may be in denial about their diagnosis, especially when they’re experiencing manic symptoms. Patients frequently stop taking BD medications during a manic episode. Also, some patients taking mood stabilizers report “missing” the highs and excitement they experienced during the beginning phase of a manic episode. Other reasons for nonadherence include concerns about real or imagined side effects and financial restraints.
Many patients with BD have comorbid psychiatric disorders, such as substance use disorder (SUD) and generalized anxiety disorder. Alcohol use disorder rates can be as high as 43% in patients with BD. SUD can mask the signs and symptoms of BD. Comorbid disorders in combination with self-medicating behaviors can complicate treatment adherence and lead to poor outcomes. These patients may need referrals to other specialists (for example, an addiction treatment program) before BD treatment can begin.
According to McCormick and colleagues, suicide risk in patients with BD is 20% to 30% greater than the general population, with suicide completion rates between 14% and 60%. Suicidal behaviors increase with alcohol use. Clinicians should regularly monitor all BD patients for suicidal thoughts and behaviors. Lithium treatment decreases suicidal behavior in many BD patients.
In addition to pharmacologic and psychosocial therapies, education is key to helping patients manage their bipolar disorder (BD). Education should include:
- getting sufficient sleep, participating in exercise and other physical activities, and consuming a nutritious diet
- engaging in ongoing self-monitoring that includes family members or significant others
- developing a plan to enact when an impending episode is recognized
- participating in reflective and meditative practices
- learning about BD and educating friends and family
- connecting with others.
Self-management can be challenging for patients with BD, particularly given that pharmacologic treatment can be complex. Teach patients that living with BD requires that they:
• stay on their medications (even when symptoms are in remission)
• keep a daily routine
• eat meals at the same time each day
• go to bed at the same time every night
• get sufficient sleep
• participate in a purposeful activity or hobby
• know and watch for signs of shifting into depression or mania.
Self-help for people with BD and their families
When educating patients and their families about BD, consider recom- mending these books:
• The Bipolar Workbook: Tools for Controlling Your Mood Swings, by Monica Ramirez Basco, PhD, teaches patients several skills, including how to break the cycle of recurring depression, recognize triggers and manage their response, and get the most out of medication.
- The Bipolar Workbook: Tools for Controlling Your Mood Swings, by Monica Ramirez Basco, PhD, teaches patients several skills, including how to break the cycle of recurring depression, recognize triggers and manage their response, and get the most out of medication.
- The Bipolar Disorder Survival Guide: What You and Your Family Need to Know, 3rd ed, by David J. Miklowitz, PhD, helps patients and family members recognize warning signs of mania and depression, find the right medication and therapy, and prevent mood swings from ruling their lives.
- Why Am I Still Depressed? Recognizing and Managing the Ups and Downs of Bipolar II and Soft Bipolar Disorder, by Jim Phelps, MD, discusses the causes of patient agitation and anxiety and how patients can work with healthcare providers to find the best treatment.
- An Unquiet Mind: A Memoir of Moods and Madness, by Kay Redfield Jamison, PhD, is a firsthand account of the author’s experience living with BD.
In addition, help patients connect with the Depression and Bipolar Support Alliance (DBSA). This national peer support organization offers hope, help, support, and education to people with mood disorders and their families. Learn more about DBSA at dbsalliance.org/about.
Be alert
BD frequently is misdiagnosed. However, when you’re alert to BD signs and symptoms, you can help connect patients with the care they need and encourage referrals as appropriate. For patients diagnosed with the disorder, you can provide education, monitor for adverse events, and encourage self-care.
To learn about how to manage BD during the COVID-19 pandemic, click here.
Cynthia Taylor Handrup is a clinical assistant professor in the psychiatric mental health nurse practitioner program and director of the primary care mental health concentration at the University of Illinois at Chicago College of Nursing.
References
Aiken C. An overview of atypical antipsychotics for bipolar depression. Psychiatric Times. January 3, 2020. psychiatrictimes.com/view/overview-atypical-antipsychotics-bipolar-depression
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. Washington, DC: American Psychiatric Association; 2013.
Ayano G. Bipolar disorder: A concise overview of etiology, epidemiology diagnosis and management: Review of literatures. SOJ Psychology. 2016. symbiosisonlinepublishing.com/psychology/psychology31.php
Basco MR. The Bipolar Workbook: Tools for Controlling Your Mood Swings. 2nd ed. New York: The Guilford Press; 2015.
Gitlin MJ. Antidepressants in bipolar depression: An enduring controversy. Int J Bipolar Disord. 2018;6(1):25.
Harrison PJ, Cipriani A, Harmer CJ, et al. Innovative approaches to bipolar disorder and its treatment. Ann N Y Acad Sci. 2016;1366(1):76-89.
Hirschfeld RM, Williams JB, Spitzer RL, et al. Development and validation of a screening instrument for bipolar spectrum disorder: The Mood Disorder Questionnaire. Am J Psychiatry. 2000;157(11):1873-5.
Hirschfeld RMA, Lewis L, Vornik LA. Perceptions and impact of bipolar disorder: How far have we really come? Results from the National Depressive and Manic-Depressive Association 2000 survey of individuals with bipolar disorder. J Clin Psychiatry. 2003;64(2):161-74.
Jamison KR. The Unquiet Mind: A memoir of moods and madness. New York: Alfred A. Knopf; 1996.
Jauhar S, Young AH. Controversies in bipolar disorder; role of second-generation antipsychotic for maintenance therapy. Int J Bipolar Disord. 2019;7(1):10.
McCormick U, Murray B, McNew B. Diagnosis and treatment of patients with bipolar disorder: A review for advanced practice nurses. J Am Assoc Nurse Pract. 2015;27(9):530-42.
Miklowvitz, D. The Bipolar Disorder Survival Guide: What You and Your Family Need to Know. 3rd ed. New York: Guilford Press; 2019.
National Institute of Mental Health. Bipolar disorder. January 2020. nimh.nih.gov/health/topics/bipolar-disorder/index.shtml
Phelps J. Why Am I Still Depressed? Recognizing and Managing the Ups and Downs of Bipolar II and Soft Bipolar Disorder. New York: McGraw-Hill Education; 2006.
Stahl SM. Prescriber’s Guide: Stahl’s Essential Psychopharmacology. 6th ed. New York: Cambridge University Press; 2017.
Suto M, Murray G, Hale S, Amari E, Michalak EE. What works for people with bipolar disorder? Tips from the experts. J Affect Disord. 2010;124(1-2):76-84.
1 Comment.
Thanks for pointing out that pressured speech can be a possible sign of mania on a person with bipolar disorder. A friend of mine recently got diagnosed with it so I want to be a lot more patient with her in case she starts showing signs of a manic episode. Hopefully I could read up more about the disorder by finding some reliable resources online.