Psy-Q: What is the hardest aspect of diagnosing bipolar disorder?

Answer: There are a number of challenges clinicians need to keep in mind, according to Chris Aiken, MD, Medical Director of the Mood Treatment Center in Winston-Salem, NIC, and editor-in-chief of The Carlat Psychiatry Report.

“One difficulty is that the diagnosis depends on symptoms of mania and hypomania, but most people don’t remember these states very well. The ‘up’ episodes are brief, lasting a few days to a few weeks, and rare – they make up only about 5 to 10% of a person’s life, while depression occupies 40 to 60% of the lifespan in bipolar,” Aiken explains. Since self-awareness drops down during mania and hypomania, people often don’t remember these states at all, he adds.

In addition, while some people associate mania with high energy and positive feelings, it’s common to have a dark side to mania. “The most complaint that patients have during a mania is ‘I’m depressed.’ They are not depressed, but mania can be very depressing,” he says, since losing control of your own thoughts and actions can be distressing.

“In psychiatry, there are two mood disorders: unipolar, or regular major depression, and bipolar. Both of these conditions usually present with depression, because that is the most common mood episode across the board. But one of them (depression) gets better with antidepressants, and for the other (bipolar) antidepressants usually don’t work or make their mood worse,”  he clarified. “So bipolar tells us about which medications are more likely to help, as well as which lifestyle changes are going to be essential to staying well – like getting into regular patterns of sleep and waking, light in the morning and darkness at night because bipolar is linked to disruptions of circadian rhythms.”

He points out that clinicians always need to approach diagnosis with an open mind. “The question is not, ‘Bipolar, Yes or No?’; it’s ‘how likely is it that they have bipolar disorder?”

Dr. Aiken shares the following tools that can help answer this diagnostic question:

  • The Rapid Mood Screener developed by Roger S. McIntyre et al is a brief rating scale that can be completed in a few minutes
  • The Bipolarity Index (which Dr. Aiken helped develop) is a more detailed version of the same concept

“Both of these [tools] diagnose bipolar disorder with a higher degree of accuracy, and that’s probably because they rely not just on symptoms but on signs that predict bipolar. Signs like age of onset, family history, and response to treatment. These are things that all doctors consider when making a diagnosis, but the DSM-5 gives no weight to signs because it is entirely symptom-driven. So these rating scales fill that gap,” Dr. Aiken stresses.

“Even with the most careful assessment, patients with major depression will often ‘convert’ to bipolar disorder down the road, particularly if they present with depression in their teenage years. So each visit is a new chance to revisit the diagnosis,” he adds.

See our full Clinician’s Guide to treating bipolar disorder including bipolar depression medications and new research on how brain patterns tied to reward anticipation may help clinicians differentiate bipolar disorder from schizophrenia.


Last Updated: Jul 14, 2021