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Diagnosing bipolar disorder.

Berk M, Berk L, Moss K, Dodd S, Malhi GS. Diagnosing bipolar disorder: how can we do it better? MJA 184:9;459-62.

Difficulties and delay in the diagnosis of bipolar disorder impede effective treatment and increase the burden of illness on the person, their family and society. In the 2000 National Depressive and Manic Depressive Association survey, the prevalence of bipolar I and II disorder in the US was estimated at 3.4%, with almost one third being incorrectly diagnosed as suffering from unipolar depression, and nearly half not having the condition recognised or diagnosed. A third of these individuals had been symptomatic for more than 10 years before the correct diagnosis was made.

The 2003 Access Economics report for SANE Australia on the costs of bipolar disorder in Australia confirmed that a 10 year gap before correct diagnosis is not uncommon. The report found that 69% of people with bipolar disorder were misdiagnosed with, most commonly, depression, anxiety disorder, schizophrenia and borderline or antisocial personality disorders.

The diagnosis of bipolar disorder is particularly complex. Although the defining features are manic or hypomanic episodes, patients typically present for treatment of depression and commonly deny symptoms of mood elevation.

A diagnosis of bipolar disorder can be assisted by asking about symptoms of mania or hypomania in every patient presenting with symptoms of depression, recognising mixed states in which manic and depressive symptoms occur simultaneously, and identifying the features of bipolar depression that distinguish it from unipolar depression.

The onset of bipolar disorder can be subtle, with relatively minor, predominantly depressive changes in mood gradually giving way to episodes of depression. Features such as increased energy, elevated mood, disinhibition and racing thoughts are common antecedents to the emergence of a full blown manic episode. There may be delay in seeking help because patients may not understand their symptoms or may be embarrassed or fearful of potential stigma.

Diagnosis of bipolar disorder is commonly complicated by substance misuse and anxiety disorders which precede the illness. Family history in a first degree relative is a strong indicator of the disorder. Other indicators are history of antidepressant induced mania or hypomania, hyperthymic personality (traits such as optimism, increased energy, reduced need for sleep, extroversion, promiscuity and overconfidence) prior to the onset of depression, early age onset, and atypical symptoms of depression (e.g. hypersomnia, hyperphagia, fatigue, sensitivity to rejection).

Few patients are "classically bipolar", alternating between episodes of pure mania and depression. The symptoms of the majority of individuals lie in a grey area between those of unipolar and bipolar disorder. The most common pitfall in diagnosis of the disorder is mixed symptoms. This can lead to inappropriate therapy which can mask the real symptoms. One of the important differences between mixed and pure mania as that the risk of suicide is far greater in the former.

Making a correct diagnosis is essential for the patient to be given the correct treatment and obtain a good treatment outcome. Extended follow up and collateral information greatly assists in the process. Current research is focusing on defining the boundaries of the diagnostic definition of bipolar disorder.

Anne Cowper

PO Box 45, Concord West NSW 2138

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Author:Cowper, Anne
Publication:Australian Journal of Medical Herbalism
Geographic Code:8AUST
Date:Mar 22, 2007
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