The diagnosis of bipolar disorder can usually be made without much problem if:
– A person presents with mania or hypomania, or
– A person presents with depression or other symptoms and we are able to elicit a clear past history of mania or hypomania, either from the patient or someone else.
This is the best-case scenario. In such situations, I don’t think there is any need to take additional measures like completing questionnaires, etc.
I cannot emphasize strongly enough how important it is to:
1. Learn how to very skillfully elicit a history of mania or hypomania.
2. If the history for the patient is not clear, to interview at least one person who knows the patient well. This can be done in person or on the phone. It does not take more than a few minutes, especially if the person does not have bipolar disorder.
After the patient (and an informant, if needed) is interviewed by someone who is skilled at eliciting a history of mania or hypomania, there are several possibilities:
1. There is a clear history of at least one manic or hypomanic episode.
2. There is clearly no history of a manic or hypomanic episode
3. The history is not clear either way. This could be due to several reasons. The patient and informant may not remember the past well or not be able to describe the symptoms well. Or, we may not be sure whether what was described by the patient or the informant was really a manic or hypomanic episode or not.
In such situations, it is hard to be sure whether the person does or does not have bipolar disorder. This is, unfortunately, quite common.
Even when there is no history of a manic or hypomanic episode, we may want to estimate the probability that the person MAY have bipolar disorder that we are unable to identify with confidence at this time. Why?
1. The history is not clear (the third of the scenarios described above), or
2. There may be other features in the person’s history that may suggest an increased risk of bipolar disorder (e.g., lack of response to several antidepressants, family history of bipolar disorder, early age of onset of depression, etc, etc)
3. Any patient who is young or even middle-aged may have bipolar disorder and may simply not have had a manic or hypomanic episode yet.
Again, a careful interview of the patient and at least one informant by someone who has learned to be skilled at eliciting a history of mania or hypomania is, by far, the most important thing. But, in addition to that, there is still something more that we can do.
The Bipolarity Index
The Bipolarity Index (Sachs, 2004) is clinician-rated instrument that can help to estimate how likely it is that a patient may have bipolar disorder. It was developed by Gary Sachs, MD, and other experts in bipolar disorder.
In one study in which only one clinician assessed a very large number of patients in his private practice in an unblinded manner (Aiken et al., 2015), a score of 50 or more on the Bipolarity Index had a sensitivity of 0.9 and a specificity of 0.9. That’s pretty good!
Important warnings:
1. The Bipolarity Index does NOT diagnose bipolar disorder. Sometimes, clinicians insist on using questionnaires and rating scales as if they have special powers that we don’t have. Let’s not do that, please.
2. The score on the Bipolarity Index indicates the probability that the person has bipolar disorder rather than the severity of the bipolar disorder.
Related Pages
Diagnosing Bipolar Disorder
How to EFFECTIVELY screen patients for possible bipolar disorder
Was the hypomania or mania “antidepressant-indu ced”?
Identifying bipolar disorder. Part one
Identifying bipolar disorder. Part two: The Bipolarity Index
Identifying bipolar disorder. Part three: MoodCheck
Manic or hypomanic episodes: Diagnostic criteria
What are the BEST books on each topic related to psychiatry/ mental health?
References
Aiken CB, Weisler RH, Sachs GS. The Bipolarity Index: a clinician-rated measure of diagnostic confidence. J Affect Disord. 2015 May 15;177:59-64. PubMed PMID: 25745836.
Sachs GS. Strategies for improving treatment of bipolar disorder: integration of measurement and management. Acta Psychiatr Scand Suppl. 2004;(422):7-17.
PubMed PMID: 15330934.
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