It is very sad that the diagnosis of bipolar disorder continues to be frequently missed. Many persons with bipolar disorder continue to be wrongly diagnosed as having a depressive disorder. The consequences of this are horrible — years wasted in treatment with antidepressants (SSRIs, SNRIs, etc), “treatment-resistance,” development of rapid cycling, and lost years of patients’ lives. Not to mention the possibility of suicide.
This is an EMERGENCY in the field of mental health! No patient with bipolar disorder should go undiagnosed or misdiagnosed.
EVERY patient with a depressive episode must be asked specifically for a history of a hypomanic/manic episode. It does not naturally occur to us to do this, so we have to prompt or train ourselves to remember to do it.
1) The patient may report normal happiness (especially after having recovered from depression) as elevated mood;
2) Persons without bipolar disorder may have the same symptoms at different times in their lives;
3) Persons with bipolar disorder may not have every specific symptom you are asking about;
4) Patients may be suggestible and endorse symptoms when asked leading questions.
How to ask
So, how specifically should we ask the patient about whether they have ever had a manic or hypomanic episode?
Step 1: help the patient understand that you are talking about 3 different states (depression, normal, and mania/hypomania)
Step 2: help patient identify a specific episode (period of time) when he was manic. Preferably choose the MOST SEVERE episode because the symptoms will be more pronounced
Step 3: ask an open-ended question about what the symptoms were like during that period. Keep referring the patient back to THAT episode.
Step 4: ask follow up questions to identify and characterize all the symptoms
Step 5: if needed, ask if there was any other reason for these symptoms, and whether the symptoms were observable by others who knew the patient well
Consider calling one or more informants (family member, friend, colleague, etc) for additional history. Think broadly and creatively about this. Talk to the informants on the phone if they cannot come in.
If the diagnosis of bipolar disorder is not reliably ruled in or out at the initial evaluation, specifically plan to pursue this in subsequent visits by: using part of a follow up session to re-interview the patient, interviewing additional informants, obtaining previous records
How to organize your information about mania/ hypomania
Write down the history of mania obtained from the patient, informant, records, or your observations (i.e., all possible sources of information) on a SEPARATE sheet of paper in the H&P. By writing on a separate sheet, you can add more information to that sheet as it is obtained (with a new date) and can even insert a new sheet if needed.
Write down direct quotes as much as possible.
When further relevant history is obtained after the initial evaluation, do NOT write it in the progress notes (why?); write it as an addendum to the above mentioned sheet about bipolar disorder.
In the future, whenever a doubt occurs about whether or not the patient really has bipolar disorder or is only suspected to have bipolar disorder, look back at this sheet. Quickly re-reading the notes will make it clear whether or not the patient has had a manic episode.
Diagnosing Bipolar Disorder (Free Content)
How to get better outcomes in bipolar disorder? (Video interview with Gary Sachs, MD)
Copyright 2015, Rajnish Mago, MD. All rights reserved. May not be reproduced in any form without express written permission.
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