Diagnosing Bipolar Disorder: The Importance of Having a Differential Diagnosis

In recognition of World Bipolar Day, held annually on March 30, Bipolar Disorders Section Editor Joseph F. Goldberg, MD, shares advice for mental health clinicians on steps to take before diagnosing a patient with bipolar disorder.

Dr. Goldberg is Clinical Professor of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York. He is presenting "Bespoke Psychopharmacology: Tailoring Individualized Pharmacotherapy for Patients with Bipolar Disorder" at the 2021 Psych Congress Regionals meeting series, which continues April 9 and 10.

Read the transcript:

On World Bipolar Day, a few comments to clinicians. Historically, bipolar disorder has been underrecognized, largely because it can be easily confused with unipolar depression. Patients often present for the depression before they ever go on to have a mania or a hypomania.

In recent years, there's been a great deal of attention paid to screening. In fact, [American Psychiatric Association] practice guidelines remind us every depressed patient needs to be screened for bipolar disorder, and that may be over the course of time, not just a single incident.

That means going back into someone's personal history. It means looking at the family history, course of illness. I guess this cuts two ways. One is to say make sure you are screening, but it also means don't be hasty about it.
There's often the temptation to make a rapid diagnosis, and it gets tricky. 

Florid mania is easy to diagnose. It takes about 3 seconds to diagnose who's manifesting all the signs of psychomotor acceleration and mania.

Someone who's hypomanic may be much more subtle, and someone whose presentation is ambiguous, where there's mood symptoms, mood instability, or anxiety, or cognitive complaints, or possibly substance use, there, we really want to take our time.

My outreach to colleagues and clinicians is, when faced with a more ambiguous presentation, don't rush to make a diagnosis. Gather all the information that you can from a patient, from collateral historians, from past treaters.

Have a differential diagnosis in mind. There are many things that can imitate bipolar disorder. Substance use, autonomic hyperarousal states, medication withdrawal effects and side effects. These are often among the most challenging patients to really sit down with, especially in second opinions, and really try to gain clarity.

Our medicines work very well for the right diagnosis. We always want to be sure and confident of our diagnosis before we prescribe anything. Because bipolar disorder can be, some have called it the great imitator, or it can have a wide differential diagnosis or comorbidities, spend the time that's necessary to make a careful diagnosis before embarking on any treatment.

More with Dr. Goldberg: Using Moderators and Mediators to Tailor Bipolar Disorder Treatment