SAN FRANCISCO — Diagnosing bipolar disorder requires not just asking the right questions but the right people, Michael J. Gitlin, M.D., said.
More than a third of 600 bipolar disorder patients sought help within a year of becoming symptomatic, but 69% were misdiagnosed (usually as having major depression). In addition, patients saw a mean of four physicians before being correctly diagnosed, a 2003 survey found.
“My quarrel with these data that get published over and over is that the implication is that the physicians” erred, said Dr. Gitlin, professor of clinical psychiatry at the University of California, Los Angeles. “I think it's more complex than that.”
Even physicians who ask the right questions often fail to get the whole story from bipolar disorder patients. “You need corroborative evidence” obtained by getting the patient's permission to talk with significant others—a spouse, boyfriend or girlfriend, sibling, or parents, he said.
The same survey of 600 bipolar disorder patients found that they reported manic symptoms far less often than they reported depressive symptoms to physicians when seeking help (J. Clin. Psychiatry 2003;64:161–74).
That's not surprising, he noted, because depression feels bad and brings people into treatment. Patients reported manic symptoms other than erratic sleep only 43% of the time or less. Only 37% of patients, for example, told physicians of feeling elated at times.
“That is much more the issue than the idea that we're not probing correctly,” he said.
Bipolar disorder patients may not recognize manic or hypomanic symptoms as abnormal, or remember having them. When they're depressed, they're dominated by depressive thoughts and symptoms, and when they're hypomanic they may not remember the depressive symptoms.
Ask significant others as well as the patient about any hypomanic symptoms immediately before or after depressed periods. The highs and lows of bipolar disorder are temporarily related, usually with mania preceding depression, but less commonly in reverse order, Dr. Gitlin said.
Don't just focus on mood, but ask about overactivity, which may be a core feature of hypomania. “The data are not entirely convincing for this, but I think it's something we really ought to be thinking about,” he said.
Ask about a family history of mood disorders, and ask whether the patient or family members have ever shown signs of antidepressant-induced hypomania. If you decide to start an antidepressant, educate the patient and significant others to watch for signs of induced hypomania.