- During this period did/do you feel especially confident, like you were on top of the world?
- How do/did you see yourself in comparison to others?
- Did/do you feel you had special powers that others didn’t?
- Did/do you feel a special connection with God?
- Do you consider yourself special in any way?
Among patients seen in a primary care setting for depressive and/or anxiety symptoms, 20% to 30% are estimated to have bipolar disorder. Although relatively common in primary care settings, bipolar disorder is still underrecognized, primarily due to misdiagnosis as unipolar depression. Patients often seek treatment when they are depressed but uncommonly present with mania or hypomania, the specific markers of bipolar spectrum disorders. An awareness of the prevalence, characteristics, and predictors of bipolar disorder can help the primary care physician to properly differentiate between bipolar depression and unipolar depression. Completing a differential diagnosis of bipolar disorder requires obtaining a comprehensive patient history that investigates symptom phenomenology and associated features, family history, longitudinal course of illness, and prior treatment response. In addition to the clinical interview, the Mood Disorder Questionnaire and the World Health Organization Composite International Diagnostic Interview 3.0 can be useful tools for evaluating patients for bipolar disorder. Screening patients at risk for bipolar disorder will help to avoid the use of unproductive or possibly even harmful treatments.
The impact of bipolar disorder on patients and on the community is substantial. Patients with bipolar disorder report more difficulties with work performance, more disruptions in social life, and more difficulties with interpersonal relationships and are more likely to report being jailed or arrested than patients without bipolar disorder.1,2 The impact continues even after syndromal recovery from a bipolar episode, with patients, particularly those experiencing episodes with psychotic features, often not having reached functional recovery 2 years later.3 In addition, bipolar disorder is associated with increased rates of both psychiatric and medical comorbidities,4,5 and with increased rates of mortality from diseases such as cardiovascular disease and diabetes and from causes such as suicide, homicide, or accidents.6 Patients with bipolar disorder are frequent users of health care,7 and bipolar disorder may be the most expensive psychiatric diagnosis to treat.8
In the past couple of decades, progress has been made in recognizing the high rate of mental disorders among primary care patients. A prevalence rate of nearly 30%, when including all psychiatric diagnoses, is now accepted, with mood and anxiety disorders accounting for the majority of these diagnoses.9–11 In addition, although the community prevalence rate for bipolar disorder is about 4%,12 a large study13 (N=1,157) in an urban general medicine clinic found nearly 10% of adult waiting room continuity patients screened positive for bipolar disorder using the Mood Disorder Questionnaire (MDQ).14
However, bipolar disorder among primary care patients has often been underrecognized, primarily due to misdiagnosis. For example, in the general primary care population mentioned above, more than two-thirds of those who screened positive for lifetime bipolar disorder had sought professional help for their symptoms, but the majority had been diagnosed with depression and/or anxiety.13 Only 8% said they had ever received a diagnosis of bipolar disorder (or manic depression), and few of those who screened positive for bipolar disorder were taking mood stabilizers. An evaluation15 conducted in a cohort of 108 consecutive anxious and/or depressed patients in a family practice setting identified 26% of the patients as having a bipolar spectrum disorder. Similarly, Hirschfeld and colleagues16 screened a population of 649 family practice patients taking an antidepressant for depression and, using structured diagnostic interviews, estimated 27.9% of the patients as having bipolar disorder. Additionally, an investigation of consecutive patients with difficult to treat depression and anxiety referred to a primary mood disorder clinic found that 39% had bipolar disorder.17
Recognizing bipolar disorder can be difficult, but the examination of key elements of the patients history via a clinical interview and the use of screening instruments can be crucial tools in the differential diagnosis of bipolar disorder. This article will address key topics to cover in the clinical interview, as well as screening instruments for bipolar disorder that have been validated for use in primary care.
Case study clinical example: Session with a client with Bipolar Disorder (fluctuations in mood)
Tracking and investigating your current sleep patterns—and disruptions to them—reveals vital information about your bipolar disorder symptoms and mood management.
Successful Bipolar Treatment Starts with Asking the Right Questions
If you were to stop reading this right now—before you see my answer—what would you say is the most important question you can ask yourself about bipolar disorder?
Or, if you’re a loved one of someone with bipolar, what do you feel is the most important question you can ask them?
Hmm. That’s a tasty question.
I suspect you might immediately think of the following:
These are excellent questions and, while they are important, they are difficult to answer when you’re in a mood swing, and, in some cases, they will upset the person with bipolar. I have a question for you that I can guarantee will help you better manage your symptoms—and it’s not specially about a mood swing.
The Surprising Power of Sleep with Bipolar Disorder
The question is, in my experience, “How is your sleep?” It’s a very calm question to ask a loved one as well—“How are you sleeping?” will provoke much a less emotional reaction than “Are you taking your meds?” When I speak to groups, I ask them what question they think I mean, and people very rarely mention sleep. Why is that, I wonder?
A friend of mine has a well-known psychiatrist who writes books on the topic. He once told her, “One day we will see bipolar disorder for what it really is: a sleep disorder.”
Commonly, people vacillate between denial and acceptance, even long after their initial diagnosis. Part of the challenge people face is understanding where normal mood variations end and where bipolar disorder starts. As David Miklowitz notes in The Bipolar Survival Guide, “having a sense of how your personality, habits and attitudes differ from your symptoms is an important part of learning to accept the disorder.” (Source: David Miklowitz)
Bipolar disorder is diagnosed with a comprehensive clinical interview, usually by a psychiatrist or psychologist. The diagnosis is based on the symptoms the person has experienced. Brain scans, blood tests and other physiological tests cannot diagnose bipolar disorder. However, a doctor may order some tests to rule out medical conditions that could mimic bipolar disorder (for example, a thyroid problem). Hopefully, the doctor conducting the evaluation specializes in mood disorders and has extensive experience diagnosing and treating bipolar disorder as there are other disorders that are often confused with bipolar.
A comprehensive clinical interview typically includes a review of medical history, including prior diagnoses, treatments, response to treatments, and family history. Finally, the doctor will ask whether certain symptoms have been experienced over a given period of time. The doctor is likely to ask about not only bipolar disorder symptoms but also about symptoms of other disorders (such as anxiety disorders and substance use disorders) that may co-exist with or may be confused with a bipolar disorder. (Source: David Miklowitz)
Bipolar disorder affects at least one in 70 people. On average there is an eight-year lag between a first episode of mania or depression and the first time the disorder is diagnosed and treated. Episodes of mania or depression can last anywhere from days to months. (Sources: David Miklowitz; Providence Center)
For some it is hard to think of mood swings as an illness, especially when emotional reactions seem justifiable and appear to be similar to what others experience. For this reason it is critically-important that a doctor be attuned to whether mood and behavior are significant departures from ones normal states. In making this assessment, a doctor must take into account factors such as how long the states last, how intense they are, and whether they impair ones functioning.
What questions should ask to bipolar patient?
- Why am I being offered an appointment for an assessment?
- What will happen after the appointment?
- Why do you think I’m ill? …
- What could have caused my symptoms?
- Who can I contact if I have a crisis or if my symptoms get worse?
- Are there any support organisations in my local area?
What are the top 3 bipolar symptoms?
- Abnormally upbeat, jumpy or wired.
- Increased activity, energy or agitation.
- Exaggerated sense of well-being and self-confidence (euphoria)
- Decreased need for sleep.
- Unusual talkativeness.
- Racing thoughts.
Why is it so hard to work with bipolar?
Is there a questionnaire for bipolar?