A Mania for Diagnosing Bipolar Disorder

PROVIDENCE, RI – During the past few years, many experts have suggested that bipolar disorder – a serious illness resulting in significant psychosocial morbidity and excess mortality – is under-recognized, particularly in patients with major depression. Even patients who are diagnosed with bipolar disorder often wait more than 10 years after initially seeking treatment for the correct diagnosis to be made.

The clinical implications of the failure to recognize bipolar disorder in depressed patients include the under-prescription of mood-stabilizing medications, and an increased risk of rapid “cycling” – swings between manic and depressive phases. But, perhaps as a consequence of concerted efforts to improve the recognition of bipolar disorder, during the past few years we have observed the emergence of an opposite phenomenon – over-diagnosis.

In my own practice, my colleagues and I have encountered patients who reported that they were previously diagnosed with bipolar disorder, despite lacking a history of manic or hypomanic episodes. To be sure, we have also seen patients seeking treatment for depression who really did have bipolar disorder. However, there seemed to be more over-diagnosis than under-diagnosis.

We therefore conducted a study to examine empirically how often bipolar disorder might be over- and under-diagnosed. Seven hundred psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV (SCID) and completed a self-administered questionnaire that asked whether they had been previously diagnosed by a health-care professional with bipolar or manic-depressive disorder. Family history information was obtained from the patient regarding their immediate relatives.