UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

Bipolar disorder in adults: Assessment and diagnosis

Authors
Trisha Suppes, MD
Victoria E Cosgrove, PhD
Section Editor
Paul Keck, MD
Deputy Editor
David Solomon, MD

INTRODUCTION

Making the diagnosis of bipolar disorder is often difficult, and following onset of symptoms, many years may elapse until the diagnosis is established [1,2]. As an example, a self-administered survey in 441 bipolar patients found that 35 percent waited at least 10 years between first seeking treatment and receiving the correct diagnosis [3].

This topic reviews the assessment and diagnosis of bipolar disorder in adults. The clinical features of bipolar disorder in adults are discussed separately, as are the clinical features and diagnosis of bipolar disorder in children and adolescents, geriatric patients, and patients with rapid cycling (ie, four or more mood episodes in a 12-month period):

(See "Bipolar disorder in adults: Clinical features".)

(See "Pediatric bipolar disorder: Epidemiology, pathogenesis, clinical manifestations, and course".)

(See "Bipolar disorder in children and adolescents: Assessment and diagnosis".)

                                

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Mon Jun 20 00:00:00 GMT+00:00 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Morselli PL, Elgie R, GAMIAN-Europe. GAMIAN-Europe/BEAM survey I--global analysis of a patient questionnaire circulated to 3450 members of 12 European advocacy groups operating in the field of mood disorders. Bipolar Disord 2003; 5:265.
  2. Phillips ML, Kupfer DJ. Bipolar disorder diagnosis: challenges and future directions. Lancet 2013; 381:1663.
  3. Hirschfeld RM, Lewis L, Vornik LA. Perceptions and impact of bipolar disorder: how far have we really come? Results of the national depressive and manic-depressive association 2000 survey of individuals with bipolar disorder. J Clin Psychiatry 2003; 64:161.
  4. Work Group on Psychiatric Evaluation, American Psychiatric Association Steering Committee on Practice Guidlines. Psychiatric evaluation of adults. Second edition. American Psychiatric Association. Am J Psychiatry 2006; 163:3.
  5. American Psychiatric Association Practice Guideline for the Psychiatric Evaluation of Adults, Second Edition, 2006. http://www.psych.org/MainMenu/PsychiatricPractice/PracticeGuidelines_1.aspx (Accessed on July 18, 2011).
  6. Freudenreich O, Nejad SH, Francis A, Fricchione GL. Psychosis, mania, and catatonia. In: Textbook of Psychosomatic Medicine: Psychiatric Care of the Medically Ill, Second Edition, Levenson JL. (Ed), American Psychiatric Publishing, Washington, DC 2011. p.219.
  7. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), American Psychiatric Association, Arlington, VA 2013.
  8. Goodwin FK, Jamison KR. Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, 2nd edition, Oxford University Press, New York 2007.
  9. Ghaemi SN, Stoll AL, Pope HG Jr. Lack of insight in bipolar disorder. The acute manic episode. J Nerv Ment Dis 1995; 183:464.
  10. Hilty DM, Brady KT, Hales RE. A review of bipolar disorder among adults. Psychiatr Serv 1999; 50:201.
  11. Sachs, G. Approach to the patient with elevated, expansive, or irritable mood. In: The MGH Guide to Psychiatry in Primary Care, Stern, TA, Herman, JB, Slavin, PL (Eds), McGraw-Hill, New York 1998. p.347.
  12. Griswold KS, Pessar LF. Management of bipolar disorder. Am Fam Physician 2000; 62:1343.
  13. Hallahan B, Newell J, Soares JC, et al. Structural magnetic resonance imaging in bipolar disorder: an international collaborative mega-analysis of individual adult patient data. Biol Psychiatry 2011; 69:326.
  14. Arnone D, Cavanagh J, Gerber D, et al. Magnetic resonance imaging studies in bipolar disorder and schizophrenia: meta-analysis. Br J Psychiatry 2009; 195:194.
  15. Chessick CA, Dimidjian S. Screening for bipolar disorder during pregnancy and the postpartum period. Arch Womens Ment Health 2010; 13:233.
  16. Yatham LN. Diagnosis and management of patients with bipolar II disorder. J Clin Psychiatry 2005; 66 Suppl 1:13.
  17. Thase ME. Bipolar depression: issues in diagnosis and treatment. Harv Rev Psychiatry 2005; 13:257.
  18. Angst J, Cassano G. The mood spectrum: improving the diagnosis of bipolar disorder. Bipolar Disord 2005; 7 Suppl 4:4.
  19. Zimmerman M. Misuse of the Mood Disorders Questionnaire as a case-finding measure and a critique of the concept of using a screening scale for bipolar disorder in psychiatric practice. Bipolar Disord 2012; 14:127.
  20. Hirschfeld RM, Williams JB, Spitzer RL, et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Am J Psychiatry 2000; 157:1873.
  21. Hu C, Xiang YT, Wang G, et al. Screening for bipolar disorder with the Mood Disorders Questionnaire in patients diagnosed as major depressive disorder - the experience in China. J Affect Disord 2012; 141:40.
  22. Kiejna A, Pawłowski T, Dudek D, et al. The utility of Mood Disorder Questionnaire for the detection of bipolar diathesis in treatment-resistant depression. J Affect Disord 2010; 124:270.
  23. Carvalho AF, Takwoingi Y, Sales PM, et al. Screening for bipolar spectrum disorders: A comprehensive meta-analysis of accuracy studies. J Affect Disord 2015; 172:337.
  24. Zimmerman M, Galione JN. Screening for bipolar disorder with the Mood Disorders Questionnaire: a review. Harv Rev Psychiatry 2011; 19:219.
  25. Zimmerman M. Screening for bipolar disorder: confusion between case-finding and screening. Psychother Psychosom 2014; 83:259.
  26. Angst J, Adolfsson R, Benazzi F, et al. The HCL-32: towards a self-assessment tool for hypomanic symptoms in outpatients. J Affect Disord 2005; 88:217.
  27. Boschloo L, Nolen WA, Spijker AT, et al. The Mood Disorder Questionnaire (MDQ) for detecting (hypo)manic episodes: its validity and impact of recall bias. J Affect Disord 2013; 151:203.
  28. Hirschfeld RM, Cass AR, Holt DC, Carlson CA. Screening for bipolar disorder in patients treated for depression in a family medicine clinic. J Am Board Fam Pract 2005; 18:233.
  29. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001; 16:606.
  30. The ICD-10 Classification of Mental and Behavioral Disorders: Clinical Descriptions and Diagnostic Guidelines. http://www.who.int/classifications/icd/en/bluebook.pdf (Accessed on September 27, 2012).
  31. Santelmann H, Franklin J, Bußhoff J, Baethge C. Test-retest reliability of schizoaffective disorder compared with schizophrenia, bipolar disorder, and unipolar depression--a systematic review and meta-analysis. Bipolar Disord 2015; 17:753.
  32. Bschor T, Angst J, Azorin JM, et al. Are bipolar disorders underdiagnosed in patients with depressive episodes? Results of the multicenter BRIDGE screening study in Germany. J Affect Disord 2012; 142:45.
  33. Stensland MD, Schultz JF, Frytak JR. Depression diagnoses following the identification of bipolar disorder: costly incongruent diagnoses. BMC Psychiatry 2010; 10:39.
  34. Øiesvold T, Nivison M, Hansen V, et al. Classification of bipolar disorder in psychiatric hospital. A prospective cohort study. BMC Psychiatry 2012; 12:13.
  35. Baldessarini RJ. A plea for integrity of the bipolar disorder concept. Bipolar Disord 2000; 2:3.
  36. Zimmerman M, Ruggero CJ, Chelminski I, Young D. Is bipolar disorder overdiagnosed? J Clin Psychiatry 2008; 69:935.
  37. Goldberg JF, Garno JL, Callahan AM, et al. Overdiagnosis of bipolar disorder among substance use disorder inpatients with mood instability. J Clin Psychiatry 2008; 69:1751.
  38. Zimmerman M, Ruggero CJ, Chelminski I, Young D. Psychiatric diagnoses in patients previously overdiagnosed with bipolar disorder. J Clin Psychiatry 2010; 71:26.
  39. Rocha-Rego V, Jogia J, Marquand AF, et al. Examination of the predictive value of structural magnetic resonance scans in bipolar disorder: a pattern classification approach. Psychol Med 2014; 44:519.
  40. Yazıcı O. Unipolar mania: a distinct entity? J Affect Disord 2014; 152-154:52.
  41. Solomon DA, Leon AC, Endicott J, et al. Unipolar mania over the course of a 20-year follow-up study. Am J Psychiatry 2003; 160:2049.
  42. Baek JH, Eisner LR, Nierenberg AA. Epidemiology and course of unipolar mania: results from the national epidemiologic survey on alcohol and related conditions (NESARC). Depress Anxiety 2014; 31:746.
  43. Geoffroy PA, Bellivier F, Scott J, Etain B. Seasonality and bipolar disorder: a systematic review, from admission rates to seasonality of symptoms. J Affect Disord 2014; 168:210.
  44. Coryell W. Diagnostic instability: how much is too much? Am J Psychiatry 2011; 168:1136.
  45. Bromet EJ, Kotov R, Fochtmann LJ, et al. Diagnostic shifts during the decade following first admission for psychosis. Am J Psychiatry 2011; 168:1186.
  46. Lenzenweger MF, Lane MC, Loranger AW, Kessler RC. DSM-IV personality disorders in the National Comorbidity Survey Replication. Biol Psychiatry 2007; 62:553.
  47. Merikangas KR, Akiskal HS, Angst J, et al. Lifetime and 12-month prevalence of bipolar spectrum disorder in the National Comorbidity Survey replication. Arch Gen Psychiatry 2007; 64:543.
  48. Bowden CL. A different depression: clinical distinctions between bipolar and unipolar depression. J Affect Disord 2005; 84:117.
  49. Frye MA, Calabrese JR, Reed ML, et al. Use of health care services among persons who screen positive for bipolar disorder. Psychiatr Serv 2005; 56:1529.
  50. Smith DJ, Griffiths E, Kelly M, et al. Unrecognised bipolar disorder in primary care patients with depression. Br J Psychiatry 2011; 199:49.
  51. Stensland MD, Schultz JF, Frytak JR. Diagnosis of unipolar depression following initial identification of bipolar disorder: a common and costly misdiagnosis. J Clin Psychiatry 2008; 69:749.
  52. Hu C, Xiang YT, Ungvari GS, et al. Undiagnosed bipolar disorder in patients treated for major depression in China. J Affect Disord 2012; 140:181.
  53. Hantouche EG, Akiskal HS, Lancrenon S, et al. Systematic clinical methodology for validating bipolar-II disorder: data in mid-stream from a French national multi-site study (EPIDEP). J Affect Disord 1998; 50:163.
  54. Lewinsohn PM, Klein DN, Seeley JR. Bipolar disorders in a community sample of older adolescents: prevalence, phenomenology, comorbidity, and course. J Am Acad Child Adolesc Psychiatry 1995; 34:454.
  55. Kupfer DJ, Frank E, Grochocinski VJ, et al. Demographic and clinical characteristics of individuals in a bipolar disorder case registry. J Clin Psychiatry 2002; 63:120.
  56. Cha B, Kim JH, Ha TH, et al. Polarity of the first episode and time to diagnosis of bipolar I disorder. Psychiatry Investig 2009; 6:96.
  57. American Psychiatric Association. Practice guideline for the treatment of patients with bipolar disorder (revision). Am J Psychiatry 2002; 159:1.
  58. Judd LL, Akiskal HS, Schettler PJ, et al. The long-term natural history of the weekly symptomatic status of bipolar I disorder. Arch Gen Psychiatry 2002; 59:530.
  59. Judd LL, Akiskal HS, Schettler PJ, et al. A prospective investigation of the natural history of the long-term weekly symptomatic status of bipolar II disorder. Arch Gen Psychiatry 2003; 60:261.
  60. Krishnan KR. Psychiatric and medical comorbidities of bipolar disorder. Psychosom Med 2005; 67:1.
  61. Matza LS, Rajagopalan KS, Thompson CL, de Lissovoy G. Misdiagnosed patients with bipolar disorder: comorbidities, treatment patterns, and direct treatment costs. J Clin Psychiatry 2005; 66:1432.
  62. Mitchell PB, Goodwin GM, Johnson GF, Hirschfeld RM. Diagnostic guidelines for bipolar depression: a probabilistic approach. Bipolar Disord 2008; 10:144.
  63. Fiedorowicz JG, Endicott J, Leon AC, et al. Subthreshold hypomanic symptoms in progression from unipolar major depression to bipolar disorder. Am J Psychiatry 2011; 168:40.
  64. Zimmermann P, Brückl T, Nocon A, et al. Heterogeneity of DSM-IV major depressive disorder as a consequence of subthreshold bipolarity. Arch Gen Psychiatry 2009; 66:1341.
  65. Moreno C, Hasin DS, Arango C, et al. Depression in bipolar disorder versus major depressive disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Bipolar Disord 2012; 14:271.
  66. Forty L, Smith D, Jones L, et al. Clinical differences between bipolar and unipolar depression. Br J Psychiatry 2008; 192:388.
  67. Souery D, Zaninotto L, Calati R, et al. Phenomenology of psychotic mood disorders: lifetime and major depressive episode features. J Affect Disord 2011; 135:241.
  68. Xiang YT, Zhang L, Wang G, et al. Sociodemographic and clinical features of bipolar disorder patients misdiagnosed with major depressive disorder in China. Bipolar Disord 2013; 15:199.
  69. Dervic K, Garcia-Amador M, Sudol K, et al. Bipolar I and II versus unipolar depression: clinical differences and impulsivity/aggression traits. Eur Psychiatry 2015; 30:106.
  70. Leonpacher AK, Liebers D, Pirooznia M, et al. Distinguishing bipolar from unipolar depression: the importance of clinical symptoms and illness features. Psychol Med 2015; 45:2437.
  71. Angst J, Azorin JM, Bowden CL, et al. Prevalence and characteristics of undiagnosed bipolar disorders in patients with a major depressive episode: the BRIDGE study. Arch Gen Psychiatry 2011; 68:791.
  72. Dudek D, Siwek M, Zielińska D, et al. Diagnostic conversions from major depressive disorder into bipolar disorder in an outpatient setting: results of a retrospective chart review. J Affect Disord 2013; 144:112.
  73. Li CT, Bai YM, Huang YL, et al. Association between antidepressant resistance in unipolar depression and subsequent bipolar disorder: cohort study. Br J Psychiatry 2012; 200:45.
  74. Inoue T, Inagaki Y, Kimura T, Shirakawa O. Prevalence and predictors of bipolar disorders in patients with a major depressive episode: the Japanese epidemiological trial with latest measure of bipolar disorder (JET-LMBP). J Affect Disord 2015; 174:535.
  75. Almeida JR, Mourao-Miranda J, Aizenstein HJ, et al. Pattern recognition analysis of anterior cingulate cortex blood flow to classify depression polarity. Br J Psychiatry 2013; 203:310.
  76. Phillips ML, Vieta E. Identifying functional neuroimaging biomarkers of bipolar disorder: toward DSM-V. Schizophr Bull 2007; 33:893.
  77. Redlich R, Almeida JJ, Grotegerd D, et al. Brain morphometric biomarkers distinguishing unipolar and bipolar depression. A voxel-based morphometry-pattern classification approach. JAMA Psychiatry 2014; 71:1222.
  78. Rive MM, Mocking RJ, Koeter MW, et al. State-Dependent Differences in Emotion Regulation Between Unmedicated Bipolar Disorder and Major Depressive Disorder. JAMA Psychiatry 2015; 72:687.
  79. Li Z, Zhang C, Fan J, et al. Brain-derived neurotrophic factor levels and bipolar disorder in patients in their first depressive episode: 3-year prospective longitudinal study. Br J Psychiatry 2014; 205:29.
  80. Rigucci S, Dimitri-Valente G, Mandarelli G, et al. Neurological soft signs discriminate schizophrenia from bipolar disorder. J Psychiatr Pract 2014; 20:147.
  81. Klassen LJ, Katzman MA, Chokka P. Adult ADHD and its comorbidities, with a focus on bipolar disorder. J Affect Disord 2010; 124:1.
  82. Sood AB, Razdan A, Weller EB, Weller RA. How to differentiate bipolar disorder from attention deficit hyperactivity disorder and other common psychiatric disorders: a guide for clinicians. Curr Psychiatry Rep 2005; 7:98.
  83. Wingo AP, Ghaemi SN. A systematic review of rates and diagnostic validity of comorbid adult attention-deficit/hyperactivity disorder and bipolar disorder. J Clin Psychiatry 2007; 68:1776.
  84. Zimmerman M. Problems diagnosing bipolar disorder in clinical practice. Expert Rev Neurother 2010; 10:1019.
  85. Ruggero CJ, Zimmerman M, Chelminski I, Young D. Borderline personality disorder and the misdiagnosis of bipolar disorder. J Psychiatr Res 2010; 44:405.
  86. Ghaemi SN, Dalley S, Catania C, Barroilhet S. Bipolar or borderline: a clinical overview. Acta Psychiatr Scand 2014; 130:99.
  87. Bassett D. Borderline personality disorder and bipolar affective disorder. Spectra or spectre? A review. Aust N Z J Psychiatry 2012; 46:327.
  88. Paris J, Black DW. Borderline personality disorder and bipolar disorder: what is the difference and why does it matter? J Nerv Ment Dis 2015; 203:3.