Let’s start with this: Bipolar disorder is quite difficult to diagnose accurately. Quite difficult. Establishing this diagnosis isn’t something to be decided upon in the first visit with a client, as this is utterly unrealistic. There are too many variables and moving parts linked to bipolar to establish diagnostic certainty early on.
Getting Started
Consider this the “warm-up” period, where you begin developing rapport, easing the client into the treatment process. Over the years I’ve settled on a couple of different approaches. The first is to simply allow the client to “tell their story.” Via this process, I’ll guide them with some initial questions such as, “are you primarily here for ongoing management, or consultation?” “What diagnosis have other clinicians discussed with you”? If they respond they’ve been previously diagnosed with bipolar, I’ll ask why – to determine what circumstances lead the treating clinician to conclude that bipolar is the issue. Some clients will respond they were hospitalized or incurred serious consequences resulting from a manic episode, in which case I’ll inquire about that episode and ask more about that. But quite commonly, they’ll say, “well, someone diagnosed me as bipolar, but I don’t know why, and it wasn’t really explained to me.”
An alternative approach is to be as systematic as possible through the employment of diagnostic screening tools such as the Mood Disorder Questionnaire, Beck Depression Inventory and Beck Anxiety Inventory. Systematic approaches are widely accepted, but keep in mind they may be only snapshots in time, in that people’s responses may only be a reflection of how they’re thinking or feeling at the time they’re filling out the questionnaire or inventory. Also, I’m not a fan of having someone fill these out in the waiting room prior to an appointment – this is the last thing an already distressed, or possibly manic, depressed individual wants to do. (I know how I feel on a first visit when a bunch of questions and forms are presented to me.) And nowadays, with practically everyone having some sort of online access, the patient can fill these out ahead of time in their own private place without having to be distracted or bothered by the flurry of activity in an office waiting room. Instead, consider trusting your own questioning, observational skills and instincts regarding the patient before you. Not everyone fits neatly into rating scale or pre-determined questioning formats. Example from the Beck Depression Inventory: “I feel I have failed more than the average person.” How does someone rate this question on a 0-3 scale? What’s an average person? How often does the average person fail?
Ask About Substance Abuse
Substance abuse of any kind complicates every aspect of diagnosis and treatment of any mental disorder, but particularly bipolar – with its potentially numerous ups and downs. Substance abuse mimics bipolar symptoms to the hilt and will absolutely influence a poor outcome. Try your best to determine the timing of these issues – which came first the substance abuse or the mood disorder? But don’t wait to get a patient sober or drug-free before proceeding with evaluation and treatment of the mood disorder.
Next Step – Focus On Previous Depressive and Manic Episodes
Ask this question: “Have there been times in your life when you’ve felt so sad, down and withdrawn that you isolated yourself in such a way that people noticed your absence and commented on it?” Using this question as a starting point will help establish how many episodes the individual may have had, and how much time has been spent in depression. The longitudinal course is important in that it identifies mood patterns. After asking about depression, move on to mania with this question: “Have there been times when you can remember having considerable energy for getting things done, whereby you needed little sleep and felt really up in such a way that other people noticed and commented, and said they thought you were acting oddly or different?” If acknowledged, then probe a bit more and hone in on the extent to which the periods of mania markedly affected functioning (indicative of bipolar I) or whether the episodes were milder and more hypomanic in nature (indicative of bipolar II).
Next Up – Family History
“Is there anyone in your family, as far back as you can remember, who has been hospitalized or treated for what turned out to be bipolar disorder, or treated for ongoing odd behavior that involved marked and distinct mood swings?” Family history is very important, particularly with bipolar disorder, due to its high level of inheritability. Alternatively, if there is no evidence of psychiatric illness in a family, then that really does question a bipolar diagnosis.
Discussing Diagnosis
After having completed the evaluation and assessment steps discussed above, spend a few minutes educating the client about your diagnostic impressions. The goal here is to convey the importance of pursuing treatment. Psychoeducation helps enhance compliance and urgency to act upon treatment recommendations. Take a compassionately direct approach: “I believe you have bipolar disorder and here’s why I think so.” Then follow that with a positive, hopeful statement: “Your condition is certainly treatable, and if you work with me, I believe that together we can achieve a favorable outcome.” “Does that sound okay to you?”
Mood Charting
The mood chart for bipolar is a tool that facilitates identification of possible “trouble on the horizon” before it continues to develop or happen. Charting is simpler, clearer, and not nearly as cumbersome as keeping an often meandering diary account or trusting one’s memory of what happened between doctor visits. As such, it informs as to when mood is changing for the worse, making it possible to alter course before becoming ensnared in a major event. It helps the person maintain awareness of how they’re feeling by being cognizant of their ups and downs, giving them a sense of control and how their condition may be affecting others, particularly loved ones. And it frees up time to discuss what’s really important to them in their future sessions with providers. (Google – NIMH daily mood chart for a mood charting PDF).
Medication
Lithium remains the gold standard for acute mania and bipolar maintenance and that’s not going to change. Unfortunately, the drug’s use is often eschewed by primary care prescribers and even some psychiatrists because lithium carries the baggage of frequent blood level monitoring – at least at first – and potentially troublesome side effects, (hypothyroidism; kidney dysfunction). Lithium substantially decreases the risk of suicide in bipolar patients. Seroquel immediate release, as well as the XR formulation; Symbyax and Latuda are the best available options for bipolar depression.
When medication is employed in treating bipolar disorder, there can be a tendency among physicians and other prescribers to be entirely too reactive to sometimes even normal day-to-day- variations in a patient’s mood. Mood and feelings shift throughout the day even in healthy subjects. So it’s important not to be too reactive and pathologize mood changes by adding more medication for what may be no more than a 2 or 3-day mood “blip.” In other words, don’t chase symptoms with yet more drugs and be willing to acknowledge that if medication treatment is failing, the diagnosis may be wrong.
One last thing: Always ask patients if they’re taking their medications, because if you don’t ask, many of them won’t tell you. And if need be, obtain blood levels if you believe the patient is non-compliant.
Everybody lies! At least from time-to-time, said Dr. House.
Attribution Statement:
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.
To learn more about Joe’s programs, visit the Programs section of this website or contribute a question for Joe to answer in a future article: joe@thepharmatherapist.com.