Jair Soares, MD, PhD, professor of psychiatry and behavioral sciences at University of Texas (UT) Health Science Center in Houston, was scheduled to present a session on challenges of assessing patients for bipolar disorder at this year’s American Psychiatric Association Annual Meeting.
In a video, he discusses why the condition is difficult to diagnose, diagnostic strategies, and common errors made in evaluating patients for the disorder.
Read the transcript of the video here:
My name is Jair Soares. I'm a professor of psychiatry and behavioral sciences at UT Health Science Center in Houston. I'm also the department chair there where I direct the Mood Disorders Center.
Why did you want to speak at the APA meeting on the diagnosis of bipolar disorder?
The APA meeting is a key meeting because it really reaches lots of psychiatrists and behavioral health practitioners in our country and beyond. It was actually an honor to have our panel selected for presentation there.
What we wanted to do was to do something very practical around diagnostic and treatment issues related to bipolar disorder. Do something very focused on the day‑to‑day clinical practice, something very applied and meaningful to the clinician who is on the trenches seeing many of these patients.
Why is bipolar disorder difficult to diagnose?
It's primarily as it pertains to the hypomania. You have to rely on the patient's recollection for certain symptoms that they may have had at some point. It becomes easier if they present with such symptoms. A lot of times, you don't get that luxury. You have to rely on their recollection and any information you can retrieve from the family and other sources that might be available.
That is where, often, bipolar disorder will be diagnosed as major depressive disorder inaccurately. There are many folks out there, where after several bouts of what you thought was unipolar depression, upon a closer look, it turns out that there were episodes of hypomania that could be well‑characterized, in which case the diagnosis gets to be changed.
In a way, you get to upgrade that from MDD to bipolar type 2. Bipolar type 1 is easier in the sense that a full‑blown manic episode or mixed episode that is required for the diagnosis, it tends not to go unnoticed. At the level of hypomania, people could still function somehow and the changes may be more subtle. People around them may not notice and they may not recall that later.
If one has gone through a full‑blown manic or mixed episode, that tends to be noticed, and chances are that they will remember or they may have ended up hospitalized, and people around them will remember that they went through that.
What are the most important steps for clinicians to take when evaluating a patient for bipolar disorder?
A careful history is very important. Whenever available, talking to the patient's family or significant other to elicit additional information. Also, not losing track that the symptoms that we talk about for hypomania or mania, they have to happen around the same time.
We're talking about a period of time when those changes were present. Sometimes that gets confused with ADHD or excessive anxiety. It's important to take a closer look and also a longitudinal look at what's going on. Otherwise, we will end up overdiagnosing bipolar disorder.
A typical one, if you get a patient with MDD who has depression that comes with a lot of anxiety, that can be mistaken as hypomania or a mixed episode. The patient may be improperly diagnosed as bipolar disorder.
Whenever there's longitudinal information available, that's very important. Also, the longer you follow these individuals, I think the more confident you'll be on the diagnosis because you will see them at different mood states.
What errors commonly lead to the misdiagnosis of bipolar disorder?
Sometimes mood lability. These patients have mood lability, but it comes in mood states that last at least for a little while. When we start talking about the rapid cyclers and then the type of mood lability that you see in patients that have borderline personality disorder, you can really misdiagnose those.
If you see somebody with a labile mood, and without taking into consideration other elements that you also need there to establish a full depressive episode or a manic, hypomanic, mixed episode, you may end up, again, incorrectly diagnosing those folks as bipolar disorder when what they have is some other condition like borderline personality disorder, for example.
That comes with a lot of mood lability, but not the type of more well‑defined and, in some ways, more enduring mood changes that you'd see in a patient with bipolar disorder. Obviously, one could have both. In theory, you could. There is some overlap in the features.