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Diagnosing Bipolar Disorder Can be Challenging

Consider the following scenario:

A person visits their doctor or psychiatrist in a state of near-suicide. After probing for other possible causes of the patient’s condition, the psychiatrist diagnoses that their patient with clinical depression and prescribes a standard antidepressant.

The pill works uncommonly fast. Within two or three days the patient’s energy has returned, their dark mood lifts and for one brief moment they know what it’s like to feel normal.

However, their mind is racing. They start making grand plans. Meanwhile, their mind keeps racing. They think this is a side effect that will go away, so they take another pill. After all, the very last thing they want to happen is to crash back into that horrible depression, knowing full well that next time there may be no return.

But their racing mind refuses to stop. Instead, it cranks into an even higher gear. They can’t sleep, their heart is pounding, they’re talking a mile a minute and soon they’re vividly hallucinating. Riding a roller-coaster is inadequate to describe the experience. One is not driving the brain. Rather, the brain is driving the person.

The illness is bipolar disorder, also known as manic depression. Toss an antidepressant at a person with bipolar – with no mood stabilizing medication to hold the antidepressant action at bay – and watch them flip out – totally manic.

For the crisis intervention psychiatrist who saw a person in this condition, it was a no-brainer. “Bipolar mixed,” they wrote on the script with no comment. With those two words, a life is changed. After a lifetime of denial, the patient knew what they were up against. Having identified their adversary, they could begin to fight it, with an excellent chance of winning.

Why hadn’t their first psychiatrist picked it up? Most people with bipolar do not receive a correct diagnosis until their third or fourth try, usually years later. Unless they happen to land in the hospital in the midst of a wildly manic episode, there is not much on which the doctor to go.

The patient was depressed. At the time, they had no knowledge of bipolar in the family (since their diagnosis they’ve discovered it exists on both sides). All they talked about was their depression. All of them – their depression within a depression, their depression following a depression, their depression following the depression on top of the depression, and so on. Their “ups” were what they mistook for normal behavior, so they didn’t feel compelled to bring them to their psychiatrist’s attention.

Mania and Hypomania

The ups – let’s talk about the ups for awhile. We all have our moments of elation, giddiness, or bliss. This is perfectly normal, as are those days when we get up on the “right” side of bed and the world seems to spin in our direction. If someone has hit the genetic jackpot, he or she can feel something like this nearly everyday, with fame and fortune and friends gravitating to them like iron filings to a magnet. Indeed, people with bipolar disorder have proved to be some of society’s most smashing success stories.

But nature is rarely that kind. Sometimes she sends us crashing back into depression. Other times that intoxicating sense of elation starts escalating out of control. One may start talking fast, spending money and engaging in inappropriate activities. Or the magic may start to wear off, as winning behavior deteriorates into crass and embarrassing caricature. Sometimes the elation turns sour, into a dysphoric rage that makes social and family life hell for all concerned.

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So terrible is the havoc that bipolar disorder can bring on that a University of Texas at Houston study has estimated the present value of lifetime cost of the illness for an individual ranges from $11,720 for those with a single manic episode to $624,785 for those non-responsive or with chronic episodes. This includes medical care, as well as unemployment and reduced earnings.

Generally, someone in a state of sustained elevation is said to have “hypomania.” Sadly, that person is the last one to think they need help. Either the high is too intoxicating or the problem lies with the rest of the world.

Full blown mania turns up the heat. If one hasn’t wrecked their life while in a state of hypomania, they’re a prime candidate going into mania. These tend to be your 911 cases, bordering on and breaking through into psychosis. Nevertheless, an antipsychotic medication or tranquilizer can bring down a person with mania in a matter of hours or less, though long-term stabilization can be a lot more problematical.

But even with our brains firmly held in place by the best medical science has to offer, there is no peace of mind. At any minute, any second, at the slightest provocation, we’re all too aware that the insides of our skulls can break loose from their pharmacological moorings and indiscriminately tear down what took us a lifetime to build.

Simply losing a night’s sleep may trigger a manic episode, not to mention the stress from work or a relationship breakup. And past trauma, bad lifestyle choices, and failure to manage stress conspire to set us up like sitting ducks.

Hence the need for vigilance. Many people with bipolar disorder are encouraged to keep mood journals, which they and their psychiatrists track like meteorologists keeping watch on baby hurricanes in the Caribbean.

What is Bipolar Depression?

Now let’s talk about those depressions, the flip side of bipolar disorder. In one way, there is nothing to distinguish bipolar depression from “unipolar” depression, from mild to severe, with similar suicide rates of about 15 percent. But now we’re beginning to discover that bipolar depression may be an entirely different animal, involving different biological processes and treatments.

Sadly, the depressive side of bipolar disorder has been overlooked by the experts. As Michael Thase MD of the University of Pittsburgh observed at the 2002 American Psychiatric Association annual meeting: “Although manic episodes are often more the emergent and notorious phase of bipolar affective disorder, depressive episodes last longer, are typically harder to treat, and result in the high ultimate risk of suicide.”

Rapid-Cycling Bipolar Disorder

The course of the illness is speeded up in some people, so that they are known as rapid-cyclers, who can go up and down and back again, sometimes in a matter of hours. Since rapid-cyclers represent a moving target, treatment is difficult. Antidepressants can induce mania, and antimania medications can induce depression. Analyzing a Stanley Foundation trial, Robert Post MD of the NIMH observed in Bipolar Disorder: “This still left some 30-40 percent of our patients inadequately responsive.”

Then there are those with “mixed states,” who can be up and down at the same time, with agitated depression or dysphoric mania. Some people with unipolar depression can also experience some of these symptoms, and here is where depression gets especially dangerous, for if one is feeling suicidal while in an agitated or manic state, then one has the energy to carry out the deed.

Bipolar Disorder is Not Just Up and Down

These ups and downs – the manic highs and the depressive lows – are what define bipolar disorder, and many authorities are content to leave it at that, as if our brains were simple pendulums swinging from one extreme than the other. But the mind, as well as bipolar, is far more subtle and insidious – and occasionally beneficent – than that.

Fast Bipolar Disorder Facts

From Stanley Bipolar Network patient data of its first 250 outpatients:

  • 85.1 percent had been hospitalized in the past, on average three times.
  • The peak age of onset was between 15 and 19 years of age.
  • The rate of suicide attempts was 50.3 percent.
  • 54 percent had a family member with bipolar disorder, and 32 percent of family members had unipolar depression.
  • A third were currently married, another third single, and the rest were separated, divorced, or widowed.
  • Despite the fact that approximately 90 percent had high school diplomas and a third had completed college, almost 65 percent were unemployed and 40 percent were on welfare or disability.
  • The rate of depressive symptoms over six months was twice the rate of manic symptoms (63.6 percent vs 33.1 percent).

A 2003 Stanley Foundation survey of its next 258 of its next bipolar outpatients, 76 percent with bipolar I, found they were depressed three times more than they were manic (33.2 percent of the year vs 10.8 percent). Despite being on 4.1 psychiatric medications, 62.8 percent had four or more mood episodes a year, two thirds were substantially impacted by their illness, 26.4 were ill for more than three fourths of the year, and 40.7 were intermittently ill.

According to the NIMH, bipolar disorder affects approximately 2.3 million American adults, or about 1.2 percent of the US population age 18 and older in a given year, equally among men and women. A 2003 University of Texas Medical Branch Galveston and other centers study suggests that the prevalence rate for bipolar could be three times as high. Researchers sent the Mood Disorders Questionnaire to 127,800 people age 18 and above selected to represent the US adult population. Of the 85,358 (66.8 percent) who responded, the positive screen for bipolar I or II was 3.4 percent, and 3.7 percent when adjusted for the nonresponse bias. Only 19.8 percent receiving positive screens reported receiving a diagnosis of bipolar from a physician while 31.2 percent reported a diagnosis of unipolar depression. Positive screens were far more common in young adults and those with low income. Migraine, allergies, asthma, and alcohol and drug dependence were “substantially higher” among those with positive screens.

A 2003 Case Western Reserve mail survey of 85,458 adults found that more than half those with symptoms of bipolar were at high risk of being fired or laid off, with nearly half reporting poor job performance. In addition, symptomatic individuals were only half as likely to marry and twice as likely to separate or divorce. The survey also found bipolar is eight times more likely to affect those aged 18 to 24 than those over 55, and that people in this age group reported that symptoms disrupted their lives 70 percent of the time.

Findings from the McLean Hospital-Harvard First-Episode Mania Study that tracked 166 bipolar patients two to four years following their first hospitalization for mania or a mixed episode found fifty percent achieved syndromal (cluster of symptoms) recovery by 5.4 weeks, 98 percent by two years, but 28 percent remained symptomatic. Factors associated with shorter time to recovery for half the subjects were female sex, shorter hospitalization and lower initial depression ratings. Only 43 percent achieved functional recovery (these patients tended to be older with shorter hospitalizations). Forty percent experienced a new episode of mania (20 percent) or depression (20 percent) within two years of syndromal recovery (19 percent switched phases without recovery). Predictors of mania recurrence were initial psychosis, lower occupational status, and initial manic presentation while predictors of depression onset were higher occupational status, initial mixed presentation, and any co-occurring illness.

Diagnosing Bipolar Disorder Can be Challenging

Psych Central Staff

Psych Central Staff writers are vetted, professional authors and science journalists. All work written under this moniker is editorially and scientifically reviewed by Psych Central.

APA Reference
Psych Central. (2020). Diagnosing Bipolar Disorder Can be Challenging. Psych Central. Retrieved on September 23, 2020, from
Scientifically Reviewed
Last updated: 17 Jan 2020 (Originally: 17 May 2016)
Last reviewed: By a member of our scientific advisory board on 17 Jan 2020
Published on Psych All rights reserved.