Written by Jaimie Lunsford, PhD
Why Screen Depressed Clients for Bipolar Disorders?
While it’s common in medical and psychotherapy settings to screen for depression and anxiety, many clinicians don’t screen for bipolar disorders. This may be because the prevalence of bipolar disorder is thought to be too low for screening to be effective. Bipolar I is relatively rare in the general population (around 1.5%). But when taking the entire spectrum of bipolar disorders into account (including bipolar II, cyclothymia, and “other specified bipolar and related disorder”), the overall prevalence is thought to be about 5.5% (Kaye, 2005). Even more importantly for therapists, among individuals seeking treatment for depression symptoms, the prevalence is much higher than in the general population.
1. The prevalence of bipolar disorders among depressed individuals is high.
As many as 1 in 4 individuals diagnosed with major depressive disorder (MDD) actually exhibit bipolar features (Angst et al., 2011), and in one study, 20% of individuals prescribed antidepressants in primary care settings actually screened positive for a bipolar disorder (Hirschfeld et al., 2005). It makes sense that a portion of individuals seeking treatment for depression will meet criteria for a bipolar disorder, because a depressive episode is a central feature of bipolar disorders, and it is much more common for people with bipolar disorders to seek treatment for depression than for hypo/manic symptoms (Regeer et al., 2015). (“Hypo/manic” is used here when a statement applies to both hypomania and mania).
2. Without screening, hypomania and mania commonly go undetected.
People with bipolar disorders spend about three times as many days depressed as they do in hypo/manic states (Kupka et al., 2007), and most often present for treatment when depressed. That means therapists are less likely to see symptoms of hypo/mania occur during treatment. Past periods of hypo/mania may also go unreported or unnoticed for multiple reasons. Hypomania may not be impairing and may be viewed as positive or productive, and therefore not a topic worth mentioning in a clinical setting. Even though mania may be noticeably impairing from the perspective of others, manic states are associated with low insight (Dias et al., 2008) and may appear unproblematic to the person experiencing the episode. In one study, bipolar I and bipolar II patients had an equally difficult time recognizing their own hypo/manic episodes (Regeer et al., 2015), even though the manic episodes were more severe. Additionally, hypo/mania may feel “ego-syntonic,” or consistent with a person’s sense of self (Miklowitz & Gitlin, 2014). That is, even though it represents a change from the client’s baseline mood and energy state, it may not be a change from a client’s typical pattern of ups and downs, and therefore may be viewed as a normal part of “being myself.”
3. Misdiagnosis has a high cost for individuals with bipolar disorders.
Individuals with bipolar disorders wait an average of 8 years (Kaye et al., 2005), and visit an average of 4 physicians (Hirschfeld et al., 2003) before receiving a correct diagnosis. Misdiagnosed individuals face unnecessarily prolonged psychosocial impairment, including loss of work, relationship strain, and higher risk of developing difficulties with substance abuse (Dunner, 2003). Antidepressant medications (especially when used alone) can trigger rapid cycling and a worsening of symptoms for people with bipolar (Ghaemi et al., 2003), creating serious problems when a person with bipolar is misdiagnosed with MDD. Additionally, suicide risk increases the greater the time spent in mood episodes (Valtonen et al., 2008), which means a lack of treatment is also dangerous for people with bipolar disorders.
4. We can be part of the solution.
There are several freely available assessment measures for bipolar symptoms. These screening tools can be used routinely to help therapists detect hypo/mania, mixed mood states (when elements of hypo/mania and depression are present simultaneously), and overall bipolar cycling patterns. Below is a link to measures available on this site. Please note that a positive screen on any of these measures is not sufficient to demonstrate a diagnosis of a bipolar disorder on its own. A positive screen should be followed up by a thorough diagnostic evaluation by a trained professional.
Additionally, high-risk depressed individuals can be educated and encouraged to self-monitor for future symptoms. Even depressed clients that initially present with no history of hypo/mania, for which a diagnosis of MDD is appropriate, may “convert” to bipolar in the future if they later experience a hypo/manic episode. In one study, around 12% of patients who initially met criteria for MDD converted to a bipolar disorder in three years (de Oliveira et al., 2021). To prevent a subsequent delay in receiving a correct diagnosis, high-risk individuals (e.g., family history of bipolar disorder, early onset of depression, recurrent, treatment-resistant depression) can be educated about hypo/manic symptoms and what to do if they arise. Here are links to two helpful educational fact sheets that can be provided to clients:
Bipolar Disorder Fact Sheet from the Black Dog Institute
Bipolar II Disorder Fact Sheet from the Mood Treatment Center
Let’s screen, educate, and monitor to prevent misdiagnosis and improve the outlook for people with bipolar disorders.
Angst, J., Azorin, J. M., Bowden, C. L., Perugi, G., Vieta, E., Gamma, A., ... & BRIDGE Study Group. (2011). Prevalence and characteristics of undiagnosed bipolar disorders in patients with a major depressive episode: the BRIDGE study. Archives of General Psychiatry, 68(8), 791-799.
de Oliveira, J. P., Jansen, K., de Azevedo Cardoso, T., Mondin, T. C., de Mattos Souza, L. D., da Silva, R. A., & Moreira, F. P. (2021). Predictors of conversion from major depressive disorder to bipolar disorder. Psychiatry Research, 297, 113740.
Dias, V. V., Brissos, S., Frey, B. N., & Kapczinski, F. (2008). Insight, quality of life and cognitive functioning in euthymic patients with bipolar disorder. Journal of Affective Disorders, 110(1-2), 75-83.
Dunner, D. L. (2003). Clinical consequences of under-recognized bipolar spectrum disorder. Bipolar Disorders, 5(6), 456-463.
Ghaemi, S. N., Hsu, D. J., Soldani, F., & Goodwin, F. K. (2003). Antidepressants in bipolar disorder: The case for caution. Bipolar Disorders, 5(6), 421-433.
Hirschfeld, R. M., Cass, A. R., Holt, D. C., & Carlson, C. A. (2005). Screening for bipolar disorder in patients treated for depression in a family medicine clinic. The Journal of the American Board of Family Practice, 18(4), 233-239.
Hirschfeld, R. M., Lewis, L., & Vornik, L. A. (2003). 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. Journal of Clinical Psychiatry, 64(2), 161-174.
Kaye, N. S. (2005). Is your depressed patient bipolar?. The Journal of the American Board of Family Practice, 18(4), 271-281.
Keramatian, K., Pinto, J. V., Schaffer, A., Sharma, V., Beaulieu, S., Parikh, S. V., & Yatham, L. N. (2022). Clinical and demographic factors associated with delayed diagnosis of bipolar disorder: data from Health Outcomes and Patient Evaluations in Bipolar Disorder (HOPE-BD) study. Journal of Affective Disorders, 296, 506-513.
Kupka, R. W., Altshuler, L. L., Nolen, W. A., Suppes, T., Luckenbaugh, D. A., Leverich, G. S., ... & Post, R. M. (2007). Three times more days depressed than manic or hypomanic in both bipolar I and bipolar II disorder. Bipolar Disorders, 9(5), 531-535.
Miklowitz, D. J., & Gitlin, M. J. (2014). Clinician's guide to bipolar disorder: Integrating pharmacology and psychotherapy. Guilford Publications.
Regeer, E. J., Kupka, R. W., Have, M. T., Vollebergh, W., & Nolen, W. A. (2015). Low self-recognition and awareness of past hypomanic and manic episodes in the general population. International Journal of Bipolar Disorders, 3(1), 1-7.
Valtonen, H. M., Suominen, K., Haukka, J., Mantere, O., Leppämäki, S., Arvilommi, P., & Isometsä, E. T. (2008). Differences in incidence of suicide attempts during phases of bipolar I and II disorders. Bipolar Disorders, 10(5), 588-596