Bipolar Disorder Assessment Questions
A comprehensive bipolar assessment must systematically evaluate current and past mood episodes (both manic and depressive), duration and pattern of symptoms, suicidality, comorbid psychiatric conditions (especially substance use and ADHD), family psychiatric history, psychosocial stressors, and medical conditions that could mimic or complicate bipolar disorder. 1, 2
Core Symptom Assessment
Manic/Hypomanic Episode Evaluation
Ask specifically about distinct periods (not just traits) of abnormal mood that represent a marked departure from baseline functioning 2:
- Elevated or irritable mood: "Have you ever had periods lasting at least 4 days (or 7 days for mania) where you felt unusually happy, 'high,' or irritable—different from your normal self?"
- Decreased need for sleep: "During these times, did you need much less sleep than usual but still felt energetic?" (This is particularly important diagnostically) 2
- Grandiosity: "Did you feel unusually confident or believe you had special powers or abilities?"
- Increased goal-directed activity or psychomotor agitation: "Were you much more active, starting many projects, or unable to sit still?"
- Racing thoughts/flight of ideas: "Did your thoughts race so fast you couldn't keep up with them?"
- Increased talkativeness or pressured speech: "Did others say you were talking much more or faster than usual?"
- Distractibility: "Was your attention pulled to unimportant things around you?"
- Risky behaviors: "Did you do things that were risky or unusual for you—like spending sprees, sexual indiscretions, or reckless driving?"
Critical diagnostic distinction: These symptoms must represent a marked change from baseline functioning, not just temperamental traits, anger outbursts, or situational reactions 2. The symptoms should be evident across multiple settings (home, work, social), not isolated to one context 2.
Depressive Episode Assessment
- Current and past depressive episodes (duration, severity, symptoms)
- Presence of mixed features (depressive symptoms during manic episodes or vice versa) 3
- Anxious distress during mood episodes 3
Longitudinal Pattern Assessment
Use a life chart approach to map the course of illness, episode patterns, severity, and treatment responses over time 2. This longitudinal perspective is crucial because acute presentations often mimic other disorders 2.
Ask about:
- Age of first mood episode
- Frequency and duration of episodes
- Seasonal patterns or triggers
- Periods of wellness between episodes
- Rapid cycling (≥4 episodes per year)
Safety Assessment
Suicidality (High Priority)
Adolescents and adults with bipolar disorder have exceptionally high suicide attempt and completion rates 2. Assess thoroughly 1:
- Current suicidal ideation (active vs. passive thoughts)
- Suicide plans and intent
- Access to lethal means (especially firearms)
- Past suicide attempts
- Hopelessness
- Patient's intended course of action if symptoms worsen
- Family history of suicide 1
Aggression/Violence Risk
- Current aggressive ideation
- Past violent behaviors
- Family history of violence 1
Comorbid Psychiatric Conditions
Bipolar disorder has exceptionally high comorbidity rates—assess systematically 2:
- ADHD (very common, especially in youth)
- Anxiety disorders (panic, GAD, social anxiety, PTSD)
- Disruptive behavior disorders (conduct disorder, oppositional defiant disorder)
- Substance use disorders (alcohol, cannabis, stimulants, opioids)—rates are extremely high 2, 4
- Developmental disorders (autism spectrum, learning disabilities)
- Personality disorders (especially borderline personality disorder) 5
Substance Use History
This is mandatory given the high prevalence of co-occurring substance use disorders 1, 2:
- Current and past use of tobacco, alcohol, marijuana, cocaine, stimulants, hallucinogens, opioids
- Misuse of prescribed medications (especially stimulants, benzodiazepines, opioids)
- Over-the-counter medications and supplements
- Pattern of use (frequency, quantity, timing relative to mood episodes)
- Current or recent substance use disorder
- Impact of substances on mood symptoms
Psychiatric Treatment History
- All past psychiatric diagnoses (many patients are initially misdiagnosed with unipolar depression) 6, 7
- Previous medications (names, doses, duration, response, side effects)
- Response to antidepressants alone (did they trigger mania/hypomania or mixed states?)
- Past psychotherapy
- Psychiatric hospitalizations
- Treatment adherence patterns 2
Family Psychiatric History
Family history is a critical diagnostic clue 2, 7:
- Bipolar disorder in first-degree relatives
- Depression, suicide, or psychiatric hospitalizations in family members
- Substance use disorders in family
- Response to psychiatric medications in relatives (can predict patient response)
Medical History
Assess conditions that can mimic or complicate bipolar disorder 1:
- Thyroid disorders (hypo- or hyperthyroidism)
- Neurological conditions (seizures, multiple sclerosis, brain injury)
- Head trauma or traumatic brain injury
- Endocrine disorders (Cushing's syndrome, hyperthyroidism)
- Infectious diseases (HIV, syphilis, Lyme disease)
- Sleep disorders (sleep apnea, narcolepsy)
- Current medications that can affect mood (corticosteroids, stimulants, antidepressants)
- Allergies and medication sensitivities
- Relationship with primary care provider
Psychosocial History
- Trauma history (childhood abuse, domestic violence, combat exposure) 1
- Current psychosocial stressors (financial, housing, legal, occupational, relationship problems) 1, 2
- Social support system
- Academic/occupational functioning (often severely impaired) 2
- Legal history (arrests, incarceration)
- Cultural factors and beliefs about mental illness 1, 2
Mental Status Examination
Document 1:
- Appearance, grooming, psychomotor activity
- Speech (rate, volume, pressure)
- Mood (subjective) and affect (observed)
- Thought process (racing thoughts, flight of ideas, tangentiality)
- Thought content (grandiosity, paranoia, suicidal/homicidal ideation)
- Perceptual disturbances (hallucinations during severe episodes)
- Cognition (attention, concentration, memory)
- Insight and judgment
Functional Impairment Assessment
- Impact on social relationships
- Family functioning
- Academic/work performance
- Self-care abilities
- Quality of life measures 6
Special Considerations for Children and Adolescents
Exercise extreme caution when diagnosing bipolar disorder in young children 2. The diagnostic validity in preschool children is not established 2.
For youth, additionally assess:
- Developmental history and milestones
- Speech and language development
- School performance and behavioral problems
- Peer relationships
- Environmental triggers and reinforcement patterns 2
Common pitfall: Chronic irritability and emotional dysregulation in children can mimic bipolar disorder but may represent other conditions (ADHD, PTSD, autism spectrum disorder, disruptive behavior disorders) 2. Look for distinct episodes with clear changes from baseline, not chronic baseline dysfunction.
Screening in Primary Care
In primary care settings, screen for past manic/hypomanic symptoms in anyone presenting with depression, anxiety, or irritability, especially with 7:
- Recurrent episodes
- Family history of bipolar disorder
- Suicidal thoughts or past attempts
- Poor response to antidepressants or worsening with antidepressants
The Mood Disorder Questionnaire can be used as a screening tool 6, though formal diagnosis should be made by a psychiatrist, ideally a mood disorders specialist 7.