What is a better approach to diagnose bipolar disorder?

From the Guidelines

A better approach to diagnose bipolar disorder involves a comprehensive clinical assessment combining multiple diagnostic tools, including standardized screening instruments and a thorough clinical interview, to identify distinct mood episodes and cyclical patterns in mood disturbances. This approach is supported by the practice parameter for the assessment and treatment of children and adolescents with bipolar disorder 1. The assessment should start with standardized screening instruments like the Mood Disorder Questionnaire (MDQ) or Bipolar Spectrum Diagnostic Scale (BSDS) to identify potential cases.

Following the screening, a comprehensive clinical interview should focus on identifying distinct mood episodes—particularly manic or hypomanic periods characterized by elevated mood, decreased need for sleep, racing thoughts, increased goal-directed activity, and impulsivity lasting at least 4-7 days. It is essential to look for cyclical patterns in mood disturbances and family history of bipolar disorder. Differentiating from unipolar depression by identifying past hypomanic/manic episodes that patients often don't report spontaneously is also crucial.

Longitudinal monitoring is essential, and tracking mood patterns daily using mood charting apps or paper diaries for at least 2-4 weeks can provide valuable insights. Collateral information from family members is crucial as patients often lack insight during mood episodes. Laboratory tests, including thyroid function tests, complete blood count, and toxicology screening, should be conducted to rule out medical causes of mood symptoms.

This multi-modal approach improves diagnostic accuracy by capturing the episodic nature of bipolar disorder and distinguishing it from other conditions with overlapping symptoms. Additionally, psychotherapeutic interventions, such as psychoeducational therapy, relapse prevention, individual psychotherapy, and social and family functioning therapies, can be beneficial in addressing the associated functional and developmental impairments and promoting medication compliance 1.

Some key points to consider in the assessment and diagnosis of bipolar disorder include:

• Using standardized screening instruments to identify potential cases
• Conducting a comprehensive clinical interview to identify distinct mood episodes and cyclical patterns
• Longitudinal monitoring to track mood patterns
• Collateral information from family members to provide additional insights
• Laboratory tests to rule out medical causes of mood symptoms
• Psychotherapeutic interventions to address associated functional and developmental impairments.

From the Research

Better Approach to Diagnose Bipolar Disorder

To assess for bipolar disorder more effectively, several factors should be considered:

• A comprehensive clinical diagnostic approach that includes a detailed patient history and assessment of past hypomanic episodes, as suggested by 2
• The use of a modified Structured Clinical Interview for DSM-IV Axis I Disorders, Clinician Version (SCID-CV) that focuses on past history of overactive behavior and hypomanic features, as outlined in 2
• Identification of objective biomarkers that represent pathophysiologic processes differing between bipolar disorder and unipolar depression, as discussed in 3
• Consideration of the patient's family history, age of onset, and presence of psychotic or reverse neurovegetative features, as mentioned in 4

Key Factors in Diagnosis

Some key factors to consider when diagnosing bipolar disorder include:

• Earlier age of onset and a family history of bipolar disorder, as indicated in 4 and 5
• Presence of psychotic or reverse neurovegetative features, as noted in 4
• Antidepressant-induced switching, as discussed in 6
• High score on the hyperthymia component of the Semi-structured Affective Temperament Interview, as associated with a greater risk of switching in 6

Treatment Considerations

When treating bipolar disorder, the following should be considered:

• Lithium as the gold standard mood-stabilising agent, as stated in 5
• The use of antipsychotics, divalproex, and carbamazepine for acute mania, as mentioned in 5
• Lamotrigine for treating and preventing bipolar depression, as noted in 5
• The potential risks of mood switches associated with antidepressant therapy, as discussed in 6