What is the best way to assess for bipolar disorder?

Best Way to Assess for Bipolar Disorder

The optimal assessment for bipolar disorder requires a structured clinical interview focused on identifying distinct, spontaneous episodes of mood elevation with decreased need for sleep and psychomotor activation, combined with longitudinal life chart mapping and collateral information from family members. 1

Core Screening Questions

The most critical screening approach targets hallmark features that differentiate bipolar disorder from other conditions:

• Ask specifically about distinct, spontaneous periods of abnormally elevated, expansive, or euphoric mood that represent clear departures from baseline functioning, not just chronic irritability 1, 2
• Screen for decreased need for sleep (not just insomnia or sleep problems, but actually feeling rested with less sleep during mood episodes) as this is a hallmark manic symptom 1
• Inquire about periods of markedly increased goal-directed activity or physical restlessness that occur spontaneously rather than in response to environmental triggers 1
• Document whether symptoms occur in distinct episodes (lasting at least 4 days for hypomania or 7 days for mania) versus chronic, persistent patterns 1

Essential Diagnostic Components

Longitudinal Assessment

• Create a life chart mapping the temporal course of symptoms, documenting when specific symptom clusters began, their duration, periods of remission, and treatment responses 1, 2
• Assess both current and past psychiatric history, including prior diagnoses that may have been incorrect, psychiatric hospitalizations, and emergency department visits for mood-related issues 1

Collateral Information

• Obtain information from family members or other observers whenever possible, as patients often lack insight during manic episodes and family members can describe behavioral changes and episodic patterns more objectively 1
• Document detailed family psychiatric history, particularly of mood disorders and bipolar disorder, as this significantly increases diagnostic likelihood 1, 2

Critical Differentiating Features

• Distinguish manic grandiosity and irritability as marked changes in mental and emotional state rather than reactions to situations or temperamental traits 1, 2
• Differentiate from ADHD, disruptive behavior disorders, and PTSD by focusing on episodic versus chronic patterns and the presence of decreased sleep need 1
• Rule out substance-induced mood disorder through detailed substance use history and toxicology screening, assessing temporal relationships between substance use and mood symptoms 1

Comprehensive Evaluation Requirements

Medical and Psychiatric Comorbidities

• Complete thorough medical evaluation including thyroid function tests, complete blood count, and comprehensive metabolic panel to exclude organic causes 1
• Screen for suicidality systematically, as bipolar disorder has exceptionally high rates of suicide attempts; assess prior suicidal ideas, plans, attempts, and current impulsivity 1
• Evaluate for substance abuse, which has particularly high rates in adolescents and adults with bipolar disorder 1, 3
• Assess for anxiety disorders, developmental disorders, and cognitive/language impairments, which commonly co-occur 1

Treatment Response History

• Document response to past psychiatric treatments, particularly noting any antidepressant-induced mood elevation or agitation, as manic episodes precipitated by antidepressants are characterized as substance-induced per DSM criteria 1
• Review history of treatment response in parents, as this may predict response in offspring 4

Screening Instruments

While clinical interview remains the cornerstone, screening tools can supplement assessment:

• The Mood Disorder Questionnaire (MDQ) can be used as an initial screening tool, but all positive screens must trigger full diagnostic interviews using standard DSM criteria 1, 2
• Two simple screening questions about mood and anhedonia can serve as effective initial screening 2
• Never rely solely on questionnaires or checklists; symptoms must be assessed in perspective given family, school, peer, and other psychosocial factors 2

Critical Pitfalls to Avoid

• Do not diagnose based on irritability alone, as this is non-specific and occurs across multiple diagnoses 1
• Exercise extreme caution in children under age 6, as diagnostic validity has not been established in this population; consider alternative explanations first including developmental disorders, psychosocial stressors, and temperamental difficulties 1
• Avoid missing the diagnosis in patients presenting with depression, as more than 1 in 5 primary care patients with depression have bipolar disorder 5
• Do not overlook the possibility of comorbid conditions such as borderline personality disorder in adolescents, as both conditions share emotional dysregulation, suicidality, and affective instability 1

Monitoring and Follow-Up

• Schedule follow-up visits to observe symptom evolution over time, as the clinical picture may evolve and diagnosis should be reassessed periodically 1
• Track mood patterns, sleep changes, and functional impairment prospectively when diagnostic uncertainty exists 1
• Educate patients and families about early signs and symptoms of mood episodes to enable prompt intervention if relapse occurs 2