Interview Questions for Bipolar Disorder Assessment
Essential Screening Questions to Identify Manic/Hypomanic Episodes
Ask specifically about distinct, spontaneous periods of mood elevation with decreased need for sleep and psychomotor activation, as these are the hallmark features that differentiate bipolar disorder from other psychiatric conditions. 1
Core Mood and Energy Questions
"Have you ever had a period of time when you felt so good, 'high,' excited, or hyper that other people thought you were not your normal self, or you got into trouble?" This targets euphoric mood changes that represent a departure from baseline functioning. 1
"During these times, did you need much less sleep than usual and still feel rested—for example, sleeping only 2-4 hours but feeling completely energized?" Decreased need for sleep (not just insomnia) is a critical differentiating feature from depression or anxiety disorders. 1
"Have you had periods lasting at least 4 days (for hypomania) or 7 days (for mania) when your mood was distinctly different from your usual self?" Duration criteria per DSM-IV-TR must be met to distinguish true episodes from brief mood fluctuations. 2
Activity and Behavior Questions
"During these high periods, were you much more active than usual, starting many new projects, or feeling like you had to keep moving?" This assesses increased goal-directed activity and psychomotor activation. 1
"Did you talk much more than usual, feel like your thoughts were racing, or jump quickly from one idea to another?" These symptoms identify pressured speech and flight of ideas characteristic of manic episodes. 1
"Did you do things that were risky or that you later regretted, like spending too much money, having sexual encounters you wouldn't normally have, or making impulsive major decisions?" This evaluates excessive involvement in pleasurable activities with high potential for painful consequences. 1
Grandiosity Assessment
- "During these times, did you feel like you had special powers or abilities, or that you could do things better than anyone else?" Manic grandiosity represents a marked change in mental state rather than just high self-esteem. 1
Critical Historical Information Required
Episode Pattern and Duration
Document the temporal pattern of mood episodes using a life chart approach. Map when specific symptom clusters began, their duration, periods of remission, and whether symptoms are chronic versus episodic. 1
Verify that manic/hypomanic episodes lasted at least 4 days for hypomania or 7 days for mania (unless hospitalization was required, which automatically qualifies as mania). 2
Assess for rapid cycling: Ask if the patient has experienced four or more distinct mood episodes within a 12-month period. 2
Depressive Episode Assessment
"Have you had periods lasting at least 2 weeks when you felt depressed, down, or lost interest in things you usually enjoy?" Bipolar disorder typically involves more time spent in depression than mania. 3, 4
During depressive episodes, specifically ask about: psychomotor retardation, hypersomnia, psychotic features, and mixed features (concurrent irritability, racing thoughts, or increased energy during depression), as these increase suspicion for bipolar rather than unipolar depression. 1
Treatment Response History
"Have you ever taken antidepressants? If so, did they make you feel agitated, 'wired,' overly energized, or cause you to need less sleep?" Antidepressant-induced mood elevation or agitation strongly suggests underlying bipolar disorder, with approximately 20% of youths with major depression eventually developing manic episodes. 1, 2
Document all past psychiatric medications and their effects, particularly noting any mood stabilizers, antipsychotics, or combinations that were helpful or harmful. 1
Family Psychiatric History
"Does anyone in your biological family have bipolar disorder, depression, or other mood disorders?" First-degree relatives of individuals with bipolar disorder have a four- to sixfold increased risk of developing the condition. 1
Specifically ask about family history of: suicide, psychiatric hospitalizations, substance abuse, and any relatives who responded well to lithium or mood stabilizers. 1
Substance Use Assessment
Obtain detailed substance use history including: current and past use of alcohol, marijuana, cocaine, stimulants, hallucinogens, and prescription medication misuse. 1
Assess the temporal relationship between substance use and mood symptoms to rule out substance-induced mood disorder. Consider toxicology screening if substance use is suspected. 1
Note that rates of substance abuse are particularly high in adolescents with bipolar disorder, making this assessment critical. 1
Safety and Comorbidity Assessment
Suicidality Evaluation
Thoroughly assess prior suicidal ideas, plans, attempts (including aborted or interrupted attempts), and current impulsivity. Bipolar disorder has exceptionally high rates of suicide attempts, with an annual suicide rate of approximately 0.9% compared to 0.014% in the general population. 3, 1
Evaluate prior aggressive behaviors, including homicidal ideation or physically aggressive acts. 1
Comorbid Conditions
Screen for anxiety disorders, ADHD, substance use disorders, and eating disorders, as these commonly co-occur with bipolar disorder and complicate diagnosis. 1, 2
In children and adolescents, differentiate manic symptoms from ADHD, disruptive behavior disorders, and PTSD, as high rates of comorbid ADHD are found in juvenile bipolar disorder. 1, 2
Functional Impairment Questions
"During these high or low periods, how did your symptoms affect your work, school, relationships, or daily activities?" Manic episodes cause marked impairment and represent a significant departure from baseline functioning. 1
Obtain collateral information from family members whenever possible, as patients often lack insight during manic episodes and family members can describe behavioral changes more objectively. 1
Special Considerations for Pediatric Populations
Age-Specific Presentations
In younger children, juvenile mania is often characterized by markedly labile and erratic mood, energy, and behavior rather than persistent symptoms. Irritability, belligerence, and mixed manic-depressive features are more common than euphoria. 2
Exercise extreme caution in children under age 6, as the diagnostic validity of bipolar disorder in very young children has not been established. Consider alternative explanations first, including developmental disorders, psychosocial stressors, and temperamental difficulties. 1
Environmental and Developmental Factors
Assess for environmental triggers, patterns of events that reinforce outbursts, language impairment, and history of maltreatment. 1
Evaluate psychosocial stressors including family, school, peer, and other environmental factors. 1
Medical Evaluation Components
Complete thyroid function tests, complete blood count, and comprehensive metabolic panel to exclude organic causes of mood symptoms such as hyperthyroidism or other medical conditions. 1
Assess vital signs and perform neurologic examination to determine if symptoms are caused or exacerbated by underlying medical conditions. 1
Common Diagnostic Pitfalls to Avoid
Do not diagnose bipolar disorder based on irritability alone, as irritability is non-specific and occurs across multiple diagnoses including ADHD, oppositional defiant disorder, and PTSD. 1
Do not overlook the possibility of bipolar disorder in patients presenting with depression, as depression is the most frequent initial presentation and diagnosis is often delayed by a mean of approximately 9 years. 3
Recognize that chronic, persistent irritability without distinct episodes suggests disruptive mood dysregulation disorder (DMDD) rather than bipolar disorder, which manifests as episodic mood changes with clear periods of elevation. 1
Schedule follow-up visits to observe symptom evolution over time and reassess diagnosis periodically, as the clinical picture may evolve and early presentations can be ambiguous. 1