Bipolar Awareness Day: The Misdiagnoses of BP

Psych Congress Steering Committee Member and Bipolar Disorder Section Editor, Craig Chepke, MD, FAPA, adjunct associate professor of psychiatry, Atrium Health, adjunct assistant professor of psychiatry, UNC School of Medicine, and medical director, Excel Psychiatric Associates, Huntersville, North Carolina, shares a message on Bipolar Awareness Day. Dr Chepke discusses the misdiagnoses of bipolar disorder and answers the question, "how can we do a better job of making this diagnosis." 

Dr Chepke shares that bipolar disorder affects approximately 1% to 1.5% of the US population, roughly 11 million people, but "up to 70% of people with bipolar disorder were initially misdiagnosed with something else."

Read the transcript:

Dr Craig Chepke: Hi, my name is Dr. Craig Chepke. I'm a psychiatrist in private practice at Excel Psychiatric Associates in Huntersville, North Carolina. I'm an adjunct associate professor of psychiatry for Atrium Health, and an adjunct assistant professor of psychiatry for the University of North Carolina. I'm also on the steering committee for Psych Congress, and the section editor for bipolar disorder in the Psych Congress Network.

In honor of the Bipolar Awareness Day, which is on March 30th of 2022 this year, I wanted to come to you and bring you some information about bipolar disorder, and how we can get a more accurate diagnostic picture. So bipolar disorder is a very prevalent condition, and it's one that we consider part of the SMI family of serious mental illnesses. It affects about 1% to 1.5% of the population, estimates are. And that means that about 11 million people in the United States are believed to have bipolar disorder.

And unfortunately, this is one of the most misdiagnosed conditions that we have. I sometimes hear people saying, "Is bipolar disorder underdiagnosed, or is it overdiagnosed?" And it's really both. It's misdiagnosed quite a bit. It's a challenging diagnosis to make. Estimates are that for bipolar I disorder, people can go up to 5 years with a misdiagnosis, and for [other SMI], it's even worse. It's twice as bad at a 10-year average, some studies can estimate. Furthermore, it leaves the bulk of people with bipolar disorder are misdiagnosed for much of the illness, unfortunately, to believe that up to 70% of people with bipolar disorder were initially misdiagnosed with something else.

So how can we do a better job of making this diagnosis? Well, one thing that I would say first is that we need to think about it like we think about someone going into a physician's office, whether that be outpatient practice, a primary care office, it could be an ER, urgent care, with chest pain. When someone walks into any medical office with chest pain, they could walk out with one of dozens of different diagnoses. It could be pneumonia. It could be costochondritis. The list goes on and on. But that person, you can bet that their health care provider [HCP] is not letting them walk out the door unless they thought about, "Is this an acute myocardial infarction [MI]?" Because if they missed that diagnosis and the patient walks out and it was an acute MI, it could be catastrophic. The level of workup might vary. It might be a full work up with troponins, and EKGs, and all that, or it could just be balancing the risk factors for the person. But they've thought about it carefully.

That is how we need to think about bipolar disorder in every person who walks into our practices with depressive symptomatology. Anyone with a complaint of depression, we need to rule out bipolar depression before we make a diagnosis of unipolar major depressive disorder [MDD]. That's how important it is. And in fact, that is the way that the DSM encourages us to do so. To make a MDD diagnosis, the symptoms should not be better explained by bipolar disorder.

And if you're wondering, if you're maybe newer to the field, that how could you mistake this? The mania seems pretty classic and characteristic, and pure mania is. In the field trials for the DSM-IV, it was the diagnosis with the most interrater reliability. When you see mania, you know it's mania. You don't mistake it for anything else.

The problem is, we don't see the mania often. And with a pure classic mania by criteria, it does cause significant functional impairment. So often, you can reconstruct it. I sometimes say that it leaves a trail of destruction in its wake like a tornado, that you may see and the patient may not have the insight or actually even remember the manic episode, I've had in some patients, even with severe manic episodes, but their family does. Their friends do. Their financial records do. The hospital stay record, medical records do. There's often a trail you can reconstruct if you look for it.

The hypomania of [other SMIs] can be a little bit trickier, though. Again, by definition, hypomania does not have a functional impairment. And with both mania and hypomania, these are not the reasons that patients are going to be presenting to a health care provider's office, because that's generally when they perceive themselves be doing the best. So, they might see the sheriff when they're manic, but they're probably not going to come see an HCP when they're manic. They're going to come see us when they're depressed.

And so that's why we need to get really good at looking for bipolar disorder in people who are presenting with depression, because the depressive episodes associated with MDD are, by DSM criteria, exactly the same as depressive episodes associated with bipolar I disorder. The criteria are exactly the same. The difference lies in, does that person have any lifetime history of manic or hypomanic episodes?

So, without any differences in the actual criteria, let me give you a few things that you are going to want to look for that can give you a leg up. Like I said, you've got to look for everyone who's presenting depressed, but some things that can tip the scales in terms of making you think it could be more likely to be bipolar disorder would be an early age of onset. And this is not just age of onset of the manic/hypomanic episodes, of depressive episodes. At first, depressive, any mood, but even a depressive episode prior to the age of 25 tips the scales in favor of potential bipolar disorder diagnosis. MDD generally has a later onset, on average. Again, the only thing pathognomonic for bipolar disorder are the manic or hypomanic episodes, respectively. I think about it kind of like scales. Each risk factor that is checked off tips the scales towards the bipolar diagnosis a little bit more. So that early age of onset is one.

A poor antidepressant response. When I say antidepressant, I mean, traditional antidepressant. That would be SSRIs, SNRIs, or some other agents like bupropion, which is very commonly used. Patients who don't do well with those, that is something that could potentially tip off a bipolar diagnosis. After all, an incorrect diagnosis is always going to lead to incorrect treatment, but there is also such a thing as treatment-resistant major depressive disorder. So again, not pathognomonic.

The number of episodes that the person has had. Again, I'm just going to refer to depressive episodes, because that might be all the history that we're getting from the patient is, what their depression has looked like over time. Greater than or equal to 5 lifetime depressive episodes tips the scales towards bipolar disorder. Bipolar disorder often has more frequent and shorter depressive episodes than unipolar depression, which is often longer and less frequent over the lifetime.

And as I kind of mentioned in there, the length of depressive episodes, generally longer in MDD and shorter in bipolar disorder. And even within bipolar disorder, bipolar I, the episodes are shorter than those of [other SMIs].

Family history is the most important risk factor. The condition of bipolar disorder is one of the most highly genetically penetrant, as we would call it, disorders that we have in psychiatry, that someone has a family history, it substantially elevates the risk that another family member could be diagnosed with it, as well. The problem there is that if we're having a tough time making that diagnosis accurately with bipolar disorder in the patient in front of us, then it's going to be difficult to get a good family history, because they probably didn't get a good diagnosis. Especially because the further you go back in time, generationally, societally, it was even less likely to be diagnosed accurately, unfortunately, due to stigma and other factors, as well.

So, these are probably the top ones that I can give you. There are other potential risk factors that can tip the scales, but these are the ones that are the most evidence-based and the ones we should really focus on at a first level. So these, again, these are things we should look for in every patient that we see presenting with depressive symptomatology in order to make sure that we are not missing a single case of bipolar disorder, if we can help it. Untreated bipolar disorder has substantial functional and quality-of-life difficulties for the patient.

And even if we do get them the right treatment later on, it may be difficult to get them back to where they need to be. There is some evidence indicating that it could be progressive. The more manic episodes or potentially even hypomanic episodes a person has, they could be suffering some neurobiological dysfunction because of that that is persistent. And then also psychosocially, potentially more importantly, the financial ruin that I mentioned, the burning of bridges of the psychosocial networks, and the family and friends, loss of jobs due to the choices made during the manic or hypomanic, potentially, episodes. These can be devastating and not easy for the person to come back from. So we need to do our best to make this diagnosis early and accurately.

Thank you very much, and please raise the awareness of bipolar disorder amongst everyone you can on this Bipolar Awareness Day. Thank you.