But in recent years, some researchers have called some bipolar diagnoses into question, while others have maintained that the number of people with the disorder, which causes severe swings in energy levels and mood, is actually greater. Bipolar disorder is often overdiagnosed, according to a review published in February 2016 in The Canadian Journal of Psychiatry that was authored by Mark Zimmerman, MD, a professor of psychiatry and human behavior at Brown University in Providence and principal investigator of the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project — an ongoing clinical research study examining the diagnosis, assessment, and outcome of patients. The review, which examined more than 20 years of data from MIDAS as well as results from other studies of diagnosis in routine clinical practice in three other U.S. cities, noted that more complete and accurate diagnostic evaluations could reduce the number of misdiagnoses and improve the detection of conditions related to bipolar disorder. This 2016 review looked at results from one of Dr. Zimmerman’s earlier studies, published in the Journal of Clinical Psychiatry, which suggested that bipolar disorder is often diagnosed in people who don’t have the condition. In that large study, his research team determined that fewer than half the people in the study who had been diagnosed with bipolar disorder met the clinical criteria for the illness. According to Zimmerman, the earlier study also revealed that some people who met the criteria for bipolar disorder had never been diagnosed with it, but in comparison, far more people had been mistakenly diagnosed as bipolar. He believes part of the reason is aggressive marketing to doctors by companies that produce the drugs used to treat bipolar disorder. “When a pharmaceutical company repeatedly says, ‘Don’t miss bipolar disorder, don’t miss bipolar disorder… and when you diagnose it, here are some medications you can use to treat it,’ there’s a tendency to expand the concept,” Zimmerman says. According to the 2016 review, the limited amount of time that some clinicians spend with patients could also contribute to incorrect diagnoses. Another factor has to do with bipolar disorder sharing some symptoms with other illnesses, such as borderline personality disorder, a condition marked by impulsive behavior and problems relating to other people. Because of this, Zimmerman says, people who have borderline personality disorder are often misdiagnosed as bipolar, as evidenced by a review published in The Scientific World Journal. People with bipolar disorder frequently have another mental health issue or condition, such as anxiety disorder, an eating disorder, or a substance abuse problem, which can also contribute to difficulty getting the right diagnosis, according to the NIMH.
How Getting the Wrong Diagnosis Can Be Harmful
For individuals who are misdiagnosed with bipolar disorder, one potential pitfall may involve health problems that result from taking the prescription drugs used to treat the condition, according to Zimmerman. He notes that some medications, including atypical antipsychotics, can increase the risk for high cholesterol and diabetes, while others, such as lithium, have been linked to thyroid and kidney problems. Conversely, up to 20 percent of people with bipolar disorder may be mistakenly diagnosed with depression by their primary care doctors, according to a study published in July 2011 in the British Journal of Psychiatry. And another study, published in August 2017 in the journal Bipolar Disorders, analyzed the delay in diagnosis of 382 people with bipolar disorder and found that 90 of those individuals initially received a diagnosis of depression before being correctly diagnosed. According to the study, the lag between diagnoses was about nine years. The patients who were originally diagnosed with depression tended to be younger, have more manic symptoms, and have better coping skills, which perhaps helped them function throughout the day and contributed to the delay in getting the correct diagnosis. These findings aren’t surprising, says Jeremy Schwartz, a psychotherapist in Brooklyn, New York. Bipolar disorder can be hard to diagnose, he says, because people often seek professional help only during their down periods and neglect to mention their up, or manic, periods. “The manic side of bipolar disorder isn’t always bothersome to people,” Schwartz says. “They have more energy and more motivation to do things. So the mental health professional doesn’t always hear about it.” In addition, some younger people with bipolar disorder may have experienced depression but not yet had a manic episode, so a misdiagnosis of depression can sometimes occur simply because a person has not yet experienced mania. In some cases, the mania may not be entirely obvious, adding to the confusion for both the patient and the provider. As a clinical practice update published in October 2017 in the journal Mayo Clinic Proceedings points out, having depression and a hypomanic or manic episode at the same time (referred to as “mixed features”) can occur in as many as 40 percent of patients with major depressive disorder, which can make diagnosis even more complicated. A patient might then be diagnosed as having depression with “mixed features,” and while that symptom alone doesn’t necessarily indicate bipolar disorder, the author notes that the provider should consider bipolar disorder as a possibility in those cases. As a consequence, Schwartz says, those with bipolar disorder are often misdiagnosed as having depression and may be given inappropriate treatment. “When bipolar disorder is missed, people can be put on medication that actually worsens the manic symptoms,” Schwartz says. “So people end up waiting much longer to get the stability in their life that they’re looking for.” In some cases, bipolar disorder may be mistaken for schizophrenia if the patient also has psychotic symptoms, according to NAMI, and someone with schizoaffective disorder can also be wrongfully diagnosed as bipolar. Attention deficit hyperactivity disorder (ADHD) and anxiety disorder can also be confused with bipolar disorder. Without proper treatment to effectively even out the peaks and valleys of manic and depressive episodes, patients face an increased risk of turning to alcohol and drugs to cope with symptoms, according to a paper published in 2015 in The Journal of Clinical Psychiatry. The author notes that when symptoms such as mania or depression are compounded by substance abuse, patients can see their relationships or job or school performance deteriorate, causing a disabling ripple effect across all areas of their life. In addition, suicidal thoughts and behavior can also be consequences of a missed diagnosis.
What You Can Do to Get the Proper Diagnosis
Being correctly diagnosed is an important step toward getting the right treatment for your bipolar disorder so you can manage your condition and live a healthy, active, and fulfilling life. One of the most important things you can do to increase your chances of receiving an accurate diagnosis is to talk with your doctor about all of your symptoms and emotions — both the good and the bad — says Schwartz. “It helps to create a fuller picture of your experience,” he explains. Once you receive your diagnosis, you can always ask your doctor about their reasoning, especially if you have any doubts or questions, notes Zimmerman. “Ask the doctor why they have made the diagnosis,” he says. “A good doctor should be willing to discuss the reasons and to explain if they’re uncertain about it.” If you don’t receive satisfactory answers, he adds, an opinion from another doctor may be in order. Additional reporting by Deborah Shapiro and Jessica Migala
