Diagnosing, Treating Bipolar Depression Across the Lifespan

A presentation at the 2022 Neuroscience Education Institute (NEI) Congress focused on bipolar depression across the lifespan of the patient, the impact of an early and correct diagnosis on treatment, and the factors that can lead to misdiagnosis of bipolar depression.

In this exclusive MedPage Today video, Manpreet Singh, MD, MS, associate professor in the Department of Psychiatry and Behavioral Sciences at Stanford University School of Medicine in California, discusses some of the main takeaways from the presentation.

Following is a transcript of her remarks:

Our goal in this presentation was to talk about bipolar depression across the lifespan and to focus on both diagnostic and treatment aspects of bipolar depression. We appreciate that there are factors that contribute potentially to the misdiagnosis of bipolar disorder broadly, but specifically bipolar depression, because of the depressed phase of illness and the need to assess for mania as well.

And then we also wanted to have the audience appreciate that the presentation can differ across a lifespan. There are features that might be developmentally presenting in children that may not be present in adults — some special considerations in special populations. And also that a good diagnosis, a correct diagnosis, has an impact on treatment. So it’s very important that you get the diagnosis right, because if you don’t, then a treatment that you might unwittingly think to address depressive symptoms might actually have untoward side effects on patients, especially if they have bipolar depression.

And finally, we spent a bit of time toward the end of the discussion talking about the evidence-based treatments that are available for bipolar depression, appreciating that there are a limited number of FDA-approved interventions currently available.

It’s not always intuitive to a lot of clinicians when a patient is presenting with distress. It’s often the case that you wanna go to where the patient’s primary complaints are, and patients will describe distress in terms of certain impairing symptoms. Depression is often what brings patients to our clinical offices, but oftentimes it’s not the mania, or the highs, or the more productive aspects of their lives. Because those manic symptoms have implications that are positive, for functioning, for patients that might otherwise be feeling quite down and unproductive. So when patients present with depression, it’s really important to assess for mania symptoms in lifetime as well as in the recent past.

And one of the things that I think prevents us from doing that is time — busy practices, and also just again, wanting to focus on the patient’s symptomatology at present. But we have to recognize that bipolar disorder is an episodic disorder. It comes and goes, it waxes and wanes. There are aspects of it that are very different from day to day, perhaps sometimes even hour to hour. So a comprehensive assessment requires for anyone who presents with any mood symptoms to my office, I ask about mania symptoms as well as depressive symptoms every single time.

And the other kind of clue that can help facilitate that, if people are maybe hesitant to talk about the stigma that they perceive or feel about reporting manic symptoms, is maybe start with a family history. So that was another takeaway from our presentation to focus on family history because it might actually be a little bit less stigmatizing to focus on others in the family, because bipolar disorder is highly familial. You can get aspects of a presentation from those other clues. So if a patient says, “I don’t have any manic symptoms, but boy, uncle Charlie, well, he’s definitely got bipolar disorder” — well, why would you say that? “Well, he experiences these things.” Well, then you would maybe follow up and ask clinically, “have you ever experienced any one of these symptoms like uncle Charlie did at, at any point in your life?” And it’s a nice backdoor into the more direct way of asking about mania symptoms, if you will.

A delay in diagnosis can be upwards of up to a decade for some people, which can lead to impairments in quality of life, in functioning. It can lead to unfortunately, more trials and errors in terms of treatments that aren’t quite the right fit for patients. And those trials and errors erode trust in patients. And so that ends up being a problem in terms of adherence, and building a therapeutic relationship. Inaccurate diagnoses and then inappropriate treatments can lead to cycling, and maybe more relapses, it may increase or escalate suicidal thoughts or even attempts. And you can also experience a significant amount of other morbidities in other aspects of life.

And so there’s a high economic cost and burden to society due to missed days of work or school. And, it’s basically you know, very symptomatic of a complex condition that has twice, if not more, the morbidity higher and mortality rate than other conditions. And so it really behooves us to take this condition very seriously and assess for it at every single instance of a mood presentation.