This piece first appeared in Psychology Today.
About the Author: Monica Starkman, M.D., is associate professor of psychiatry emerita at the University of Michigan. Her novel The End of Miracles, suspensefully reveals the complexity and strength of the human mind.
- Bipolar disorder, particularly Type II, is often misdiagnosed.
- People tend to spend much more time in a depressive state and often do not recognize mild or hypomanic symptoms.
- The chance of getting properly diagnosed is increased by using online screening tools and bringing family/friends to doctor visits.
It often takes many years before a person with bipolar disorder receives the correct diagnosis. People with bipolar type II, in particular, are often misdiagnosed as having pure major depressive disorder. They spend those years taking antidepressants, which, in a person with bipolar disorder, can result in mixed episodes: symptoms of depression and mania combined. They can have an increased risk of suicide, as well as an increased frequency of episodes.
Willa Goodfellow is such a person. An ordained Episcopal priest, author, and lecturer, she suffered for many years from misdiagnosis and incorrect treatments. (Note: She is not my patient, but instead is a writing colleague sharing the same publisher of her non-fiction book Prozac Monologues and my psychological novel The End of Miracles. )
What follows is a conversation with her about why such misdiagnoses are too frequently the rule. We also consider strategies that can improve the speed of receiving the correct diagnosis. These strategies, in Willa’s words, "do not require patients to diagnose themselves." Instead, they empower the patient to be a partner with their doctor and help ensure that the correct diagnosis is made.
A story of misdiagnosis
"Home from a week’s vacation in Costa Rica, I was at the office of my general practitioner to get a prescription for a different medication for my depression. I told the doctor that I had spent my vacation entirely in my hotel room 'maniacally writing.' While my wife went to the beach, explored neighborhoods, and visited my family who lived there, I just wrote. And wrote. And wrote. I wrote so much that I came home with seven chapters of what would become my first book.
"I needed a new prescription because my first prescription for depression, Prozac, had made me irritable. I also could not concentrate, couldn't sleep, and my language was coarse. These symptoms had been taken by the doctor to indicate a deeper depression, and so she had originally increased the dosage. But a new problem, a side effect of diarrhea, pushed me to noncompliance. I quit taking the medication, and went to Costa Rica during the period needed to wash it out of my system before getting a different medication.
"But now, at this appointment, my use of the word 'maniacally' caused my doctor to pause. Antidepressants can cause people with bipolar disorder to 'flip' into mania or hypomania. So she screened me by asking just one question, 'Are you manic?'
"I answered, 'No. I'm not manic, I'm excited!' With that, she gave me the next antidepressant.
"This continued a sorry trail that included three psychiatrists and six failed antidepressants, each leaving me more agitated, more insomniac, and more suicidal than the last. It took five years for me to be correctly diagnosed with bipolar disorder. That, in fact, is actually less time than the average of seven-and-a-half years.“
Why the diagnosis is difficult
- People with bipolar disorder spend much more time in a depressive state than in mania or hypomania. This is especially true of bipolar type II. Chances are, a doctor will not observe manic or hypomanic symptoms during an evaluation when the patient is in a depressed state.
- People with bipolar disorder don't remember or even recognize mild or hypomanic symptoms as problematic. They assume these rare breaks from depression are what it feels like to be normal. Willa says: "I didn't go to the doctor to complain that I wrote a book in one week. If I didn't already have the appointment, the doctor would never have heard about it."
- People with bipolar disorder may not understand the diagnostic criteria when asked about them — especially if not asked in easily-understood language. Flight of ideas? Psychomotor agitation? As Willa says: “Our very perspective during an episode prevents us from thinking we have 'inflated self-esteem' and 'irritability.' Instead, we think other people are the ones who are irritating when they can't acknowledge our importance. And an abnormally elevated mood — is that the same as saying we are crazy? And who wants to think they are going on spending sprees or making foolish business decisions?"
How to increase the chance of getting the correct diagnosis
- Use an online screening tool that is written in plain language. The mood disorder questionnaire (MDQ) and the bipolar spectrum disorder scale (BSDS) can be found easily online — for example, here and here. They can correctly identify about 75% of people who do have bipolar disorder. They can misidentify 10 to 15% of people who screen positive but turn out not to have bipolar disorder upon further investigation. Bring this screen to your doctor to encourage them to take a more thorough history that can steer them toward the correct diagnosis.
- Include partners, family members, or close friends in your evaluation with your doctor. While people with undiagnosed bipolar disorder can easily identify depressive moods, family and friends are more likely to recognize the manic symptoms such as increased energy and activity.
- If you have been diagnosed with depression, ask your doctor to screen for bipolar with every new episode and with every anti-depressant failure. One screening for bipolar is not enough. Every episode of depression can increase the risk for a switch into mania or hypomania.
In her book, Prozac Monologues , Willa Goodfellow tells her personal story and shares her road to recovery. She also lists books, articles, and organizations she found most helpful along the way. She is a wonderful example of how people can educate themselves and become full partners in their own treatment.