Diagnosing Bipolar - Doing Better to Prevent Suicide

How can I be a better psychiatrist for you?

Frankly, I was gobsmacked by that question. It came in response to reading my book, Prozac Monologues: A View from the Edge. The book is a comedic memoir of misdiagnosis and a self-help book for bipolar. It is both uproariously funny and brutally frank about my suicidal episodes, usually at the same time.

There are two directions to go with that question. This particular psychiatrist cares about both.

What kind of behaviors and qualities could he display that would make the relationship more helpful? Honestly, not all psychiatrists are interested in this question. I don't do relationships; I use psychopharmacology to treat psychiatric disorders, a psychiatrist once told me. Well, that had the benefit of clarifying things.

How can I improve my diagnostic skills? Nevertheless just about any psychiatrist wants to get the answer to the puzzle right, even the ones who treat patients as no more than a puzzle.

So this week I am going with the question about diagnostic skills. Buckle up for lots of links to research articles. The links appear in a different color. Click on them and end up at reports written by the experts. Or ignore the links, if you can take my word for it.

Bipolar is hard to diagnose. And they are not getting better at it. It takes 7.5 years on average from first appearance of symptoms to the correct diagnosis. A third of us are misdiagnosed for over ten years. Over time, these numbers are not improving. It turns out, telling yourself that bipolar is hard to diagnose doesn't help you get better at it. And during all those years, we patients receive treatments (antidepressants) that make our prognosis worse and flip us into mixed episodes with their heightened risk of suicide. Our lives depend on getting the diagnosis right.

There are ways to do a better job. Research validates various techniques that improve results. Many of these are a couple decades old, but for whatever reason have not found their way into standard practice. Nevertheless, some doctors, psychiatrists and family practitioners both, still ask that question, How can I improve my diagnostic skills? So here are some techniques with links to the research studies that support them:

• MDQ, Mood Disorder Questionnaire. This is a simple screening questionnaire using real, nontechnical language that patients and their family members fill out. It's like those screens for depression and anxiety that are becoming standard practice for annual physicals. It doesn't make the diagnosis by itself; but it tells doctors whether they need to look at the question more carefully before prescribing antidepressants to treat the presenting episode.

• BSDS, Bipolar Spectrum Diagnostic Scale. This is a similar simple screening questionnaire in narrative form. It tells a story, while the patient decides how well the story describes his/her own experience. 

Both of these instruments have sensitivity (~70) and specificity (~90) comparable to other screening instruments. This means they catch roughly 70% of those who do have bipolar and their "false positive" rate is 10%. The screens themselves can be found here.

• Whatever screens or questions used, it is good practice to ask family members or close friends for their input. The patient notices depressive symptoms, but often does not notice or remember symptoms of hypomania or mania that the family can see.

• When taking a history from a depressed patient, ask about overactive behavior, whether there was ever a time that the patient was able to do a lot more things, get a lot more done than usual, before asking about a time when s/he had elevated mood. It has been demonstrated that it is easier for patients to remember episodes of excess behavior than to remember elevated mood. (It was demonstrated fifteen years ago! Why hasn't this finding been incorporated into the Structured Clinical Interview, SCID-CV?)  Asking about behavior/energy first improves the accuracy of the diagnosis.

I'll leave it there. Two simple screens, two simple changes in practice, each of them are demonstrated to improve the diagnosis of bipolar.

No, I'll add one more.

• Every episode of depression adds a new risk of "conversion" to bipolar, throwing the patient into hypomania, mania, or mixed episode. There is no length of time that confirms a diagnosis of MDD over bipolar. Screen for bipolar again with each episode and each failed antidepressant.

It is hard to change practices that doctors were taught in medical school. But what they were taught in medical school leads to a 50% success rate, also known as a 50% failure rate, in differentiating between major depression and bipolar. The mantra, bipolar is hard to diagnose, doesn't cut it when the consequence of getting it wrong leads to years of suffering, lives that go off the rails, and lives that even end suddenly and tragically in suicide.

Doctors want to do better. And they can. Research has shown them how.

photo used under the Creative Commons license