The Dangers of Bipolar Disorder Misdiagnosed as Depression

Andy Behrman was only a teenager when he was diagnosed with depression. Over the years he would come to be diagnosed with depression again and again, not by one doctor, but by a total of eight mental health care professionals. For more than ten years, he and his physicians labored under the belief that depression was what was driving his suffering, even as antidepressants failed to provide relief. Finally, after more than a decade of unsuccessful treatment and suffering that grew ever deeper, his doctor gave a new name to his illness: bipolar disorder.

Bipolar disorder was not a welcomed diagnosis. In fact, Andy was terrified of it. But it also gave him answers; it explained why his years of treatment had yielded no results and had in fact worsened his condition, fuelling destructive manic behaviors that he had come to regard as simply the normal state of things. “These included a roller coaster of racing thoughts, insomnia, overspending, sexual promiscuity, poor judgment, and drug and alcohol abuse which always ended in outbursts of rage, deep depression, suicidal ideation, and, at times, complete paralysis,” he writes in a moving essay for NAMI. In retrospect, his symptoms were a virtual word-for-word description of bipolar I disorder. So why didn’t anyone notice?

“It wasn’t clear to me at the time, but I was being diagnosed improperly because I only visited these doctors during dark periods of depression and I was not accurately presenting the symptoms of my illness or honestly answering questions about my condition,” Andy says. “In retrospect, had I shared more information with them, perhaps it would have been easier for these doctors to diagnose me correctly and treat me more quickly. And certainly, I would have suffered for so many less years.”

Unfortunately, Andy’s misdiagnosis is not an extreme case or an aberration. According to Drs. Tanvir Singh and Muhammad Rajput, 69% of people with bipolar disorder are initially misdiagnosed with another mental health disorder, most commonly unipolar depression. More than 30% of those remain misdiagnosed for 10 years or more and the average patient remains misdiagnosed for 5.7-7.5 years. Despite efforts within the medical community to reduce misdiagnosis levels through physician education, Singh and Rajput’s research does not indicate that misdiagnosis rates are dropping.

So why is misdiagnosis so prevalent? Andy’s essay describes one of the most common reasons: people tend to seek out help during depressive phases and focus solely on those symptoms. “The manic side of bipolar disorder isn’t always bothersome to people,” explains Jeremy Schwartz, a psychotherapist in Brooklyn, New York. “They have more energy, more motivation to do things. So the mental health professional doesn’t always hear about it.” For some, the omission of information about hypomanic or manic episodes is deliberate: some enjoy the experience and do not want to medicate it away. In other cases people simply don’t realize they are experiencing anything abnormal, either because their manic or hypomanic symptoms are mild or because they are so used to them that they do not identify them as unhealthy; the varied nature of manic and hypomanic symptoms means that many people’s experiences don’t fit into their preconceived notions of what bipolar disorder looks like. In some of the most troubling instances, however, people do recognize their manic or hypomanic symptoms but are too ashamed to talk about them for fear of judgment or because it is too painful to admit to. This may be particularly true in cases where mania manifests in hypersexual behavior, rage, overspending, drug and alcohol use, or other stigmatized or destructive behaviors.

The combination of deliberate and inadvertent omission of information regarding manic or hypomanic episodes means that a physician can be apt to miss them if they are relying solely on self-reported symptomatology. But another reason for misdiagnosis is that when many patients first seek out care, they have in fact only experienced depression, and have not yet presented with any manic or hypomanic symptoms. Because there is no foolproof way to differentiate between unipolar and bipolar depression without the presence of manic/hypomanic symptoms, there is no way for the physician—or the patient—to know the true diagnosis at this point. Unfortunately, once a diagnosis is made and treatment is initiated, many mental health professionals keep working under the assumption of unipolar depression, even if treatment is unsuccessful, unless the patient explicitly complains of manic or hypomanic symptoms.

Misdiagnosing bipolar disorder, whether type I or type II, as unipolar depression can have major consequences, in part due to the effects of antidepressants. Research has revealed that antidepressants, particularly SSRIs, are not as effective at lifting bipolar depression as unipolar depression, resulting in inadequate treatment for depressive episodes. More alarmingly, antidepressants can trigger both manic episodes and rapid cycling. One study published in the Journal of Clinical Psychiatry found that 55% of people with bipolar disorder developed mania following a misdiagnosis of unipolar depression, and 23% became rapid cyclers. Another group of researchers found that the use of antidepressants was associated with continuation of cycling in 51% of patients with rapid cycling bipolar disorder and “73% of the rapid cyclers were taking antidepressants at the time of the onset of their cycling.”

While misdiagnosis can have dire consequences as the result of incorrect treatment, it also prevents the initiation of correct treatment, particularly the use of mood stabilizers. This delay “has been associated with increased healthcare costs, which include increased suicide attempts and higher rates of hospital use.” This may be explained both by the absence of mood stabilizer use and the destabilizing effects of antidepressants, as increased frequency of mood switching has been linked to greater suicide risk. Simultaneously, unchecked bipolar disorder can have severe repercussions on your ability to function in daily life, form and maintain meaningful relationships, and participate in educational and professional pursuits. Your risk for turning to dangerous and self-destructive coping mechanisms such as substance abuse rises. And, perhaps most importantly, it can destroy your confidence, your trust in yourself, and your sense of self-determination.

If you suspect that you or a loved one is struggling with bipolar disorder misdiagnosed as depression, it can be difficult to know where to turn. Your existing mental health care professional may not have the resources or training to make an accurate diagnosis and the nature of outpatient care often does not provide opportunities for optimal diagnostic clarity. Residential mental health treatment facilities with comprehensive diagnostic procedures can be the best setting in which to find answers.

At Bridges to Recovery, we understand that healing can only begin when the true nature of your illness has been identified. That is why we offer in-depth neuropsychological and psychodiagnostic evaluations for all of our clients using a range of sophisticated, broad-spectrum tools to achieve diagnostic clarity. Our assessments rely on the most advanced screening tools and assessment techniques available to get a complete picture of your psychological health, personality traits, and cognitive function; these include not only standardized questionnaires that can give important clues about the nature of your depression and identify manic or hypomanic symptoms, but also examining your medical history and conducting clinical interviews with both you and your loved ones. These pieces are crucial to uncovering bipolar disorder symptoms that may not be immediately apparent or recognized by patients themselves; even the exact presentation of your depression can provide invaluable information about whether or not you are suffering from bipolar disorder or unipolar depression. At the same time, we can identify any co-occurring disorders to address the full scope of your needs.

By engaging in comprehensive and holistic assessment, our team is able to gain a detailed and nuanced picture of your mental health early on in the treatment process and craft a personalized treatment plan to guide you toward recovery. The close contact you maintain with clinicians and staff throughout your stay also allows us to continuously monitor your response to treatment and any new behaviors that could have important implications for diagnosis, giving us the opportunity to rapidly reassess your diagnosis if necessary and modulate your treatment to optimize outcomes.

But we also offer more than diagnostic tools and clinical excellence; we provide a warm, inviting atmosphere in which you are valued, supported, and honored. At Bridges, you do not have to be reluctant to share the parts of your illness that have caused you shame. You do not have to be frightened of your diagnosis. Here, you are given the resources you need to unlock your true potential, overcome your challenges, and find joy, stability, and self-acceptance.

Bridges to Recovery offers comprehensive residential treatment for bipolar disorder as well as co-occurring impulse control and eating disorders. Contact us for more information about our innovative treatment program and to learn more about how we can help you or your loved on start the journey toward healing.

Image Source: Pexels user Hannah Morgan