Recently, the health care profession has taken a closer look at areas of unmet need and burden of illness. Among the top ten causes of disability worldwide, five are behavioral health disorders, including major depression (#1 cause of disability), alcohol problems (#4), bipolar disorder (#6), schizophrenia (#9), and obsessivecompulsive disorder (#10). Bipolar disorder continues to be a major unmet need.

Lately, we have begun to evaluate the most common presentations (symptoms, actions, and reports of trouble) of patients with bipolar disorder who enter clinical research studies at the Mood Disorders Program in Cleveland, Ohio. It was once believed that the majority of patients that entered clinical research studies were those that had not responded to conventional treatments in the past. To our surprise, we have found that the reverse is true. Most patients who enter our clinical research have never been accurately diagnosed or treated.

We recently evaluated the first 359 patients with rapid cycling bipolar disorder enrolled in two National Institute of Mental Health (NIMH)-funded long-term studies designed to compare the effectiveness of two mood stabilizers. Eighteen percent of patients had never been diagnosed with any mental illness; 37% of patients had been incorrectly diagnosed as having unipolar depression and treated with antidepressants without the benefit of any type of mood stabilizer, and 43% had previously been diagnosed and treated for bipolar disorder but had an inadequate response to treatment. The average time from symptom onset to accurate diagnosis and treatment was 16 years for the general group of people with bipolar disorder, 18 years for those who not only had bipolar disorder but also problems with alcohol or drugs, and 22 years for those who had been previously incarcerated (APA 2003). This is even more alarming than the results of DBSA’s 2001 constituent survey, which found that an average of more than 10 years passed between the first onset of bipolar symptoms and an accurate diagnosis.

There is reason to believe that people who have bipolar disorder with rapid cycling (frequent alternations between highs and lows) must wait longer before being accurately diagnosed and treated. This also appears to be the case for patients who have bipolar II disorder (periods of depression alternating with mild highs, or hypomanias), and those who have bipolar disorder along with alcohol or drug abuse problems. The relationship between bipolar disorder and alcohol or drug use is particularly evident among prisoners with bipolar disorder – disproportionately younger adult males – 90% of whom have a lifetime history of alcohol or drug abuse. All of these factors tend to make the illness less likely to be diagnosed and treated.

Some believe these trends may correlate with the availability of adequate health insurance. In fact, in our two NIMH-funded studies, only 40% of patients had private health insurance; 40% were uninsured and 20% had either Medicaid or Medicare as their health insurance.

In general, the above findings are similar to those reported by Robert M.A. Hirschfeld, M.D., and colleagues at the 2002 annual meeting of the American Psychiatric Association. In this community study, the Mood Disorder Questionnaire (MDQ) was used as the self-administered diagnostic inventory for bipolar disorder (see www.DBSAlliance.org to review or take the MDQ). Among the respondents in Dr. Hirschfeld’s study, approximately 50% had never received a diagnosis of bipolar disorder or major depression, 30% were misdiagnosed with unipolar depression and only 20% had been told that they had bipolar disorder.

Hirschfeld’s study also uncovered the disturbing information that psychiatrists were accurately diagnosing bipolar disorder in only about one-half of instances. Family physicians were making an accurate diagnosis in about one-fourth of the cases, as were psychologists, counselors, and other therapists. Many people believe that the sadness and hopelessness of depression and the mild mood elevation of hypomania are normal experiences, or parts of someone’s personality. Because of this, symptoms are often ignored, downplayed or underreported by patients and unrecognized and untreated by professionals. To find appropriate treatment and improve quality of life, it is extremely important that patients share all of their symptoms – the highs as well as the lows – with their doctors, and doctors routinely ask questions to determine whether patients have ever experienced any symptoms of mania or hypomania.

There is a great need to educate health care professionals on more effective ways of recognizing symptoms of hypomania. Failing to detect and diagnose the symptoms of hypomania can have catastrophic consequences for the patient when it comes to receiving the correct treatment.

When hypomania co-exists with recurrent episodes of depression, the diagnosis should change from recurrent major depression to bipolar II disorder, and mood stabilizers should be added to the treatment plan. In the presence of hypomanic or manic symptoms, antidepressants should be used with mood stabilizers.

Misdiagnosed and untreated bipolar disorder is an unmet mental health need that requires immediate attention. With the education of patients, families, health care professionals and the public, we can begin to meet this need.

Joseph R. Calabrese, M.D. Director, Mood Disorders Program
Professor of Psychiatry
Co-Director, Dual Diagnosis Center of Excellence, University Hospital of Cleveland
Case Western Reserve University