Recently on Yahoo! Answers, a member posted a question asking whether bipolar disorder can be misdiagnosed as depression. This is an excellent question, and it made me think that we should post something on this important issue.

The answer is yes; bipolar disorder can be and often is misdiagnosed as depression. This could be a very dangerous misdiagnosis, because many of the medications prescribed to treat depression can trigger mania in those who have a genetic predisposition to bipolar disorder. In other words, you could go into your doctor’s office depressed and as a result of the anti-depressants experience a manic episode.

This is why it is so important for doctors to carefully screen patients whose only complaint is depression before prescribing antidepressants. The doctor must first rule out any past occurrences of mania or hypomania. Your doctor does this by asking a series of questions about any symptoms in the past that could suggest mania or hypomania, such as periods of time (lasting more than a few hours and being different than baseline) during which you experienced the following:

• Needing little to no sleep
• Euphoric or irritable mood
• Starting a million projects
• Feeling on top of the world or super-confident
• Doing things that got you into trouble, such as spending too much money, gambling away all your money, or driving recklessly

Patients don’t often report these symptoms, because they typically feel pretty “up” at these times – feeling euphoric and full of energy is not something that most people would associate with illness. To find out about a patient’s susceptibility to hypomania or mania, however, the doctor needs to ask these questions whenever interviewing a patient who is currently reporting symptoms of depression.

A patient’s family history may also raise some red flags. If a family member in the past was diagnosed as having bipolar disorder or schizophrenia, for example, this could raise some suspicion that would cause your doctor to ask some additional diagnostic questions.

Some doctors perform a dangerous game of what I like to call “diagnosis by prescription.” A patient shows up depressed, so the doctor prescribes an antidepressant. The patient starts taking the antidepressant and, after a few weeks, begins experiencing symptoms of mania or hypomania. When the patient returns, the doctor then diagnoses the condition as bipolar disorder and prescribes a mood stabilizer.

Diagnosis by prescription is not an effective or useful way to diagnose or treat depression or bipolar disorder. Having a manic episode from antidepressants doesn’t necessarily mean that a person has bipolar disorder, although it can certainly lead a doctor to explore that possibility. Relying on a person’s response to a medication is no way to arrive at an accurate diagnosis.

Antidepressant-induced mania can occur even if a doctor does a thorough screening and an outstanding job of reviewing a patient’s history, so nobody can jump to the conclusion that a doctor acted improperly, if he or she does not recognize a particular patient’s genetic vulnerability to mania. Sometimes, the history provides little or no warning.

Sometimes people don’t experience a real manic episode until later in the illness – even in their 30’s or 40’s. The symptoms of mania may not have been present prior to that, so when they report to their doctors, their history may paint a diagnostic portrait only of someone who has been recurrently depressed for a long time – not someone who potentially has bipolar disorder.

Doctors generally follow the Hippocratic oath and “first do no harm.” More and more doctors are becoming aware that some antidepressants can unmask bipolar mania in patients who are predisposed to it and are more careful to do a thorough screening or refer a patient to a qualified psychiatrist before prescribing anything. If you are seeing your doctor for depression, just make sure the doctor also screens for any past signs or symptoms of mania or elevated moods that have lasted a long time. Otherwise, the medications you are given could create more problems than solutions.

Warning: This is not to say that if you are taking antidepressants, you should stop taking them. Depression is a serious problem that requires treatment, usually in the form of prescription medication. Treating depression in people with bipolar disorder is also essential, but is much more challenging.

In a future post, I will be exploring some of the most challenging aspects of treating bipolar depression in an attempt to explore some difficult questions, such as:

• Are antidepressants necessary?
• Can they help in conjunction with a mood stabilizer?
• How long do we continue a patient with bipolar depression on antidepressants?