• Suspect bipolar disorder in people who present with mania, hypomania, depression and a history of previous episodes of possible mania or hypomania, or a mixture of both manic and depressive symptoms.
• Mania is suggested by:
• Abnormally elevated mood, extreme irritability, and sometimes aggression.
• Increased energy or activity, restlessness, and a decreased need for sleep (e.g. the person feels rested after only 3 hours of sleep).
• Pressure of speech or incomprehensible speech.
• Flight of ideas or racing thoughts.
• Distractibility, poor concentration.
• Increased sexual drive, disinhibition, and sexual indiscretions.
• Extravagant or impractical schemes (e.g. business investments, spending sprees).
• Psychotic symptoms: delusions (usually grandiose) or hallucinations (usually voices speaking directly to the person).
• Hypomania is suggested by symptoms of mania that are not severe enough to cause marked impairment in social or occupational functioning, with the absence of psychotic features. Such people may present with:
• Mild elevation of mood, or irritability.
• Increased energy and activity.
• Feelings of well-being, or physical and mental efficiency.
• Increased sociability, talkativeness, and over-familiarity.
• Depression is suggested by feelings of persistent sadness or low mood, loss of interest or pleasure, and low energy. Diagnosis is identical to that for unipolar depression: see the section on Assessment and diagnosis in the CKS topic on Depression, and the section on Diagnosis in the CKS topic on Depression in children.
• A mixed episode is suggested by a mixture, or rapid alternation (usually within a few hours), of manic/hypomanic and depressive symptoms.

• Detection of bipolar disorder in people presenting with depressive symptoms may be improved by:
• Asking about a history of overactive, disinhibited behaviour.
• Using the Mood Disorder Questionnaire (MDQ), a brief, validated, self-report form; which can be found at www.psychiatrist.com (pdf).
• Other features that increase the possibility of bipolar disorder in people with depressive symptoms include:
• Family history of bipolar disorder, particularly in a first-degree relative.
• Precipitation of mania or hypomania with antidepressant medication.
• Failure to respond to antidepressants.
• Atypical depressive features, particularly hypersomnia, abrupt onset and offset of episodes, or a seasonal pattern.
• The person is younger than 25 years of age (as bipolar disorder has an earlier age of onset than unipolar depression).
• Manic episodes usually begin abruptly and last for between 2 weeks and 4–5 months (median duration about 4 months).
• Depressive episodes tend to last longer (median duration about 6 months) than manic episodes.

Features of mania, hypomania, depression, and mixed episodes

• Features of the different types of episode are based on: diagnostic criteria in the International statistical classification of disease [WHO, 1992] and the Diagnostic and statistical manual of mental disorders [DSM-IV, 1994]; a clinical review, Mental health emergencies [Atakan and Davies, 1997]; the Scottish Intercollegiate Guidelines Network publication, Bipolar affective disorder: A national clinical guideline [SIGN, 2005]; the National Institute for Health and Clinical Excellence (NICE) guideline, Bipolar disorder: the management of bipolar disorder in adults, children and adolescents, in primary care and secondary care [National Collaborating Centre for Mental Health, 2006; NICE, 2006]; and a review, Role of the primary care physician in bipolar disorder [Tylee and Goodwin, 2006].

Methods of detecting bipolar disorder in people with depressive symptoms

• The recommendation to 'ask about a history of overactive, disinhibited behaviour' has been adapted from the NICE guideline, Bipolar disorder: the management of bipolar disorder in adults, children and adolescents, in primary care and secondary care [NICE, 2006]. NICE recommends that primary care professionals 'ask about hypomanic symptoms when assessing a patient with depression and overactive, disinhibited behaviour'.
• The Mood Disorder Questionnaire (MDQ) is recommended by NICE [National Collaborating Centre for Mental Health, 2006]:
• It has good sensitivity (73%) and specificity (90%) in people attending a psychiatric clinic [Hirschfeld et al, 2000].
• In a general population, sensitivity is low (28%) but specificity remains high (97%) [Hirschfeld et al, 2003a].
• Other features that may alert healthcare professionals to the possibility that a person presenting with depression may suffer from bipolar disorder are from review articles [Manning, 2003; Berk et al, 2005a], and from a study which found that nearly 20% of people with depression unresponsive to at least one antidepressant screened positive for bipolar disorder [Calabrese et al, 2006].

Justification for improving detection of bipolar disorder in people with depressive symptoms

• People with bipolar disorder are more likely to present during an episode of depression than during an episode of hypomania or mania, and they rarely report all their manic symptoms [Hirschfeld et al, 2003b].
• Bipolar disorder is often underdiagnosed or misdiagnosed as unipolar depression:
• In a study in a suburban family practice in the United States, up to 26% of people diagnosed with a depressive or anxiety disorder by a primary care physician had a lifetime history of hypomanic or manic symptoms [Manning et al, 1997].
• In another study in a general outpatient family medicine clinic in the United States, 21% of people taking an antidepressant for depression screened positive for bipolar disorder [Hirschfeld et al, 2005].
• There are long delays in people with bipolar disorder receiving an accurate diagnosis [Hirschfeld et al, 2003b; National Collaborating Centre for Mental Health, 2006].
• In people with bipolar disorder:
• Antidepressant monotherapy can be harmful (by inducing a manic episode or accelerating mood cycles) [Tylee and Goodwin, 2006].
• Lithium treatment may reduce suicide risk from 30 times to 6.5 times that of the general population [Berk et al, 2005b].

In depth