Undiagnosed bipolar disorder is one of the most common scenarios I encounter as psychiatrist.  I am often asked to give second opinion evaluation for patients who have not responded to treatment for diagnosis of depression and anxiety. Undiagnosed bipolar disorder makes up a large percentage of these people who are considered “non-responders” by other physicians because they actually did not have a correct diagnosis.  Undiagnosed bipolar disorder is so common because the diagnosis is sometimes very tricky to make and in our field we have no lab tests or objective testing to prove a diagnosis of any kind. The most common reason for the misdiagnosis is the fact that a patient presents with atypical or non-classic manic symptoms which cause them to be diagnosed for years with depression, anxiety or panic disorder erroneously.

Here are some signs to watch for that will help shed some light on any readers who may not be responding to treatment for diagnoses of depression or anxiety.  To briefly describe bipolar disorder, it involes both episodes of “mania” and “depression.”  It used to be labeled “manic-depressive” disorder until the name was changed in the 1970’s to bipolar disorder. There are 2 defined severities-bipolar 1 and bipolar 2.  Bipolar 2 has “hypomanic” episodes which are more mild manic episodes mixed with episodes of severe depression.  Bipolar 1 has severe manic episodes also mixed with severe depressive episodes.  Here are some commong signs of undiagnosed bipolar disorder:

1-Recurrent episodes of severe depression (especially more than 3 )  *do not count episodes following trauma or associated with grief.

2-Early childhood onset symptoms of depression that continue throughout adulthood

3-Having migraine headaches are highly comorbid with bipolar disorder. Up to 30 percent of bipolar patients have migraines.  (this does not mean if you have migraines you have bipolar but it is just one factor to consider)

4-Family history of severe depression or bipolar disorder

5-Alcohol addiction or family history of severe alcoholism

6-Depression that does not respond to several anti-depressants (true non-bipolar depression typically will show a signifigant response to anti-depressants, especially after trying 2 or 3 different ones) If you do not respond to medication you may want to consider bipolar disorder

7-Taking anti-depressants make you irritable, hyper, restless or agitated. We call this “activation” by an anti-depressant and these symptoms can be considered a pseudo-manic feeling. People that respond this way to regular anti-depressants are likely actually bipolar

8-If your depressive episodes tend to include- excessive sleeping, excessive eating, and feeling overly sensitive to criticism (these are referred to as atypical depression and is the common presentation of depression in someone with bipolar disorder)

9-Were diagnosed with ADHD as a child or have several children diagnosed with ADHD. Symptoms of bipolar disorder and ADHD are laregely indistinguishable during childhood and kids are often misdiagnosed with adhd when in reality they have either bipolar disorder or a combination of bipolar disorder with ADHD.

10-Moderate-severe depressive episode or any psychotic episode following pregnancy (post-partum depression or psychosis)-Psychosis involves losing touch with reality, being paranoid or hallucinating.  Moderate-severe depressive post-partum episodes are much more common in bipolar patients and should raise a red flag if this occurs and you are not diagnosed with bipolar

11-Have episodes of ongoing “panic” or anxiety symptoms lasting 24/7, during the night and without any break for weeks or months at a time.  True generalized anxiety or panic disorder cause very discreet, relatively short-lived attacks of anxiety. Sometimes they last hours long but more commonly only last 10-20 minutes.  If you have periods of days or weeks at a time where you feel excessively anxious, especially if it is keeping you awake at night, this is a big red flag for undiagnosed bipolar disorder.

These are some of the factors I discuss with my patients who do not necessarily meet the DSM criteria for bipolar disorder but who I suspect have a undiagnosed bipolar disorder  The implications are huge for properly and accurately diagnosing bipolar disorder since the treatment for bipolar disorder is completely different for unipolar major depression.  The medications used for unipolar depression can drastically worsen bipolar depression even though the depressive episodes look similar in both unipolar and bipolar presentations of depression.

If you have been suffering for years from recurrent episodes of depression and have not responded to multiple trials of medication and psychotherapy, you may want to seek out a psychiatrist to further clarify your diagnosis.  People unfortunately are extremely scared of having a bipolar diagnosis, however in reality bipolar disorder is one of the most treatable psychiatric disorders with an extremely good long-term outcome.  Nothing at all to be ashamed of and the more open anyone is about their diagnosis, the less stigma will be present.


Michael Yasinski M.D