05/20/2015 01:52 pm ET | Updated May 20, 2016

Another Peek Behind the Curtain: How a Psychiatrist Diagnoses and Treats Bipolar Disorder

My previous article "How a Psychiatrist Treats Depression: A Peek Behind the Curtain" discusses the experience of seeing a psychiatrist for the first time. However, not every patient who comes to my office for an initial evaluation with depression has major depressive disorder. Some people suffering from depression may have (or think that they have) bipolar disorder.

In brief, as a psychiatrist, when a new patient presents for evaluation and treatment, I always conduct a detailed patient interview to collect a thorough history. The patient will find that we have a wide ranging discussion. At times it will be open-ended and at other times it can be very structured. My training has taught me to evaluate for specific diagnostic criteria (nuances in the patient's story) to differentiate between many possible diagnoses. Many of these "differential diagnoses" present with seemingly similar symptoms to an untrained eye. A proper diagnosis is essential for developing a treatment plan that optimizes outcomes. You can read more about an initial evaluation in my previous articles.

In my experience, one of the most difficult and critical diagnostic considerations is differentiating unipolar from bipolar depression in a patient who presents to the clinic with severe depression. What makes this most challenging is that patients with both bipolar disorder (bipolar depression) and major depressive disorder (unipolar depression) can present with depression that looks, feels and appears to be identical.

Therefore, when a patient presents to my office with depression, I ALWAYS rule out bipolar disorder.

Symptoms of Bipolar Disorder include:

  • Distinct periods of three to four days (or longer) when the patient's mood has been consistently elevated or irritable
  • During these periods they went without sleep (or with very little need for sleep).
  • Increased energy (despite getting little or no sleep)
  • Increased risk taking behaviors (gambling, spending money they do not have, brief sexual encounters)
  • Talking fast/thinking fast
  • Feeling more distracted than normal
  • Feeling on top of the world and starting a lot of projects
A period of elevated or irritable mood is necessary to make a diagnosis of bipolar disorder. When someone comes to your office during one of these periods, it can be easy to make a diagnosis of bipolar disorder. In many cases however, patients will present to the office during a period of depression. There is a useful cluster of suspicious symptoms, often called "atypical depression," that can help distinguish unipolar from bipolar depression. There are also several additional risk factors that raise your risk of developing Bipolar Disorder. Factors that increase your chances of having/developing bipolar disorder:
  • Younger age of onset of depression (younger than age 20)
  • Sleeping and eating more during the episode of depression
  • A first episode of depression with a postpartum onset (soon after having a baby)
  • A family history of bipolar disorder
  • A history of not responding well to traditional antidepressants
  • A history of multiple episodes of depression (greater than 6)
The major reason why it is vitally important to make a proper diagnosis is because the treatments used in major depressive disorder (unipolar depression) and bipolar disorder are very different. My goal is to assist patients with bipolar disorder achieve long-term medication management that can take away the peaks (aka "the highs") and valleys (aka "the depression"). As the diagnosis, treatment considerations and ongoing medication management can be very delicate and nuanced, I always recommend that patients who are considering an evaluation or treatment of bipolar disorder consult a psychiatrist. (Psychiatrists are medical doctors with specialized training that enables them to accurately diagnose and treat conditions related to mental health). There is a lot at stake. Mistaking bipolar disorder for major depressive disorder, for example, can lead to worsening symptoms, adverse outcomes, over medication and unnecessary hospitalization. Your primary care doctor, Therapist or insurance company can refer you to a psychiatrist in your area. Your primary care doctor can be a great resource as well, if you have trouble getting into a psychiatrist right away. Patients with bipolar disorder are often some of my most creative, successful and engaging patients. There is no reason why fear of a diagnosis should keep you from getting the help that you need. Once your mood is stabilized, you will be able to wake up every morning and count on your mood being solid and no longer a roadblock to your success. In my experience, the longer a patient with bipolar disorder remains unstable and improperly treated, the more frequent and severe their mood swings, crashes and depression will become.

If you have a family member or a friend who you think needs to get help with their mood, please share this article with them. One of the most important things is understanding the difference between mental illness and wellness. The more we talk about mental health the way we talk about physical health, the more we can decrease the stigma and shame that often impedes those in our communities from getting the help that they need. Please share your stories, join the discussion and stay tuned!

Dr. Goldenberg has written numerous articles about mental health and addiction topics. You can access additional article on Mental Health and Addiction by Dr. Goldenberg at and follow him on Twitter: @docgoldenberg.