Getting diagnosed with bipolar disorder

There is no blood test or brain scan that shows bipolar disorder. A doctor makes the diagnosis by learning about your moods over many months or years. Tests are still used, but to rule out other illnesses that can look like it.^3,6

Getting the right diagnosis can take time. Many people are first told they have depression, sometimes for years.^1,4 This page explains why that happens and what the checkup involves. It also shows how you and your family can help the doctor see the full picture.

Why bipolar disorder is often missed

Bipolar disorder has two sides: deep lows (depression) and highs (mania, or a milder form called hypomania). You can read more on signs of mania, hypomania and bipolar depression. The trouble is that the two sides rarely show up at the doctor's office together.

People usually seek help during the lows. Depression feels bad, so people go to the doctor. A high often feels good, or at least productive. Many people do not see it as a problem, so they never mention it.¹ This is especially common in bipolar II, where the highs are milder.¹ See types of bipolar disorder for how bipolar I and II differ.

The doctor only sees one moment. A visit is a snapshot. If you are depressed that day, the doctor sees depression. NIMH advises looking at how moods have changed over days and weeks, not just at how a person feels right now.¹

Other conditions can blur the picture. Many people with bipolar disorder also have anxiety, ADHD, alcohol or drug problems, or an eating disorder.¹ When psychosis (losing touch with reality, such as hearing voices or holding false beliefs) is present, the illness may be mistaken for schizophrenia. It can also be confused with borderline personality disorder.^1,3

How long it can take

The best-known U.S. survey of people with bipolar disorder was done in 2000. It found that 69% had been misdiagnosed at first. The most common wrong diagnosis was depression. People who were misdiagnosed saw an average of 4 doctors before getting the right answer.⁴

Newer guidelines tell a similar story. Many people are not correctly diagnosed until up to 10 years after their symptoms begin. Along the way, they may receive as many as four other diagnoses.⁵ A delay matters, because treatment that does not fit the illness can mean a harder course.⁵

Clues that depression might be bipolar

Experts list some features that should make a doctor look harder for bipolar disorder in a person who is depressed.⁵ None of them proves it. But each is worth mentioning:

• Depression that first started at a young age
• Many episodes of depression that keep coming back
• A parent, brother, sister or child with bipolar disorder
• Depression with psychosis
• Feeling restless and agitated rather than slowed down
• Sleeping and eating much more than usual during low times
• Depression or psychosis after giving birth
• Past suicide attempts
• A past high, or very fast mood swings, after starting an antidepressant

When an antidepressant triggers mania

Antidepressants help many people with depression. But in a person with bipolar disorder, an antidepressant taken alone can sometimes tip mood into mania. It can also cause rapid cycling (four or more mood episodes in a year).¹

The FDA label for antidepressants warns about this. The Zoloft (sertraline) label, for example, says treating depression with an antidepressant may set off a manic or mixed episode in someone with bipolar disorder. It tells prescribers to ask about any personal or family history of bipolar disorder, mania or hypomania before starting.⁷ Other antidepressant labels carry a similar warning. Read more on antidepressant medicines.

What this means for you:

• Before starting an antidepressant, tell the doctor about any past times of very high energy, little need for sleep, or racing thoughts. Mention relatives with bipolar disorder, too.
• If mood goes up fast after starting one, tell your doctor right away. Signs include sleeping very little but not feeling tired, talking fast, spending a lot, or acting out of character.
• Do not stop the medicine on your own. Talk with your doctor or pharmacist before changing anything.

Doctors take a high that starts on an antidepressant seriously. It is one reason they may change a diagnosis from depression to bipolar disorder.⁶ For bipolar depression, antidepressants are generally not used alone, because of the risk of a switch into mania.⁶ See medicines for bipolar disorder.

What happens at the evaluation

Often a primary care doctor starts the process and then refers you to a mental health professional, such as a psychiatrist.^1,3 The diagnosis is based on how severe your symptoms are, how long they last, and how often they come back over your life. Family history counts too.¹

The doctor may:²

• Ask about your health problems and every medicine you take
• Ask about recent mood swings and how long they lasted
• Do a physical exam and order lab tests
• Watch your mood and behavior during the visit
• Talk with family members, with your permission, about what they have noticed

Family input matters. People often do not remember their highs clearly, or did not see them as a problem. Family and friends often notice the mood changes as unusual.¹ A spouse, adult child or close friend may recall things you do not.

Some clinics use short screening questionnaires about past highs. These can flag people who need a closer look. Experts say they should only be a helper, not the way a diagnosis is made.⁵

How a mood chart helps

A mood chart is a simple daily record. Each day you rate your mood, often on a scale from very low to very high. You also note hours of sleep, medicines, alcohol, and big events.

Patterns that are hidden in one visit can show up over weeks or months. Guidelines say mood charting can reveal bipolar patterns that only become clear over time.⁵ NIMH also suggests keeping a life chart or mood journal to help spot mood swings.¹

A mood chart can be a paper calendar, a notebook, or a phone app. Filling it in every day can feel like a chore, and apps may make it easier.⁵ Keep it short so you stick with it. The living well page explains how to use mood charts after diagnosis, too.

1. Pick a time each day, such as bedtime.
2. Rate your mood from -3 (very low) to +3 (very high), with 0 as steady.
3. Write down your hours of sleep.
4. Note any medicine changes, alcohol, caffeine, or stressful events.
5. Bring the chart to every appointment.

Ruling out medical causes

Some health problems, medicines and substances can cause symptoms that look like bipolar disorder. So the doctor checks for them first.^1,2

When a medical cause is suspected, the first tests often include a urine drug screen, a complete blood count, a blood chemistry panel, thyroid tests, and vitamin B and folate levels.⁶ Brain scans are not used to diagnose bipolar disorder itself.⁶ But a doctor may order one if there are signs of a brain problem.

Learn more about medicines that can affect mood and memory.

When mania first appears in later life

Bipolar disorder usually starts in the late teens or early adult years.¹ So a first high after age 50 is a red flag for another cause. Doctors look harder for a medical cause when:⁶

• Mania starts after age 50
• The neurological exam or vital signs (such as pulse and blood pressure) are not normal
• Health or medicines changed recently
• Treatment works in an unusual way
• The person has no past mental health problems and no family history

In an older adult, a sudden high may come from a medicine side effect or a brain condition.^8,9 Many people whose bipolar disorder starts later in life have no clear medical cause. Still, looking for treatable causes is good practice with any first episode of mania, at any age.⁹ It deserves a full medical checkup, not just a mental health visit. A personality change in later life can also be a sign of frontotemporal dementia. See bipolar disorder in later life for more.

Common questions

When to get help

• Call 911 if someone is in danger, cannot be kept safe, or has stopped making sense and may hurt themselves or others.
• Call or text 988 (the Suicide & Crisis Lifeline) if you or someone you love is thinking about suicide or is in emotional crisis.¹
• Call the doctor the same day if someone has gone days with very little sleep, is taking big risks, or has had a sudden change in mood, especially after a new medicine.
• Make an appointment if you have had repeated depression along with times of feeling unusually energetic or "wired."

If you are worried about a family member, see supporting someone with bipolar disorder. You can also make a safety plan ahead of time.

Education only. This page is general information written from the sources listed. It is not medical, legal or financial advice and does not replace a doctor, therapist or lawyer who knows your situation. How we write and check pages.