March 24, 2019

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Why is Bipolar Disorder Overdiagnosed?

A 2007 study published by Moreno, et al. in the Archives of General Psychiatry

(https://www.ncbi.nlm.nih.gov/pubmed/17768268) found that, between 1994 and 2003, diagnosis of bipolar disorder in youth increased by about 40-fold. Diagnosis of bipolar disorder nearly doubled for adults during this same time-frame. In their conclusions, the authors summarized, “This increase highlights a need for clinical epidemiological reliability studies to determine the accuracy of clinical diagnoses of child and adolescent bipolar disorder in community practice.” This study’s results are fairly spectacular and unmatched by other similar studies I have reviewed. However, other more modest studies (https://www.ncbi.nlm.nih.gov/pubmed/17306773) also show remarkable increases in bipolar disorder diagnosis. For example, Blader & Carlson found “the rate in 1996 was 1.3 per 10,000 U.S. children and climbed to 7.3 per 10,000 U.S. children in 2004.” How could this be possible? There would be no rational explanation for why bipolar disorder would actually become more common over a mere 8 to 10 year period. While it is possible that some of this inflation was the result of previous under-diagnosis, the primary reason for this inflation is current over-diagnosis.

 

Based on my clinical experience, this is usually due to one or more of the following reasons:

  1. Money: Clinicians can bill medical insurance for bipolar disorder. Some clinicians realize that a patient has borderline personality disorder or another diagnosis. However, many insurance companies will not reimburse for these diagnoses (or will heavily limit reimbursement). The companies will reimburse for bipolar disorder so the doctor gives a bipolar diagnosis instead.

  2. Clinician Inexperience: The majority of patients seeking diagnosis of and treatment for bipolar disorder are first seen by general practitioners or family doctors. These clinicians generally do not have advanced training in mental health and often have a high volume of patients they must see daily.  Many such physicians have completed a single months-long psychiatry rotation during medical school but have little training or experience beyond this. Even many mental health professionals genuinely do not know or understand the diagnostic criteria for bipolar disorder. Many clinicians hear “mood goes up and down,” immediately assume bipolar, and provide the diagnosis. Sadly many clinicians do not realize a manic episode must last at least a week in order to qualify (unless the severity requires hospitalization or emergency treatment). For some clinicians, diagnosis is essentially left to guess-work.

  3. Insufficient Resources: Some mental health professionals feel rushed, burned out, or are limited in resources (e.g., one person may have an