Bipolar disorder is characterised by episodes of mania or less severe hypomania, and depression. Bipolar I disorder is determined by the existence of mania, which may include psychotic features, while bipolar II disorder is determined by less severe hypomania. Cyclothymic disorder is an overall milder form of bipolar disorder, however symptoms occur fairly often and constantly. 

A manic episode is at least one week of extremely high spirited or irritableness most of the time. There are changes in normal behaviour. These include exaggerated self-esteem/grandiosity, less sleep, talking more, talking loudly and quickly, being easily distracted, doing many activities at once, very risky behaviour, having uncontrollable and racing thoughts, and/or quickly changing ideas or topics. A depressive episode is a period of at least two weeks of intense sadness, despair, helplessness, hopelessness or worthlessness. There may be loss of interest in activities once enjoyed, feelings of guilt, restlessness or agitation, sleep problems, slowed speech or movements, changes in appetite, loss of energy, difficulty concentrating, remembering or making decisions, and/or thoughts of death or suicide.

What is the evidence regarding diagnosis of bipolar disorder?

For adults

Moderate to high quality evidence finds reasonable diagnostic stability of bipolar disorder over time. There was better inter-rater and test-retest reliability for diagnosing bipolar disorder using any method, than for diagnosing schizoaffective disorder, schizophrenia, or unipolar depression. Compared to people with schizoaffective disorder, people with bipolar disorder are usually older, married, have a later age of illness onset, a shorter duration of illness, have less psychotic and negative symptoms (e.g. social withdrawal), less depression, more years of education, and more likelihood of being Caucasian.

Moderate to high quality evidence finds the Hypomania Checklist, the Bipolar Spectrum Diagnostic Scale and the Mood Disorder Questionnaire have good accuracy for detecting bipolar disorder. The Hypomania Checklist was better at detecting bipolar disorder II than the Mood Disorder Questionnaire. Moderate quality evidence finds reasonable predictive value and moderate agreement for bipolar disorder diagnosis between administrative databases using the ICD-10, and clinical or research diagnoses. However, an estimated 17% of people in primary care settings that were diagnosed with depression had undiagnosed bipolar disorder. Results from structural and functional neuroimaging studies analysed using machine learning show similar, moderate levels of accuracy for determining bipolar disorder diagnosis from other psychiatric diagnoses or from healthy controls.

For children and adolescents

Moderate quality evidence finds the clinical features associated more often in children or youth with bipolar depression than in children or youth with unipolar depression include; more psychiatric comorbidities and behavioural problems (i.e. oppositional disorder, conduct disorder, anxiety disorders, irritability, suicidal/self-harm, social impairment, substance use); earlier onset of mood symptoms; more severe depression; and having a family history of any psychiatric illness.

There is good reliability of checklists for identifying bipolar disorder in children. Checklists are better at detecting bipolar disorder than at detecting schizophrenia or schizoaffective disorder, but not as good as detecting unipolar depression. Caregiver report was more accurate at detecting bipolar disorder than youth self-report or teacher report, and checklists that focus on manic symptoms were most accurate.

August 2021

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Early detection of bipolar disorder can prevent or delay the onset of the disorder, and improve clinical outcomes in people who develop it.

What is the evidence regarding early detection of bipolar disorder?

Moderate to high quality evidence suggests large effects of having psychotic symptoms or a family history of bipolar disorder as risk factors for transition to bipolar disorder in people with major depression. There was a medium-sized effect of higher risk of transition to bipolar disorder with early age of onset of depression, and a small effect of having a family history of any mood disorder. The risk of transition to bipolar disorder was greatest in the early stages of having a major depressive disorder (up to 5 years).

Moderate quality evidence suggests subclinical symptoms preceding an initial mood episode last around 27 months, and subclinical symptoms preceding a recurrent mood episode last around 1 month. Common subclinical symptoms (in order of decreasing prevalence) are too much energy, diminished ability to think, indecisiveness, pressured speech, talkative, elated mood, academic or work difficulties, insomnia and depressed mood. Less common subclinical symptoms (in order of decreasing prevalence) are over-productive/goal-directed behaviour, agitation, rage attacks, racing thoughts, anxiety, decreased need for sleep, irritable mood, fatigue, distractibility, sleep disturbance, disinhibition, weight loss/loss of appetite, hyperactivity, suicidal thoughts, feeling of worthlessness, mood swings, delusions, unkempt or bizarre appearance, guilt, and auditory hallucinations. Rare subclinical symptoms (in order of decreasing prevalence) are loss of interest, somatic complaints, being over-sensitive, hypersexuality, flight of ideas, hypersomnia, weight gain, self-harm, suicide attempts, and visual hallucinations.

Low quality evidence is unable to determine the accuracy of instruments used for early detection. Review authors conclude that the Child Behavioral Checklist – Pediatric Bipolar Disorder Phenotype and the General Behavioral Inventory – Revised have the better validity and utility than the Hypomanic Personality Scale, the Behavioral Activation Scale or the Family History Scale, and that more studies assessing these scales are required.

September 2021

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Reliable and valid assessment tools are vital for assessing a range of variables including symptoms, functioning and quality of life. They are used within a controlled research environment but are also useful in clinical practice.

The quality of assessment tools can be measured in various ways. ‘Reliability’ refers to the reproducibility of an instrument’s results across different assessors, settings and times. ‘Construct validity’ is the extent to which an instrument measures the theoretical construct it was designed to measure. This involves ‘convergent validity’, which is the degree of correlation between different scales measuring the same construct, confirming they are measuring the same thing; and ‘divergent validity’, which is the lack of correlation between scales measuring different constructs, confirming that they are measuring different things. Similarly, ‘known groups’ validity’ is the extent to which an instrument can demonstrate different scores for groups known to vary on the variables being measured. ‘Content validity’ is the extent to which each individual item on a scale represents the construct being measured, and ‘internal consistency’ is the degree of correlation between individual items within a scale.

‘Predictive validity’ refers to sensitivity, which is the proportion of correctly identified positives. It also refers to specificity, which is the proportion of correctly identified negatives. Sensitivity and specificity are measured by comparing an instrument’s results with known ‘gold standard’ results. ‘Responsiveness’ is the extent to which an instrument can detect clinically significant or practically important changes over time, and ‘area under the curve’ (AUC) is a global measure of test performance.

What is the evidence for outcome assessment tools for bipolar disorder?

Moderate to low quality evidence finds patient-rated measures with the highest clinical utility for assessing symptoms were the Altman Self-Rating Mania Scale (ASRM), the Quick Inventory of Depressive Symptomatology–Self Report (QIDS – SR) and the Internal State Scale (ISS). Clinician-rated measures with the highest clinical utility for assessing symptoms were the Bech-Rafaelsen Mania Rating Scale (MAS), the Quick Inventory of Depressive Symptomatology (QIDS), and the Bipolar Inventory of Symptoms Scale (BISS). Electronic self-monitoring of depression, but not mania was found to be reliable, being similar to clinically rated instruments (Montgomery Asberg Depression Rating Scale (MADRS), the Hamilton Depression Rating Scale (HDRS) or the Inventory of Depressive Symptomatology (IDS).

The most commonly used scales for assessing functioning in people with bipolar disorder were the Global Assessment of Functioning and the Functional Assessment Short Test.

September 2021

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