Shortening the Road to a Bipolar Diagnosis: Justin T. Ray, PMHNP-BC

Bipolar disorder can take 5 to 10 years to diagnose, according to Justin T. Ray, PMHNP-BC, founder of South Chesapeake Psychiatry Center, and the research backs that up. A 2020 population-based study of nearly 9000 patients found that diagnostic delay averaged 6.46 years and noted that it can stretch to as long as 10 to 15 years.¹ Every year spent on the wrong treatment can make the disease worse.

Earlier recognition, aided by validated screening tools and attention to how a patient differs from their own baseline, can help prevent the disruption to work, relationships, and health that often follows a missed diagnosis.

In an interview with The American Journal of Managed Care^® (AJMC^®), Ray discussed the signs that set bipolar disorder apart from ordinary mood changes, what is at stake when the diagnosis is missed, and how he frames adherence with patients once treatment is underway.

This transcript has been lightly edited for clarity.

AJMC: What is bipolar disorder, and why does it so often go undiagnosed?

Ray: Bipolar disorder is basically depression with extra, as I like to say. There’s depression, and then there’s a period of mania, whether that be mixed episodes or just straight mania. We would say the average time it takes to diagnose somebody with bipolar disorder is between 5 and 10 years, which is not great. We can miss it often. Some scales can be helpful, like the Mood Disorder Questionnaire or the Rapid Mood Screener, so encouraging people to use those and come to a diagnosis earlier is always something we should be doing.

AJMC: What are the consequences when the diagnosis is delayed or missed?

Ray: The cost can be substantial. If we’re not treating patients correctly for the disorder they have, we can actually make their disease worse. It can cause disrupted education or employment, poor interpersonal relationships, difficulty with a spouse or children, financial consequences, hospitalization, and even death. Getting it right is important, and putting things in place to do that is essential in what we do.

AJMC: How do you distinguish a mood episode from normal emotional ups and downs?

Ray: Sometimes you just have a bad day and you’re irritable, but you don’t tend to have a bad day every day for a week. I focus on whether there is a change from the client’s usual baseline, the intensity, how long it has been going on, and what problems it is causing for them.

Normal emotions make sense in context. If you get a flat tire, you’re obviously going to be irritated, but you’re probably not going to smash your windshield. So there’s a difference in intensity. It’s usually a cluster of things that are off from the client’s baseline. When you see a reduced need for sleep for periods of days, which isn’t usual for them, and on top of that they feel unusually energized, they’re talking really fast, and their speech is pressured, those are signs that something’s not quite right, and we need to see what’s going on.

AJMC: What does successful treatment look like, and how do you talk with patients about adherence?

Ray: We’re not just trying to prevent hospitalizations. We’re trying to help people maintain relationships, maintain employment and stay in the workforce, and take care of themselves physically. Even brushing one’s teeth is something we may take for granted.

When it comes to adherence, it’s a constant reminder: Remember where we were, and remember the destruction that occurred previously. One of the reasons you’re doing okay now is your adherence to treatment. You come in, you take the medications, you do the things you’re supposed to be doing, and that’s why you’re better. It wasn’t just a phase. You have this condition, and if we treat it, you’ll do okay. If not, we may regress.

These aren’t weak people, and it’s not a character flaw. It’s no different than having diabetes. If you have diabetes, you see a provider and take insulin; here, we use other medications, like mood stabilizers or antipsychotics such as olanzapine/samidorphan (Lybalvi). It is treatable, but we have to find the right diagnosis. It’s important for patients to give us the full information and not hold back because they’re embarrassed. We’ve heard it all. When people come in and participate in treatment, they can get better and do well in life.

Reference

1. Lublóy Á, Keresztúri JL, Németh A, Mihalicza P. Exploring factors of diagnostic delay for patients with bipolar disorder: a population-based cohort study. BMC Psychiatry. 2020;20(1):75. doi:10.1186/s12888-020-2483-y