Bipolar I Disorder Screening in Practice Video

This Clinical Insights video highlights the challenges in differentiating bipolar I disorder (BP-1) from major depressive disorder (MDD) and outlines how to use measurement-based care tools such as the Rapid Mood Screener to screen for BP-1 in patients previously diagnosed with MDD.

Transcript:

Hello, and welcome to NP Psych Navigator’s Clinical Insights series. I’m Alan “Tony” Amberg, a mental health nurse practitioner in Chicago, Illinois. I’m glad you joined us today as we discuss the diagnostic challenges in differentiating bipolar I disorder, or BP-1, from major depressive disorder, or MDD. As you know, this can be a real challenge in day-to-day practice. Today, we’ll also take a look at a practical tool that may help with screening for BP-1 in your patients.

Many of us have cared for patients who have faced long-term depression and tried various treatments without finding relief. These patients highlight one of the key challenges we, mental healthcare providers, face in treating patients with BP-1: the difficulty in making a timely and accurate diagnosis of BP-1.

Research has shown that BP-1 is frequently misdiagnosed as MDD, with at least 60% of patients with bipolar initially misdiagnosed with MDD.¹ In fact, studies indicate the delay between the onset of illness for bipolar and receiving an accurate diagnosis can be anywhere from 5 to 10 years.² Think about that—half a decade or more before patients get the appropriate care.

As the statistics indicate, misdiagnosis of BP-1 may occur and have a significant impact on the patient’s course of illness.

Understanding why these misdiagnoses occur requires a closer look at the overlapping features and clinical course of bipolar I and major depressive disorder.

To begin, the diagnostic criteria for a depressive episode in bipolar I and those for MDD are identical. When patients present during a depressive episode, which is often when they initially seek mental healthcare, it may be difficult to distinguish between BP-1 and MDD.³

Second, contrary to popular belief, bipolar disorder is not just about “swinging between moods.” The vast majority of the time, the mood pole lived by the patient is depression. Only a relatively short period of time is spent in the hypomanic or manic state. This was highlighted in the Systematic Treatment Enhancement Program for Bipolar Disorder study, also known as the STEP-BD study. The study showed that patients with bipolar disorder, when followed for an average of 309 days for recurrence, experienced the depressive phase approximately 72% of the time compared to manic episodes, about 11% of the time.^4,5

Adding to this complexity, it is well-known that some patients with BP-1 may not initially recognize their manic symptoms, either because they do not consider these symptoms to be problematic or because mania can be associated with impaired memory. So, while depressive symptoms bring them into care, their history of mania often goes unreported.^6,7 As a result, many patients with BP-1 may seek help for their depressive symptoms while the manic symptoms remain undiagnosed. This incomplete picture of their illness can lead to the misdiagnosis of bipolar as major depressive disorder.

Together, these factors can add to the challenges in accurately differentiating between bipolar I and major depressive disorder.

Misdiagnosis of bipolar I and the resulting delay in a patient receiving appropriate treatment may also result in a subsequent negative impact on the patient’s clinical and functional outcomes.

Evidence from longitudinal studies supports that the longer appropriate treatment is delayed, the greater the risk of more frequent depressive episodes and longer duration of illness. Patients with untreated bipolar I may also experience a higher rate of rapid cycling and require more hospitalizations.⁴ Beyond these clinical outcomes, extended duration of untreated bipolar I has been linked to impairments in social, occupational, and executive functioning.⁸ Perhaps most concerning and reflective of the toll untreated bipolar I can have on patients, those with a longer duration of untreated bipolar I face a 1.82 times greater risk of suicide compared to those who receive treatment earlier.⁹  

These findings underscore the critical importance of timely diagnosis and management in altering the long-term outcomes of patients with bipolar I.

In addition, misdiagnosis of bipolar I as major depressive disorder can also result in the patient receiving inappropriate treatment. Antidepressant monotherapy is considered the first-line treatment for MDD, while current clinical guidelines recommend atypical antipsychotics or mood stabilizers for bipolar I depression.⁴

When a patient with BP-1 is treated with antidepressant monotherapy, there may be a risk of affective switch from depression to mania, known as a treatment-emergent affective switch, or TEAS.¹⁰ While different classes of antidepressants may be associated with different levels of risk for TEAS, studies have shown that TEAS can be associated with a higher possibility of rapid cycling, potentially worsening patient outcomes.^4,10-14

If the patient reports severe agitation, irritability, or even feelings of "jitteriness" while on antidepressant therapy, it’s important to thoroughly investigate the possibility of a potential TEAS. A comprehensive medication history and, with the patient’s permission, input from family members, may help uncover these changes and support accurate identification.^15,16

Given these risks, improving the early and accurate identification of BP-1 should be a clinical priority. One key strategy is incorporating measurement-based care into clinical practice. Measurement-based care refers to the routine use of standardized, validated measurement tools to help assess symptoms, track severity, and/or monitor treatment progress over time. By implementing regular use of measurement tools in clinical visits, healthcare providers can help support evidence-based decision making and shared treatment planning.¹⁷

For patients with bipolar I, validated assessment tools that can be used to screen for bipolar I may be helpful.

One such tool is the Rapid Mood Screener, or RMS. The RMS is a screening tool that was developed to help clinicians differentiate bipolar I from major depressive disorder in patients with depressive symptoms who've been diagnosed with MDD.^1,18

The RMS is a self-reported questionnaire with 6 items: three items assessing the depressive features and three items assessing manic features of bipolar I.¹

The RMS takes about two minutes to complete, which makes it easy to incorporate into a clinical visit, and it uses a simple yes/no format.¹

A score of four or more “yes” responses suggests a high likelihood of having bipolar I, with a sensitivity of 88% and a specificity of 80%. However, even three “yes” answers can signal a higher probability of bipolar I than major depressive disorder.¹

While the RMS can help shed light on whether a patient is more likely to have bipolar I than major depressive disorder,¹ it’s important to note that the RMS is not a diagnostic tool.^1,19 It is essential that providers conduct a comprehensive patient assessment that includes detailed patient medical and family psychiatric history, as well as probing questions that inquire about a past history of manic symptoms. A complete history of medication types, doses, and durations the patient has tried is an important component of the comprehensive assessment.²⁰

As mentioned earlier, with the patient’s permission, asking their family members, friends, or significant other to provide insight into the patient’s symptom history can be helpful to gather thorough information.¹⁶ In addition, it is important to rule out other psychiatric conditions with overlapping or similar symptoms, such as symptoms of anxiety, trauma, and substance use.³

To date, the RMS is validated specifically in bipolar I populations.¹

In conclusion, the timely and accurate identification of bipolar I remains a significant clinical challenge. By incorporating the use of validated screeners such as the RMS and conducting a comprehensive patient evaluation to carefully assess past manic symptoms, mental healthcare providers can potentially reduce diagnostic delays and minimize inappropriate treatment to help improve outcomes for patients with bipolar I.

I hope you found this video helpful in highlighting how bipolar I screening tools, when paired with a comprehensive evaluation, can support timely and accurate identification of patients with potential BP-1. Thank you for joining me today!

Relationships with coworkers, friends, and acquaintances may also be affected by depressive symptoms. People with major depressive disorder can miss work due to their illness and, when at work, may perform responsibilities poorly or ineffectively due to their condition.²⁶ In a survey from 2001–2003, people with major depressive disorder lost an average of 27.2 workdays—8.7 days were due to absenteeism and 18.2 days from presenteeism.²⁹Problems with memory, attention, and executive function are also associated with lower wages and unemployment.^26,28 Patients with major depressive disorder may have difficulty extricating themselves from their own thoughts and, as a result, may appear self-focused and disinterested in social activities and forging bonds with others.³⁰ Along with a diminished ability to read nonverbal cues from other people, they may come across as insensitive and have few friends.³⁰
Caregivers such as family and friends of people with major depressive disorder can also be negatively impacted. This unpaid informal work can be time consuming and emotionally challenging,³¹ possibly leading to lost income and health insurance due to reduced work hours.³² In addition, they may experience fatigue, distress, and poor sleep, and may develop depressive symptoms themselves.³
Relationships with coworkers, friends, and acquaintances may also be affected by depressive symptoms. People with major depressive disorder can miss work due to their illness and, when at work, may perform responsibilities poorly or ineffectively due to their condition.²⁶ In a survey from 2001–2003, people with major depressive disorder lost an average of 27.2 workdays—8.7 days were due to absenteeism and 18.2 days from presenteeism.²⁹Problems with memory, attention, and executive function are also associated with lower wages and unemployment.^26,28 Patients with major depressive disorder may have difficulty extricating themselves from their own thoughts and, as a result, may appear self-focused and disinterested in social activities and forging bonds with others.³⁰ Along with a diminished ability to read nonverbal cues from other people, they may come across as insensitive and have few friends.³⁰
Caregivers such as family and friends of people with major depressive disorder can also be negatively impacted. This unpaid informal work can be time consuming and emotionally challenging,³¹ possibly leading to lost income and health insurance due to reduced work hours.³² In addition, they may experience fatigue, distress, and poor sleep, and may develop depressive symptoms themselves.³²

References

McIntyre RS, Patel MD, Masand PS, et al. The Rapid Mood Screener (RMS): a novel and pragmatic screener for bipolar I disorder. Curr Med Res Opin. 2021;37(1):135-144. doi:10.1080/03007995.2020.1860358 
Phillips ML, Kupfer DJ. Bipolar disorder diagnosis: challenges and future directions. Lancet. 2013;381(9878):1663-1671. doi:10.1016/S0140-6736(13)60989-7   
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association Publishing; 2013.   
McIntyre RS, Laliberté F, Germain G, MacKnight SD, Gillard P, Harrington A. The real-world health resource use and costs of misdiagnosing bipolar I disorder. J Affect Disord. 2022;316:26-33. doi:10.1016/j.jad.2022.07.069
Perlis RH, Dennehy EB, Miklowitz DJ, et al. Retrospective age at onset of bipolar disorder and outcome during two-year follow-up: results from the STEP-BD study. Bipolar Disord. 2009;11(4):391-400. doi:10.1111/j.1399-5618.2009.00686.x  
Youngstrom E, Van Meter A, Algorta GP. The bipolar spectrum: myth or reality? Curr Psychiatry Rep. 2010;12(6):479-489. doi:10.1007/s11920-010-0153-3  
Vrabie M, Marinescu V, Talaşman A, et al. Cognitive impairment in manic bipolar patients: important, understated, significant aspects. Ann Gen Psychiatry. 2015;14:41. doi:10.1186/s12991-015-0080-0
Macellaro M, Bucca C, Balla I, Galimberti C, Dell’Osso B. Duration of untreated illness in bipolar disorder. Psych Res Comm. 2025;5(3):100223. doi:10.1016/j.psycom.2025.100223
Nery-Fernandes F, Quarantini LC, Guimarães JL, et al. Is there an association between suicide attempt and delay of initiation of mood stabilizers in bipolar I disorder? J Affect Disord. 2012;136(3):1082-1087. doi:10.1016/j.jad.2011.10.046
Salvadore G, Quiroz JA, Machado-Vieira R, et al. The neurobiology of the switch process in bipolar disorder: a review. J Clin Psychiatry. 2010;71(11):1488-1501. doi:10.4088/JCP.09r05259gre

American Psychiatric Association. Practice Guideline for the Treatment of Patients With Bipolar Disorder. 2nd ed. American Psychiatric Association; 2002.    
Viktorin A, Lichtenstein P, Thase ME, et al. The risk of switch to mania in patients with bipolar disorder during treatment with an antidepressant alone and in combination with a mood stabilizer. Am J Psychiatry. 2014;171(10):1067-1073. doi:10.1176/appi.ajp.2014.13111501  
Carvalho AF, Dimellis D, Gonda X, et al. Rapid cycling in bipolar disorder: a systematic review. J Clin Psychiatry. 2014;75(6):e578-86. doi:10.4088/JCP.13r08905 
Tondo L, Vázquez G, Baldessarini RJ. Mania associated with antidepressant treatment: comprehensive meta-analytic review. Acta Psychiatr Scand. 2010;121(6):404-14. doi:10.1111/j.1600-0447.2009.01514.x
Seiner S, Baldessarini R, Camprodon J, et al. Psychopharmacology and neurotherapeutics. In: Walker A, Schlozman S, Alpert J, eds. Introduction to Psychiatry. Cambridge University Press; 2021:342-388.
Goldberg JF, Ernst CL. What to do when your depressed patient develops mania. Fed Pract. 2016;33(suppl 2):26S-33S.
Lewis CC, Boyd M, Puspitasari A, et al. Implementing measurement-based care in behavioral health: a review. JAMA Psychiatry. 2019;76(3):324-335. doi:10.1001/jamapsychiatry.2018.3329
AbbVie Medical Affairs. Rapid Mood Screener. September 2024. Accessed May 5, 2025. https://rapidmoodscreener.com/
Mitchell PB, Goodwin GM, Johnson GF, Hirschfeld RM. Diagnostic guidelines for bipolar depression: a probabilistic approach. Bipolar Disord. 2008;10(1 pt 2):144-152. doi:10.1111/j.1399-5618.2007.00559.x   
Marzani G and Neff AP. Bipolar disorders: evaluation and treatment. Am Fam Physician. 2021;103(4):227-239.

This resource is intended for educational purposes only and is intended for US healthcare professionals. Healthcare professionals should use independent medical judgment. All decisions regarding patient care must be handled by a healthcare professional and be made based on the unique needs of each patient.  

NP Psych Navigator is sponsored by AbbVie Medical Affairs. The contributor is a paid consultant for AbbVie Medical Affairs and was compensated for their time.

The Rapid Mood Screener is not a diagnostic tool.

The Rapid Mood Screener was developed with funding and input provided by AbbVie and external experts, who received financial support from AbbVie for research, honoraria and/or consulting services depending on the author.