Screen, assess, diagnose​

Rapid assessment

In a primary care setting, a rapid assessment of a possibly manic or hypomanic patient must primarily address the safety of the patient and the family or caretakers, as well as health care providers. The complexity and severity of symptoms in mania often necessitate hospitalization for rapid symptom control. Agitation, irritability and severe aggression are common and are associated with self-harm (Yatham et al., 2006; Yatham et al., 2009).

Primary care providers should routinely screen for bipolar disorder in all patients with affective symptoms (Das et al., 2005). Patients with co-occurring anxiety disorders, substance use disorder or impulse dyscontrol (e.g., a gambling disorder) should be closely scrutinized for bipolar disorder.

Mood Disorder Questionnaire

In a busy office setting, a screening tool such as the Mood Disorder Questionnaire (MDQ)  is a valid and efficient way to probe for bipolar symptomatology. The patient-administered MDQ involves 13 yes/no questions about manic and hypomanic symptoms. A positive screen requires seven "yes" responses and some symptoms must occur concurrently and be causing a moderate level of functional impairment. A positive screen should be explored further to confirm or refute a bipolar diagnosis (Hirschfeld et al., 2000).

Ruling out organic pathology

Organic pathology can be reasonably excluded by focusing on biological factors that may be associated with mania.

For example, a physical exam evaluating for focal neurological signs or evidence of head trauma may be warranted. In addition, laboratory screening for thyroid abnormalities is generally recommended. Primary care providers should consider and seek consent for toxicology screening if they suspect surreptitious illicit drug use.

Clinical clues of bipolar depression

The key elements of bipolar presentations in primary care include:

• initial presentation of depression that progressed into treatment-resistant depression
• antidepressant monotherapy exacerbating or unmasking hypomania
• prominence of anxiety, agitation and hyperactivity
• poor impulse control
• family history of mental illness
• early age onset of disturbance