Making a Diagnosis

Bipolar disorder often has long delays to first diagnosis and treatment. Both early onset and treatment delay are risk factors for a poor outcome in adulthood. Poor recognition and treatment of the illness can lead to an accumulation of episodes with their attendant risks for cycle acceleration, neurobiological abnormalities, treatment resistance, cognitive dysfunction, and premature loss of many years of life expectancy. Complicating the appropriate diagnosis is the highly variable presentation of the illness and its multiple imitators and comorbidities, including anxiety disorders, attention-deficit/hyperactivity disorder, oppositional defiant disorder, depression, and substance abuse. One of the most critical keys to correct diagnosis is the longitudinal perspective, both retrospectively assessed in detail and systematically continued prospectively. Awareness of the high incidence of childhood-onset bipolar disorder in the United States compared with Canada and most European countries will hopefully lead to correction of one of the remedial risk factors for a poor outcome—the duration of delay to first treatment. With early and sustained treatment of a first episode of mania, episode recurrence and its attendant cognitive dysfunction may be prevented. Episodes, stressors, and bouts of substance abuse can accumulate and sensitize to further and more severe occurrences, likely on an epigenetic basis. Early diagnosis and treatment are imperative to stopping these mechanisms of illness progression in bipolar disorder.