Diagnosing bipolar disorder is a notoriously inexact science. The disorders characteristic combination of symptomsbouts of depression interspersed with periods of an abnormally elevated mood known as maniais easy to miss or misread, even for trained experts. People with bipolar disorder, who often receive an initial diagnosis of unipolar (or major) depression, can struggle with their symptoms for years before the disorder is recognized and treated. By some estimates, as many as half of all bipolar cases are not identified.
Women with bipolar disorder may be especially susceptible to misdiagnosis. A recent study estimated that the odds that a woman with bipolar disorder will fail to be correctly diagnosed are roughly three times the odds for a man. This disparity may be explained in part by the fact that bipolar disorder tends to look different in women than it does in menin the same way that physicians sometimes fail to catch heart disease in women because they are effectively looking for the male version of the disease, mental health professionals may not always be aware of the distinctive signs of bipolar disorder in women.
"Women are more demonstrativethey have more of whats known as 'affective loading'so it's not surprising that bipolar disorder might be underdiagnosed in women compared to men," says Vivien Burt, MD, PhD, director of the Womens Life Center at UCLAs Resnick Neuropsychiatric Hospital.
Less intense manic phases
Jil, a 29-year-old from Mississippi, first experienced symptoms of bipolar disorder (depressed mood, insomnia, excess energy) in high school. When she was 16, her doctor diagnosed her with major depression and prescribed the antidepressant sertraline (then known by its brand name, Zoloft). The medication made Jil "completely manic"which antidepressants are believed to do in some people with bipolar disorderand a year later, a different doctor finally diagnosed her as bipolar.
"I've always had more severe depression than mania," Jil explains. "My depression is debilitating. When Im manic I dont sleep and sometimes spend money when I know I shouldnt, but mainly I am very productive and mean as a hornet. I used to cycle rapidly, but medications have slowed things down a lot, so I dont have ups and downs as frequently as I did before."
Compared to the average woman with bipolar disorder, Jils experience is unusual in some ways. The age at which she was diagnosed, for instance: Most people with bipolar disorder have their first manic episodes in their 20s or 30s, and research suggests that women tend to develop symptoms of the disorder three to five years later than men, on average.
In other ways, Jils story is all too typical. One of the reasons that bipolar disorder may be underdiagnosed in women is that the milder form of mania that Jil experiences appears to be more common in women. Although each case of bipolar disorder falls on a spectrum, rather than into neat categories, two main types of the disorder have been identified. The first, known as bipolar I disorder, is characterized by pronounced manicand even psychoticepisodes that often lead to hospitalization, and therefore a correct diagnosis. Bipolar II disorder features a more moderate form of mania known as hypomania, which is easier to mistake for an ordinary mood swing. While the prevalence of bipolar I is roughly the same among men and women, it has been suggested that bipolar II appears more often in the latter.
Rapid cycling, in which four or more episodes of mania or depression occur in a year, is also thought to be more common among women, perhaps because it is more closely associated with bipolar II. The same is true of so-called mixed mania, in which manic and depressive symptoms occur simultaneously.
"Nobody really knows why some people with bipolar disorder present with mixed mania, or why women are more likely to experience this condition than men. Bipolar symptoms in women may overlie a baseline demonstrative mood and temperament, and this may in part explain their increased prevalence of mixed mania," says Dr. Burt. "Also, women are 'hormonally challenged' throughout their childbearing years, from month-to-month, and from reproductive event to reproductive event, whether its pregnancy, postpartum, perimenopause, or menopause, and this too may be related to the gender-specific differences in presentation of bipolar disorder and other mood disorders in women."
Jil, in fact, has noticed that she can confuse the symptoms of an oncoming depressive episode with those of premenstrual syndrome. Hormones do appear to play a role in the course of bipolar disorder, since childbirth and menopausetwo other events marked by a rapid change in estrogen and progesterone levelscan also precipitate depression in bipolar women.
It is not uncommon for women to have mood swings and believe that they have mood changes related to premenstrual syndrome (PMS) or premenstrual dysphoric disorder (PMDD), says Dr. Burt. "Properly evaluated, some of these women may have bipolar disorder, or some other condition." Women who present with self-diagnosed PMS or PMDD should be evaluated through prospective ratings, in which a daily calendar of symptoms is completed, with the menstrual days circled, says Dr. Burt. In this way, a determination can be made if symptoms occur only during the premenstrual time of the month, or at other times of the months as well.
Bipolar drugs, pregnancy, and side effects
The biological differences between men and women are seen most readily when it comes to the treatment of bipolar disorder. Although talk therapy has of late assumed a more prominent role, the disorder continues to be treated primarily through medicationoften lots of it. Some medications prescribed for bipolar disorder have been linked to birth defects, however, which presents a dilemma for women of childbearing age. (The Food and Drug Administration, for instance, has warned that babies born to mothers who take lamotrigine in the first three months of pregnancy may have a higher chance of being born with a cleft lip or palate. )
Women with bipolar disorder who become pregnant will find themselves weighing the small risk of birth defects against the risk of relapse, which runs as high as 70% for women who cease their medication altogether during pregnancy. In addition, bipolar women are especially vulnerable to postpartum depression and its more severe form, postpartum psychosis; a small 2008 study that examined 56 women who received a referral for postpartum depression found that more than half had some type of bipolar disorder. Postpartum psychosis, meanwhile, is thought to be a variant of bipolar disorder.
According to Dr. Burt, the current protocol is to keep women, especially those with severe bipolar I disorder, on a mood stabilizer throughout the pregnancy. In some cases, women with milder symptoms may decide to cease medication for the first trimester, or even for the duration of the pregnancy, and then start again immediately after childbirth. Whenever treating a woman with a medication through pregnancy, the goal is to keep her stable and well, while choosing the medication that is safest for the developing fetus.
Jil currently takes lamotrigine (as a mood stabilizer), Cymbalta (for depression), and Geodon (for the "pesky background radio noises" that she experiences on occasion). She also used to take clonazepam (Klonopin) for anxiety, but she is off that now and sees a therapist whom she credits with helping her manage the anxiety without medication.
She has slowly begun to wean herself off her medication, however, because she and her husband want to have a child. "I want to completely go off medication for the pregnancyand that scares everyone involved," Jil says. "Ive been taking medications consistently for nearly six years, and its scary to think about what will happen when they are out of my system."