The Other Depression

Jane.

Jane was first diagnosed with depression at age seventeen, when she attempted suicide by taking a bottle of her mother’s Benadryl. Her reason for doing it was to escape the confusion, the chaos in her mind, which never stopped. She received no treatment for that episode of depression, and subsequently attempted suicide two more times. Between her bouts of depression, she had periods when, inexplicably, she felt better. She had energy and drive. She didn’t need sleep. She felt great. This would last for a couple of weeks. Then, suddenly, she’d be down again. When she was twenty, her doctor put her on Prozac. After a while, she took herself off it because she felt it had stopped working.

When I met her, Jane had been alternating between periods of feeling good and periods of depression. She had been on and off Prozac for fifteen years and was seeing a psychiatrist. But Jane did not come to my office for depression. She came to bring me her daughter, who was crying and doing poorly at school. It wasn’t until after I had diagnosed and begun to successfully treat her daughter for bipolar disorder (BD) that we began to think Jane might have it, too. As it turned out, she had a strong family history of mental illness and many of the symptoms of BD. I put her on a mood stabilizer. But even after significant improvement, her psychiatrist resisted the diagnosis.

Bipolar disorder is misdiagnosed because it is difficult to distinguish from the simple, more common depression we are most familiar with. The characteristics that differentiate bipolar disorder from simple depression are not readily apparent, especially during a brief encounter. An accurate diagnosis requires information about the patient that may appear to the patient and the doctor to be unrelated to his immediate symptoms. It requires that the doctor have a template for bipolar disorder that will lead him to ask the right questions.

Essentially, each of my patients hires me to help him feel well and stay well. When he does not feel well, he comes in wanting me to fix his problem. He also wants me to put a label on what he is feeling - one that legitimizes his seeking and paying for treatment. Sometimes, there really isn’t anything wrong with him. Then my job is to tell him he’s okay. That means I have ruled out any significant cause for what he is experiencing. I don’t have a label for him. I don’t even have a billing code. “Normal” is not a diagnosis.

In any event, each of my encounters is problem-oriented. Even a routine physical is focused on looking for what might be abnormal. My goal is to catch problems early, when they are most easily and most successfully treated, and before they cause damage. Usually, this is before they have even caused symptoms.

But I cannot do routine check-ups for mental health. Mental health is subjective. There are no vital signs that I measure or tests I can run. I depend upon having people come to me when they feel something is wrong. The difficulty is that people often do not recognize mood problems in themselves, and perhaps don’t even know what “normal” is. Unless a dark mood comes on them very suddenly, they may think that what they have been feeling is normal.

Sometimes, mental illnesses are intertwined with physical illnesses. A patient comes in with migraines, but complicating the migraine problem is a chronic mood disorder¹ that the patient has never identified. I can treat the migraines, but unless I also treat his mood disorder, he will not do well.

Some people know that they are depressed or anxious and come in to be treated for these conditions. Fortunately, the stigma that used to surround depressive illness has faded in recent years, and there is a general understanding that a persistent low feeling of sadness, grief, guilt and fatigue is not normal, especially when it is not warranted by circumstances.

When a patient tells me he is sad, blue, and maybe hopeless; that his life is a mess; he has family problems; maybe has thoughts of suicide; maybe also complains of anxiety, nervousness or excessive worry; it is easy to diagnose him with depression and to prescribe an antidepressant medication. Depression is easier than ever to talk about. I know how it presents itself and even know how to detect it as an underlying factor in some of my patient’s physical illnesses. In spite of this, I have misdiagnosed many of my depressed patients and given them treatments that did not help them and actually made their condition worse.

Almost four times out of ten, when a person is diagnosed with “depression”, he has something other than simple depression. He has bipolar disorder.² Bipolar disorder is very like the simple depression we are most familiar with, except that it periodically expresses itself as “mania”, a mood extreme as far from normal in one direction as depression is on the other. In fact, simple depression is sometimes called “unipolar” depression to distinguish it from BD. I call bipolar disorder “the other depression”, because it has been so often overlooked by both the psychiatric and medical communities. The consequences of this are far-reaching and have led to a crisis in the way the health care community currently cares for mood disorders.

Studies done by Drs. Hirschfield and Manning, two prominent experts on bipolar disorder, have shown that doctors are much more likely to misdiagnose and mistreat a mood disorder than to diagnose and treat it correctly, not just once, but again and again. More than two times out of three, mental health specialists and primary care doctors misdiagnose BD.³

The most common mistake is treating a bipolar patient with the medications designed for those with simple depression. This may destabilize him, making him vulnerable to the high-risk impulses characteristic of the manic phase of BD, one of which is suicide. Furthermore, it takes the place of treatment that could slow down the natural progression of the disease and bring his symptoms under control. This is critical, because behavior at either end of the bipolar spectrum can be extremely destructive. Ruined marriages, job loss, unintended pregnancies, alcoholism, bankruptcy, incarceration, and drug abuse are some of the common consequences of BD.⁴ In addition; people with bipolar disorder are at increased risk for almost every type of medical problem.⁵

One major factor in the misdiagnosis of bipolar disorder is a lack of appreciation for the meaning of the word “depression”. Depression is not an illness, or even a diagnosis, in and of itself. It is a symptom complex that expresses a psychological condition. The importance of this distinction becomes clear when we think of another symptom complex we are more familiar with: congestive heart failure. Again, many people think of congestive heart failure as a diagnosis, but it is actually a set of symptoms that can be caused by any of a number of widely divergent conditions. Congestive heart failure can result from coronary artery disease, or from hypertension, or from a bad heart valve, or from a virus. These conditions look very different in the early stages, but in the end they all result in shortness of breath, swollen feet, enlarged heart, and lungs full of fluid. Most, but not all, congestive heart failure is caused by hypertension. But to treat congestive heart failure properly, the doctor must have an accurate understanding of the root problem.

Likewise, major depressive disorder is the term we use for any depressive episode disruptive enough to significantly impair functioning, as evidenced by the presence of a particular set of symptoms. The two classes of illness that cause this symptom complex are unipolar depression and bipolar disorder. Thinking of depression as a diagnosis tempts us to treat major depressive disorder as if it were unipolar depression, even though both bipolar disorder and unipolar depression involve major depressive disorder. In fact, the use of the term “major depressive disorder” as a diagnostic label for unipolar depression is so widespread that the two have become interchangeable in the minds of many people, even those who should know better. This obscures the possibility that the depression is caused by BD.

Another factor in the misdiagnosis of bipolar disorder is the mistaken perception that it is a rare condition. In the classic manic presentation we usually associate with it, it is relatively rare. But our whole concept of bipolar disorder is too limited. Most of the time, most people who have BD are depressed.⁶ And most of those who are manic do not display extreme behavior. Doctors do not see classic mania often, so they do not think they see bipolar disorder. Therefore they do not watch for it.

There are also social reasons for misdiagnosis. The stigma that used to be associated with unipolar depression is now associated with bipolar disorder. Nobody wants to be called manic, or bipolar, because these terms are so strongly associated with classic mania. For most people, this conjures up images of someone completely insane. “Maniac” comes from the Greek word for madness and has traditionally been defined as “mad; raving with madness; raging with disordered intellect”.⁷

Bipolar disorder is seldom so obvious. A patient with bipolar disorder may show up in the office with any variety of complaints, including anxiety, depression, fatigue, migraines, moodiness or PMS. He may have problems he attributes to attention-deficit/hyperactivity disorder or posttraumatic stress syndrome. Bipolar disorder can mimic these diseases, or the patient could have both. Bipolar disorder may have made him impulsive, self-aggrandizing or quick-tempered. The social fall-out from these traits can include financial difficulties, job loss, frequent job changes, marriage problems or multiple marriages. Not everyone with a history of these problems has bipolar disorder, but such a history is a red flag marking the possible underlying presence of BD. Alcohol and drug use are also common in people trying to cope with bipolar disorder; 50-60% of those with bipolar disorder abuse drugs or alcohol.⁸ Recognizing bipolar disorder requires an awareness of many more presentations than just classic mania.

Doctors who have only very limited exposure to their patients are at a disadvantage in diagnosing bipolar disorder, because it is likely they never see that facet of the patient’s life that would reveal it. This is one reason psychiatrists, who are the doctors most highly trained in mental health, regularly miss it. In many mental health care settings, the psychiatrist has only a few minutes with a patient before assigning him to the follow-up care of a counselor.⁹ That is rarely enough time to rule out bipolar disorder. The psychologists and social workers who follow up on these patients are not medical doctors, and, in my experience, are generally biased against making the diagnosis of bipolar disorder.

Even under the best conditions, the psychiatrist usually sees the patient in isolation from his family and without having seen his physical health record. He assesses the patient on the basis of what the patient tells him. If the bipolar patient just describes himself as depressed, the psychiatrist may not ask the questions that would differentiate this patient from one with unipolar depression. Also, because people generally do not end up in a psychiatrist’s office until they are seriously ill, the bipolar cases referred to him are often quite far advanced. Extreme moods make up a disproportionate amount of his clinical experience. The psychiatrist is far less familiar with the more subtle forms of bipolar disorder and seldom recognizes them when he sees them.

All of us have been fooled by the many faces of BD. It is a hard disease to track down. When it is present, it weaves its way through all of a person’s life, impacting everything, becoming almost invisible, disguised as something else. But people with bipolar disorder are not crazy. If it were that simple, we would have no trouble identifying them. Instead, they occupy an entire spectrum of disease states. Bipolar people contribute disproportionately to the populations of drug and alcohol treatment centers and prison. But they are also disproportionately represented in the ranks of artists and creative geniuses. Some of the most influential, most innovative, and most productive people have been bipolar. Buzz Aldrin, Francis Ford Coppola, Art Buchwald, Robin Williams, and Brian Wilson are all bipolar. Virginia Woolf was bipolar. So is Sting.

What people with bipolar disorder have in common is a lifelong condition, which causes them to experience intermittent periods of depression and at least one period at its opposite extreme. More often than not, they are great risk-takers. Many of them have incredible drive. But they live on the brink of despair.

Depression is like a desert – hot and inhospitable. Not much rain falls. A few things live there, but not many. The plants are impermeable and covered with spines. Most deserts, like the Sahara, do not bloom. But some do. Very occasionally, when it rains, these deserts bloom and fill with life, and their landscape is completely changed. Instead of spines, they show flowers. This may not happen often. But whether it happens once a year or once every hundred years, a desert that blooms is a different kind of desert. Likewise, bipolar disorder is a different kind of depression.

Mood disorders are in the class of problems that specifically effect mood as opposed to thoughts, anxiety, conduct or personality. Mainly, this term refers to all of the subtypes of unipolar and bipolar disorder.
J.D. Lish, S. Dilme-Meenan, P.C. Whybrow, R.A. Price, and R.M. Hirschfield. “The National Depressive and Manic-Depressive Association Survey of Bipolar Members,” J Affective Disord. 1994;31(4):281-294.
R.M. Hirschfield, J.R. Calabrese, M.M. Weissman, et al. “Screening for Bipolar Disorder in the Community,” J Clin Psychiatry. 2003; 64:53-59.
Frye MA. Bipolar Disorder: Keys to Reducing the Burden – and Improving the Quality of Life. Consultant. Sept 2005;45(suppl 10):52-53.
Bipolar disorder: The importance of quality-of-life outcomes. Consultant. Sept 2005;45(suppl 10):S4-S6.
Shelton RC. Future directions in bipolar depression. Bipolar Depression Bulletin.. Nov 1994;6:2. Presented by Curr Psychiatry.
McKechnie JL, ed. Webster’s New Twentieth Century Dictionary of the English Language, Unabridged. 2nd Edition. Cleveland: World Publishing Company, 1970:1095.
D.A. Regier, M.E. Farmer, D.S. Rae, et al. “Comorbidity of Mental Disorder with Alcohol and Other Drug Abuse; Results from the Epidemiologic Catchment Area (ECA) Study,” JAMA. 1990;264:2511-2518.
There are psychiatrists who take the time required to make an accurate diagnosis of bipolar disorder, but they are not accessible to everyone. Many practices are closed to new patients or work with only certain insurance companies. Private insurers generally provide less coverage for mental health care than for physical health care, so even with the right provider and the right insurance, psychiatric care can be out of reach for some people. Patients without health care coverage end up in the public mental health care system, which is underfunded, understaffed and overwhelmed with the number of patients needing intervention. Managed care has not come through with a solution either. Usually, if it does not direct patients to clinics that are already too busy or closed to new clients, it refers them to psychologists or social workers, most of whom are ten years behind the curve with respect to recognizing and diagnosing bipolar illness. Over and over again, I have found myself in conflict with psychologists who refuse to acknowledge that a patient is bipolar in spite of clear evidence.



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Book Description	Jane. Jane was first diagnosed with depression at age seventeen, when she attempted suicide by taking a bottle of her mother’s Benadryl. Her reason for doing it was to escape the confusion, the chaos in her mind, which never stopped. She received no treatment for that episode of depression, and subsequently attempted suicide two more times. Between her bouts of depression, she had periods when, inexplicably, she felt better. She had energy and drive. She didn’t need sleep. She felt great. This would last for a couple of weeks. Then, suddenly, she’d be down again. When she was twenty, her doctor put her on Prozac. After a while, she took herself off it because she felt it had stopped working. When I met her, Jane had been alternating between periods of feeling good and periods of depression. She had been on and off Prozac for fifteen years and was seeing a psychiatrist. But Jane did not come to my office for depression. She came to bring me her daughter, who was crying and doing poorly at school. It wasn’t until after I had diagnosed and begun to successfully treat her daughter for bipolar disorder (BD) that we began to think Jane might have it, too. As it turned out, she had a strong family history of mental illness and many of the symptoms of BD. I put her on a mood stabilizer. But even after significant improvement, her psychiatrist resisted the diagnosis. Bipolar disorder is misdiagnosed because it is difficult to distinguish from the simple, more common depression we are most familiar with. The characteristics that differentiate bipolar disorder from simple depression are not readily apparent, especially during a brief encounter. An accurate diagnosis requires information about the patient that may appear to the patient and the doctor to be unrelated to his immediate symptoms. It requires that the doctor have a template for bipolar disorder that will lead him to ask the right questions. Essentially, each of my patients hires me to help him feel well and stay well. When he does not feel well, he comes in wanting me to fix his problem. He also wants me to put a label on what he is feeling - one that legitimizes his seeking and paying for treatment. Sometimes, there really isn’t anything wrong with him. Then my job is to tell him he’s okay. That means I have ruled out any significant cause for what he is experiencing. I don’t have a label for him. I don’t even have a billing code. “Normal” is not a diagnosis. In any event, each of my encounters is problem-oriented. Even a routine physical is focused on looking for what might be abnormal. My goal is to catch problems early, when they are most easily and most successfully treated, and before they cause damage. Usually, this is before they have even caused symptoms. But I cannot do routine check-ups for mental health. Mental health is subjective. There are no vital signs that I measure or tests I can run. I depend upon having people come to me when they feel something is wrong. The difficulty is that people often do not recognize mood problems in themselves, and perhaps don’t even know what “normal” is. Unless a dark mood comes on them very suddenly, they may think that what they have been feeling is normal. Sometimes, mental illnesses are intertwined with physical illnesses. A patient comes in with migraines, but complicating the migraine problem is a chronic mood disorder¹ that the patient has never identified. I can treat the migraines, but unless I also treat his mood disorder, he will not do well. Some people know that they are depressed or anxious and come in to be treated for these conditions. Fortunately, the stigma that used to surround depressive illness has faded in recent years, and there is a general understanding that a persistent low feeling of sadness, grief, guilt and fatigue is not normal, especially when it is not warranted by circumstances. When a patient tells me he is sad, blue, and maybe hopeless; that his life is a mess; he has family problems; maybe has thoughts of suicide; maybe also complains of anxiety, nervousness or excessive worry; it is easy to diagnose him with depression and to prescribe an antidepressant medication. Depression is easier than ever to talk about. I know how it presents itself and even know how to detect it as an underlying factor in some of my patient’s physical illnesses. In spite of this, I have misdiagnosed many of my depressed patients and given them treatments that did not help them and actually made their condition worse. Almost four times out of ten, when a person is diagnosed with “depression”, he has something other than simple depression. He has bipolar disorder.² Bipolar disorder is very like the simple depression we are most familiar with, except that it periodically expresses itself as “mania”, a mood extreme as far from normal in one direction as depression is on the other. In fact, simple depression is sometimes called “unipolar” depression to distinguish it from BD. I call bipolar disorder “the other depression”, because it has been so often overlooked by both the psychiatric and medical communities. The consequences of this are far-reaching and have led to a crisis in the way the health care community currently cares for mood disorders. Studies done by Drs. Hirschfield and Manning, two prominent experts on bipolar disorder, have shown that doctors are much more likely to misdiagnose and mistreat a mood disorder than to diagnose and treat it correctly, not just once, but again and again. More than two times out of three, mental health specialists and primary care doctors misdiagnose BD.³ The most common mistake is treating a bipolar patient with the medications designed for those with simple depression. This may destabilize him, making him vulnerable to the high-risk impulses characteristic of the manic phase of BD, one of which is suicide. Furthermore, it takes the place of treatment that could slow down the natural progression of the disease and bring his symptoms under control. This is critical, because behavior at either end of the bipolar spectrum can be extremely destructive. Ruined marriages, job loss, unintended pregnancies, alcoholism, bankruptcy, incarceration, and drug abuse are some of the common consequences of BD.⁴ In addition; people with bipolar disorder are at increased risk for almost every type of medical problem.⁵ One major factor in the misdiagnosis of bipolar disorder is a lack of appreciation for the meaning of the word “depression”. Depression is not an illness, or even a diagnosis, in and of itself. It is a symptom complex that expresses a psychological condition. The importance of this distinction becomes clear when we think of another symptom complex we are more familiar with: congestive heart failure. Again, many people think of congestive heart failure as a diagnosis, but it is actually a set of symptoms that can be caused by any of a number of widely divergent conditions. Congestive heart failure can result from coronary artery disease, or from hypertension, or from a bad heart valve, or from a virus. These conditions look very different in the early stages, but in the end they all result in shortness of breath, swollen feet, enlarged heart, and lungs full of fluid. Most, but not all, congestive heart failure is caused by hypertension. But to treat congestive heart failure properly, the doctor must have an accurate understanding of the root problem. Likewise, major depressive disorder is the term we use for any depressive episode disruptive enough to significantly impair functioning, as evidenced by the presence of a particular set of symptoms. The two classes of illness that cause this symptom complex are unipolar depression and bipolar disorder. Thinking of depression as a diagnosis tempts us to treat major depressive disorder as if it were unipolar depression, even though both bipolar disorder and unipolar depression involve major depressive disorder. In fact, the use of the term “major depressive disorder” as a diagnostic label for unipolar depression is so widespread that the two have become interchangeable in the minds of many people, even those who should know better. This obscures the possibility that the depression is caused by BD. Another factor in the misdiagnosis of bipolar disorder is the mistaken perception that it is a rare condition. In the classic manic presentation we usually associate with it, it is relatively rare. But our whole concept of bipolar disorder is too limited. Most of the time, most people who have BD are depressed.⁶ And most of those who are manic do not display extreme behavior. Doctors do not see classic mania often, so they do not think they see bipolar disorder. Therefore they do not watch for it. There are also social reasons for misdiagnosis. The stigma that used to be associated with unipolar depression is now associated with bipolar disorder. Nobody wants to be called manic, or bipolar, because these terms are so strongly associated with classic mania. For most people, this conjures up images of someone completely insane. “Maniac” comes from the Greek word for madness and has traditionally been defined as “mad; raving with madness; raging with disordered intellect”.⁷ Bipolar disorder is seldom so obvious. A patient with bipolar disorder may show up in the office with any variety of complaints, including anxiety, depression, fatigue, migraines, moodiness or PMS. He may have problems he attributes to attention-deficit/hyperactivity disorder or posttraumatic stress syndrome. Bipolar disorder can mimic these diseases, or the patient could have both. Bipolar disorder may have made him impulsive, self-aggrandizing or quick-tempered. The social fall-out from these traits can include financial difficulties, job loss, frequent job changes, marriage problems or multiple marriages. Not everyone with a history of these problems has bipolar disorder, but such a history is a red flag marking the possible underlying presence of BD. Alcohol and drug use are also common in people trying to cope with bipolar disorder; 50-60% of those with bipolar disorder abuse drugs or alcohol.⁸ Recognizing bipolar disorder requires an awareness of many more presentations than just classic mania. Doctors who have only very limited exposure to their patients are at a disadvantage in diagnosing bipolar disorder, because it is likely they never see that facet of the patient’s life that would reveal it. This is one reason psychiatrists, who are the doctors most highly trained in mental health, regularly miss it. In many mental health care settings, the psychiatrist has only a few minutes with a patient before assigning him to the follow-up care of a counselor.⁹ That is rarely enough time to rule out bipolar disorder. The psychologists and social workers who follow up on these patients are not medical doctors, and, in my experience, are generally biased against making the diagnosis of bipolar disorder. Even under the best conditions, the psychiatrist usually sees the patient in isolation from his family and without having seen his physical health record. He assesses the patient on the basis of what the patient tells him. If the bipolar patient just describes himself as depressed, the psychiatrist may not ask the questions that would differentiate this patient from one with unipolar depression. Also, because people generally do not end up in a psychiatrist’s office until they are seriously ill, the bipolar cases referred to him are often quite far advanced. Extreme moods make up a disproportionate amount of his clinical experience. The psychiatrist is far less familiar with the more subtle forms of bipolar disorder and seldom recognizes them when he sees them. All of us have been fooled by the many faces of BD. It is a hard disease to track down. When it is present, it weaves its way through all of a person’s life, impacting everything, becoming almost invisible, disguised as something else. But people with bipolar disorder are not crazy. If it were that simple, we would have no trouble identifying them. Instead, they occupy an entire spectrum of disease states. Bipolar people contribute disproportionately to the populations of drug and alcohol treatment centers and prison. But they are also disproportionately represented in the ranks of artists and creative geniuses. Some of the most influential, most innovative, and most productive people have been bipolar. Buzz Aldrin, Francis Ford Coppola, Art Buchwald, Robin Williams, and Brian Wilson are all bipolar. Virginia Woolf was bipolar. So is Sting. What people with bipolar disorder have in common is a lifelong condition, which causes them to experience intermittent periods of depression and at least one period at its opposite extreme. More often than not, they are great risk-takers. Many of them have incredible drive. But they live on the brink of despair. Depression is like a desert – hot and inhospitable. Not much rain falls. A few things live there, but not many. The plants are impermeable and covered with spines. Most deserts, like the Sahara, do not bloom. But some do. Very occasionally, when it rains, these deserts bloom and fill with life, and their landscape is completely changed. Instead of spines, they show flowers. This may not happen often. But whether it happens once a year or once every hundred years, a desert that blooms is a different kind of desert. Likewise, bipolar disorder is a different kind of depression. Mood disorders are in the class of problems that specifically effect mood as opposed to thoughts, anxiety, conduct or personality. Mainly, this term refers to all of the subtypes of unipolar and bipolar disorder. J.D. Lish, S. Dilme-Meenan, P.C. Whybrow, R.A. Price, and R.M. Hirschfield. “The National Depressive and Manic-Depressive Association Survey of Bipolar Members,” J Affective Disord. 1994;31(4):281-294. R.M. Hirschfield, J.R. Calabrese, M.M. Weissman, et al. “Screening for Bipolar Disorder in the Community,” J Clin Psychiatry. 2003; 64:53-59. Frye MA. Bipolar Disorder: Keys to Reducing the Burden – and Improving the Quality of Life. Consultant. Sept 2005;45(suppl 10):52-53. Bipolar disorder: The importance of quality-of-life outcomes. Consultant. Sept 2005;45(suppl 10):S4-S6. Shelton RC. Future directions in bipolar depression. Bipolar Depression Bulletin.. Nov 1994;6:2. Presented by Curr Psychiatry. McKechnie JL, ed. Webster’s New Twentieth Century Dictionary of the English Language, Unabridged. 2nd Edition. Cleveland: World Publishing Company, 1970:1095. D.A. Regier, M.E. Farmer, D.S. Rae, et al. “Comorbidity of Mental Disorder with Alcohol and Other Drug Abuse; Results from the Epidemiologic Catchment Area (ECA) Study,” JAMA. 1990;264:2511-2518. There are psychiatrists who take the time required to make an accurate diagnosis of bipolar disorder, but they are not accessible to everyone. Many practices are closed to new patients or work with only certain insurance companies. Private insurers generally provide less coverage for mental health care than for physical health care, so even with the right provider and the right insurance, psychiatric care can be out of reach for some people. Patients without health care coverage end up in the public mental health care system, which is underfunded, understaffed and overwhelmed with the number of patients needing intervention. Managed care has not come through with a solution either. Usually, if it does not direct patients to clinics that are already too busy or closed to new clients, it refers them to psychologists or social workers, most of whom are ten years behind the curve with respect to recognizing and diagnosing bipolar illness. Over and over again, I have found myself in conflict with psychologists who refuse to acknowledge that a patient is bipolar in spite of clear evidence.

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