Dr. Birmaher noted that young people with bipolar disorder usually have recurring episodes of major depression, but that “depressive episodes are not necessary for making the diagnosis.” For some, mania is the primary symptom.
When depression is the symptom that brings patients to professional attention, the correct diagnosis can be especially tricky. As Dr. Ketter explained, depressed individuals may be unable to recall previous episodes of mania that occurred when they were not depressed.
Dr. Miklowitz said one of the first signs of bipolar disorder is “mood dysregulation — the child is angry or depressed one moment, then is excited and happy and full of ideas moments later.”
He listed characteristics of mania that can help parents distinguish them from normal teenage highs and lows. The symptoms, several of which should be noticeable to other people, can include “grandiose thinking, decreased need for sleep, rapid or pressured speech and/or flight of ideas, racing thoughts, distractibility, excessive goal-driven activity, and impulsive or reckless behavior,” Dr. Miklowitz said.
With depressive symptoms, he suggests looking for “an impairment in functioning — suddenly not going to school or going late, not finishing homework, sleeping through classes, a drop in grades, not wanting to eat with anyone else, talking about suicide, self-cutting.”
Depending on the severity of a child’s impairment, if nonlife-threatening symptoms are caught in the early teens, Dr. Miklowitz said it may be possible to start with psychotherapy and avoid medication, which has side effects. “But if the child’s life is at risk, if he can’t function at home or at school, medication may be the answer,” he said. “There are risks to not medicating.”
When medication is necessary, he said, the dosage should be just high enough to control symptoms and not be overly sedating.