Why bipolar disorder is often misdiagnosed

Each year, World Bipolar Day offers an opportunity to deepen understanding of a condition that remains widely misunderstood. Whilst awareness of bipolar disorder has improved in recent years, accurate diagnosis continues to present challenges, even within experienced clinical settings.

For many individuals, the journey to a correct diagnosis is not straightforward; an estimated 69% of individuals with bipolar disorder are initially misdiagnosed, and more than a third remain misdiagnosed for 10 years or more (survey by the National Depressive and Manic-Depressive Association (DMDA)). 

It can involve years of uncertainty, multiple assessments and, at times, treatment approaches that do not fully address the underlying condition. This is not due to a lack of care, but rather the complexity of bipolar disorder itself and the way it can present differently from person to person.

Understanding why bipolar disorder is often misdiagnosed can help reduce frustration, support earlier intervention, guide individuals towards more appropriate, effective care, and improve overall wellbeing.

The complexity of presentation

Bipolar disorder is not a single, uniform condition. It exists on a spectrum, typically involving alternating periods of depression and elevated mood, which may present as mania or hypomania. However, these mood states do not always follow a clear or predictable pattern.

Depressive episodes are often more frequent and longer-lasting than periods of elevated mood. As a result, many individuals seek help during depression, when symptoms may closely resemble those of unipolar depression.

Manic or hypomanic episodes, particularly when less severe, may not be recognised as problematic. They can be experienced as periods of increased energy, productivity, or creativity, and may not initially cause concern. In some cases, they are only identified retrospectively, if at all.

This imbalance in how symptoms are experienced and reported can make it difficult to identify the cyclical nature that characterises bipolar disorder.

Although our understanding continues to evolve, bipolar disorder is not a new condition. In 1854, Jules Falret described a pattern of alternating depression and elevated mood, which he termed folie circulaire. It later became known as manic depressive psychosis, and more commonly as manic depression. Whilst the language has changed, and clinical understanding has developed significantly over time, the core features of the condition have long been recognised.

Overlap with other mental health conditions

One of the primary reasons bipolar disorder is misdiagnosed is its overlap with other mental health conditions. Symptoms can resemble those seen in depression, anxiety disorders, personality disorders and attention deficit hyperactivity disorder.

For example:

• Depressive episodes may be indistinguishable from major depressive disorder without a detailed history.
• Periods of emotional intensity or impulsivity may be attributed to personality-related difficulties.
• Restlessness, reduced need for sleep and increased activity can be mistaken for anxiety or ADHD.

Without careful assessment over time, it is understandable that clinicians may initially diagnose the condition that best fits the symptoms presented in that moment.

Because the symptoms of bipolar disorder can also resemble those seen in ADHD, major depressive disorder, borderline personality disorder, schizophrenia and other mood conditions, some research has suggested that bipolar disorder may at times be over-diagnosed. 

At the same time, other studies indicate that it can be underdiagnosed or misidentified as other psychiatric conditions. In some clinical settings, both patterns may occur, highlighting the difficulty of reaching a clear and accurate diagnosis when symptoms overlap.

The role of timing and context

Diagnosis in mental health is rarely based on a single appointment. It requires an understanding of patterns over time, including shifts in mood, behaviour and functioning.

In the early stages, bipolar disorder may not yet show its full pattern. A first depressive episode can occur years before any noticeable hypomanic or manic episode. In these cases, a diagnosis of depression may be appropriate at the time, even if it later evolves.

External factors can also influence presentation. Stress, substance use, sleep disruption, and significant life events can all affect mood and behaviour, sometimes masking or mimicking underlying bipolar patterns.

This highlights the importance of ongoing review rather than viewing diagnosis as fixed or immediate.

The impact of misdiagnosis

Being misdiagnosed does not mean that care has failed, but it can affect the course of treatment and recovery.

For instance, when bipolar disorder is treated solely as depression, individuals may be prescribed antidepressant medication without mood stabilisation. In some cases, this can contribute to mood instability or trigger hypomanic or manic episodes.

Beyond medication, misdiagnosis can shape how individuals understand their own experiences. It may lead to confusion, self-doubt, or a sense that treatment is not working, when in reality the underlying condition has not yet been fully identified.

Recognising and addressing misdiagnosis can therefore be an important step in restoring clarity and confidence in the recovery process.

Barriers to accurate diagnosis

Several factors can make the diagnosis more complex:

• Individuals may not recognise or report elevated mood states, particularly if these feel positive or productive.
• Shame, stigma, and fear of judgement can limit openness during assessment.
• Co-occurring conditions, including substance use or trauma-related disorders, can obscure the clinical picture.
• Time constraints within some healthcare settings may limit the depth of initial assessment.

These challenges are not uncommon, and they reinforce the value of thorough, compassionate and ongoing clinical engagement.

The importance of understanding patterns over time

A key element in diagnosing bipolar disorder is the ability to observe patterns over time. This includes not only symptom tracking, but also an understanding of personal history, family history, and environmental influences.

In more comprehensive treatment settings, there is a greater opportunity to build this picture. Structured assessment, regular clinical review, input from a multidisciplinary team, and the ongoing monitoring of mood patterns can all contribute to a more accurate and nuanced diagnosis.

Equally important is the individual’s own insight. As understanding grows, people are often better able to recognise shifts in mood and communicate these experiences more clearly.

Moving towards the right support

Receiving an accurate diagnosis can be a turning point. It allows for a treatment approach that reflects the true nature of the condition, often involving a combination of mood stabilising medication, psychological therapy, and lifestyle support.

It can also bring a sense of relief. Experiences that once felt confusing or inconsistent begin to make sense within a coherent framework.

At the same time, it is important to acknowledge that support does not follow a single path. Some individuals access help through outpatient services, whilst others may benefit from the structure and depth of residential treatment, particularly when symptoms are complex or longstanding.

A more informed and compassionate perspective

Bipolar disorder is a complex and often nuanced condition. Misdiagnosis is not uncommon, and in many cases reflects the evolving nature of mental health rather than error alone.

By approaching diagnosis as a process rather than a single event, it becomes possible to respond with greater flexibility, understanding and care.

On World Bipolar Day, the focus is not only on awareness but on deepening the quality of that understanding. With time, careful assessment and the right support, individuals can move towards greater stability, clarity, and long term wellbeing.

Depression and bipolar treatment in Spain

Here at our luxury residential mental health treatment clinic, located on the beautiful Spanish island of Ibiza, we have a team of highly qualified staff who are experienced in a range of therapies to assist with the treatment of bipolar and other mood disorders. We are also able to offer transcranial magnetic stimulation (TMS) on-site as a part of our wider treatment programme.

TMS is a non-invasive form of brain stimulation therapy that has proven effective in the treatment of neurological and mental health conditions, including treatment-resistant depression.

For information on all available therapies and admissions details, contact sharon@ibizacalm.com.

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