Most mental health experts will acknowledge that diagnosing disorders can be as much art as science. In this annual ADHD Awareness month—and, of course, through the rest of the year—it’s worth a reminder that despite what some eager entrepreneurs may promise, there is still no blood test or brain scan or any other concrete measurement that can pin down whether someone has Attention-deficit/hyperactivity disorder.
Of course, this also applies to other serious mental disorders, which is just one more thing that makes ADHD so bedeviling.
The classic symptoms of ADHD—such as restlessness, distraction, and impulsivity—can be caused by a wide variety of factors, from genes, to brain injuries, to sleep problems, to bipolar disorder. Misdiagnosis is always a risk, but confusing ADHD with bipolar disorder (formerly known as manic depression) is particularly easy—and dangerous.
Several symptoms of mania are similar to those of ADHD, especially the hyperactive and impulsive set of symptoms. People with both bipolar disorder and ADHD, for instance, tend to leap without looking, interrupt others in conversation, and have difficulty sleeping. Both disorders also run in families, although that’s much more common with ADHD.
For help in understanding this controversial issue, I turned to the psychologist Stephen Hinshaw, a best-selling author, longtime researcher, and leading expert in both of these conditions. As he explained, the main problem comes when doctors see ADHD when it’s really bipolar disorder, and prescribe stimulants. Stimulants can be effective for ADHD, but in some cases lead to psychosis in people with bipolar disorder. An additional problem is the high risk of suicide attempts in people with untreated bipolar disorder—up to 50 percent will attempt it at some point in their lives.
On the other hand, particularly over the past 15 years, doctors have also made the reverse mistake, diagnosing bipolar disorder in cases of serious ADHD, and thus depriving people who might be helped by stimulants, while also imposing needless side-effects of the antipsychotic drugs.
Complicating matters, says Hinshaw, is that for much of clinical history, doctors believed that bipolar disorder didn’t exist before puberty, beginning only in late adolescence or early adulthood. In the early 1990s, however, a few investigators argued that it can and does show up in kids, where it is often mistaken for ADHD. A complication is that in both disorders, medications are often overprescribed, while at the same time many people in need of treatment never get help.
The takeaway for this era of rising ADHD diagnoses is that doctors, patients, and parents need to keep in mind that diagnoses can’t be made casually—i.e. in the limited time currently provided by most insurance plans. Doctors need time to fill in a life history, not only by the patient but by parents or others, whose judgment presumably wouldn’t be impaired by those symptoms. Understanding someone’s life course is particularly important in this case, since the key difference between these two disorders is that ADHD is chronic and always present, while bipolar disorder is episodic, marked by extreme highs and lows.
This process takes time and attention—both elements in ever-shorter supply in our harried times. Here’s hoping the Obamacare health reforms will allow for more careful differentiation.