Sidra Gebirrebbi
September 1st, 2025
Edited by the YNPS Publications team.
Abstract
Bipolar disorder is a serious mood disorder that often begins in adolescence, yet is continuously misdiagnosed or undiagnosed in this population. One of the central challenges in identifying bipolar disorder in adolescents is its clinical similarity to other psychiatric conditions, especially attention-deficit/hyperactivity disorder (ADHD) and unipolar depression. The overlapping symptoms, such as irritability, mood swings, impulsivity, and difficulty concentrating, can obscure the underlying bipolar presentation. This paper reviews existing research and clinical case studies that explore these diagnostic difficulties, emphasizing how symptom misinterpretation can delay or prevent proper treatment. Key findings reveal that misdiagnosis can lead to inappropriate interventions, worsening clinical outcomes, and increased risk of self-harm. This paper concludes with a discussion of practical strategies to improve early detection, including clinician education, standardized diagnostic tools, and careful evaluation of symptom history and family context.
Introduction
Bipolar disorder is a chronic psychiatric illness characterized by alternating episodes of depression and mania or hypomania. While traditionally associated with adults, research shows that the onset of bipolar symptoms often occurs during adolescence, with early manifestations that are frequently subtle, episodic, or mistaken for other disorders. Studies even suggest up to 60% of adult patients with bipolar disorder experienced their first symptoms before the age of 21 (Birmaher, 2021).
Many teenagers with bipolar disorder are initially misdiagnosed with depression or attention-deficit/hyperactivity disorder (ADHD), partly because these conditions share similar symptoms. For example, mood changes, lack of focus, and irritability are common in both ADHD and bipolar disorder, making it harder for clinicians to tell them apart.
This paper aims to explore how and why these misdiagnoses occur. Instead of collecting new data, it draws from several published case studies and reviews to highlight common patterns, challenges, and clinical insights. Understanding these issues is important because the wrong
diagnosis can lead to treatments that don’t work or even make symptoms worse. With better awareness and more careful evaluation, early diagnosis and support for adolescents with bipolar disorder can be improved.
Background
Adolescence is a period of significant emotional, cognitive, and behavioral development, which can make it especially difficult to distinguish between typical teenage behavior and early signs of psychiatric illness. In the case of bipolar disorder, symptoms such as emotional instability, impulsive decisions, changes in sleep patterns, and irritability are sometimes dismissed as normal adolescent moodiness or misunderstood as disciplinary issues. Unlike adults, adolescents with bipolar disorder often present with more rapid mood fluctuations, mixed episodes, or symptoms that do not clearly align with either mania or depression.
Another factor that complicates diagnosis is the way symptoms are communicated and observed. Teenagers may struggle to describe their emotional experiences accurately, and parents, teachers, or caregivers may not interpret changes in behavior as signs of a mood disorder. In some cases, young people with bipolar disorder can still maintain school performance or social relationships, which may further delay recognition of an underlying condition.
Although awareness of pediatric bipolar disorder has grown, there is currently no single biological test or marker that can confirm the diagnosis. Instead, clinicians rely on clinical judgment, symptom tracking, and longitudinal observation. These methods require time, careful assessment, and collaboration between the patient, family, and healthcare provider. Inconsistent access to mental health services and varying levels of clinician experience can contribute to delays or errors in diagnosis. As a result, many adolescents do not receive appropriate treatment until symptoms have significantly progressed.
Literary Findings
A study that directly addressed the misdiagnosis in youth found that bipolar disorder is significantly underdiagnosed, while ADHD is frequently overdiagnosed (Chilakamarri, Filkowski, & Ghaemi, 2011). In a sample of 64 children and adolescents aged 7 to 18, researchers found that only 38% of those with bipolar disorder had actually received the correct diagnosis. In contrast, ADHD was diagnosed even in patients without clear signs of the condition, including 29% of them with bipolar disorder and 38% with depression. The results suggest that clinicians are more likely to interpret symptoms like mood swings or restlessness as signs of ADHD rather than bipolar disorder, especially when there is no family history of bipolar disorder. These findings highlight the diagnostic confusion that occurs when overlapping symptoms lead to assumptions instead of thorough clinical assessment.
In addition, studies over decades show little improvement in diagnostic accuracy. Surveys conducted in 1994 and 2000 revealed that approximately 69% of individuals with bipolar
disorders were originally misdiagnosed, with over one-third remaining incorrectly diagnosed for ten years or longer (Lish et al., 1994; Hirschfeld, Lewis, & Vornik, 2003). A European survey involving 1,000 people with bipolar disorder reported an average delay of 5.7 years from initial misdiagnosis to correct diagnosis (Morselli & Elgie, 2003). Another study found that patients remain misdiagnosed on average 7.5 years before receiving an accurate diagnosis (Ghaemi et al., 1999). These findings underscore the persistent challenge of timely and accurate identification of bipolar disorder, which can critically impact treatment and patient outcomes.
This diagnostic challenge is further complicated by the considerable symptom overlap between bipolar disorder and ADHD, both of which typically begin in childhood or early adolescence and are often undiagnosed or misdiagnosed. The symptoms of ADHD and bipolar disorder (BD), especially during hypomanic or manic phases of BD, are very similar. Both conditions can manifest as hyperactivity, distractibility, impulsivity, irritability, racing thoughts, rapid speech, and restlessness. (Edinoff et al., 2021; Nierenberg et al., 2005; Zaravinos-Tsakos & Kolaitis, 2020). This symptom overlap complicates diagnosis, especially as ADHD symptoms are generally persistent, while BD symptoms tend to be episodic.
Comorbidity (presence of two or more diseases in a patient) rates are substantial: about 20% of children with ADHD are later diagnosed with bipolar disorder, and BD with comorbid ADHD is linked to a more severe illness course, including earlier onset and shorter intervals between episodes (Franke et al., 2018; Edinoff et al., 2021; Nierenberg et al., 2005). Epidemiologically, approximately 1 in 6 BD patients also have ADHD, and about 10% of ADHD patients develop BD over their lifetime (Brancati et al., 2021; Sandstrom et al., 2021). Prevalence of ADHD within BD patients is highest in childhood (73%) and decreases with age (Sandstrom et al., 2021).
Genetic studies support a shared vulnerability, with relatives of BD patients showing increased ADHD rates and vice versa, and up to 33 genetic loci implicated in both disorders (Faraone et al., 2012; O’Connell et al., 2021; Fahira et al., 2019; Hitomi et al., 2019; MacArthur et al., 2017). Environmental risk factors such as prenatal maternal stress, substance abuse, and childhood trauma are also linked to both ADHD and BD (Marangoni et al., 2016; Sciberras et al., 2017; Manzari et al., 2019; Perez Algorta et al., 2018; Brown et al., 2017; Agnew-Blais & Danese, 2016).
The developmental trajectory of ADHD varies, influenced by neurobiological factors and comorbidities. Several neurodevelopmental models explain symptom persistence or remission from childhood through adolescence, highlighting that conduct problems and early comorbidities may increase the risk of developing bipolar disorder later (Biederman et al., 2010; Faraone et al., 2006; Song et al., 2021; Shaw & Sudre, 2021; Faedda et al., 2014).
Overall, the clinical, genetic, and environmental overlaps between ADHD and bipolar disorder highlight the complexity of differentiating these disorders, underscoring the importance of careful assessment to improve diagnostic accuracy and treatment outcomes.
Impact of Misdiagnosis
Misdiagnosis of bipolar disorder significantly complicates its management by delaying needed treatment and increasing the risk of recurrent and chronic episodes (Bowden, 2005; Hirschfeld & Vornik, 2004). The most common misdiagnosis is unipolar depression, which can lead to inappropriate use of antidepressants. This treatment approach is problematic because antidepressants may trigger manic episodes and promote rapid cycling in bipolar patients (Ghaemi, Lenox, & Baldessarini, 2001; Calabrese et al., 1999; Altshuler et al., 1995).
One study found that among bipolar patients initially diagnosed with unipolar depression, 55% later developed mania and 23% experienced rapid cycling (Ghaemi et al., 2001). Furthermore, Wehr and colleagues (1988) showed that in more than half of rapid cycling bipolar patients, antidepressant use was linked to continued cycling, and nearly three-quarters were on antidepressants when rapid cycling began. These patients often first presented only depressive symptoms, which likely contributed to the misdiagnosis and the use of antidepressant monotherapy.
Delays in starting mood stabilizers not only worsen clinical outcomes but are also associated with increased healthcare costs, higher rates of hospitalization, and greater suicide risk (Li, McCombs, & Stimmel, 2002; McCombs, Thiebaud, & Shi, 2003; Cooke, Robb, Young, & Joffe, 1996). The lifetime risk of suicide attempts among individuals with bipolar disorder ranges from 25 to 50%, significantly higher than in unipolar depression, with most suicides occurring during depressive episodes (Jamison, 2000).
Conclusion
In light of the persistent challenges and serious consequences associated with the misdiagnosis of bipolar disorder, particularly when it is mistaken for conditions like unipolar depression or ADHD, it becomes clear that accurate and timely diagnosis is essential. Research consistently shows that delays in correct identification can lead to inappropriate treatment, extended emotional distress, and poorer long-term outcomes. Ensuring that bipolar disorder is recognized early is not just a clinical priority but a necessary step toward improving patients’ quality of life.
Patients and their families play a key role in this process. Maintaining thorough records of mood changes, sleep disturbances, and behavioral shifts offers clinicians a more comprehensive understanding of the patient’s condition. Involving family members or close friends in discussions with healthcare providers can be valuable, as they might observe patterns or symptoms the patient may overlook. Open communication about all symptoms ensures a more accurate and well-rounded assessment.
When uncertainty arises, asking for clarification or seeking a second opinion from a mental health professional with experience in mood disorders can make a significant difference. Recognizing the subtler signs of bipolar II disorder, such as hypomanic episodes without psychosis or the need for hospitalization, is crucial, as these symptoms are frequently overlooked or misunderstood.
Educating oneself about bipolar disorder empowers patients to better understand their condition, engage meaningfully in the diagnostic process, and advocate for the care they need. Through active participation, informed communication, and increased clinical awareness, the risk of misdiagnosis can be meaningfully reduced.
References
Bipolar Disorder: Why It’s Often Misdiagnosed – Child Mind Institute. (2025, March 4). Child Mind Institute.
https://childmind.org/article/bipolar-disorder-difficult-to-diagnose-in-adolescents/ Birmaher, B. (2013). Bipolar disorder in children and adolescents. Child and Adolescent Mental Health, 18(3), 140–148. https://doi.org/10.1111/camh.12021
Bowden, C. L. (2001). Strategies to Reduce Misdiagnosis of Bipolar Depression. Psychiatric Services, 52(1), 51–55. https://doi.org/10.1176/appi.ps.52.1.51
Chilakamarri JK;Filkowski MM;Ghaemi SN. (2015). Misdiagnosis of bipolar disorder in children and adolescents: a comparison with ADHD and major depressive disorder. Annals of Clinical Psychiatry : Official Journal of the American Academy of Clinical Psychiatrists, 23(1). https://pubmed.ncbi.nlm.nih.gov/21318193/
Comparelli, A., Polidori, L., Sarli, G., Pistollato, A., & Pompili, M. (2022). Differentiation and comorbidity of bipolar disorder and attention deficit and hyperactivity disorder in children, adolescents, and adults: A clinical and nosological perspective. Frontiers in Psychiatry, 13. https://doi.org/10.3389/fpsyt.2022.949375
Singh, T., & Rajput, M. (2006). Misdiagnosis of Bipolar Disorder. Psychiatry (Edgmont), 3(10), 57. https://pmc.ncbi.nlm.nih.gov/articles/PMC2945875/#B12
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