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By Madison Avenue TMS & Psychiatry - March 28, 2025
As its name suggests, bipolar disorder presents itself as a pairing of opposites: People who suffer from the mental health condition experience major depressive episodes offset by periods of manic or hypomanic behavior.
These manic or hypomanic episodes are marked by persistently elevated, expansive or irritable moods that disrupt one’s ability to function and are noticeable by others. They typically last for several days or even weeks — yet they may go years without resurfacing.
“Bipolar disorder is a very serious illness that is tricky to diagnose,” says Dr. David Woo, owner and head clinical psychiatrist at Madison Avenue TMS and Psychiatry in New York. “Most people with bipolar are initially misdiagnosed with major depression because people don’t recognize or don’t ask them about mania or hypomania. All it takes is one episode to make you bipolar.”
Formerly known as manic depression, bipolar disorder affects an estimated 11.5 million American adults at some point in their lives. It’s typically diagnosed as one of three types based on its severity:
- Bipolar I, defined by manic episodes that last at least seven days, usually accompanied by depressive episodes
- Bipolar II, defined by less severe hypomanic episodes
- Cyclothymic disorder, or cyclothymia, defined by a recurring cycle of hypomanic and depressive symptoms that are less intense or long-lasting, so they do not meet the clinical threshold for manic or depressive episodes
In a Q&A session, Dr. Woo spoke about how the condition presents, how it’s treated and why the manic half of the condition is especially difficult to address.
Q: You say that bipolar is both overdiagnosed and underdiagnosed. Can you explain?
A: It’s underdiagnosed in the regular practice of treating people with depression, resulting in people being put on antidepressants who shouldn’t be. It’s overdiagnosed in certain patients who have had substance-use problems, because when people are using alcohol or cocaine, there are changes in mood that can resemble bipolar disorder. So a lot of people — young people especially, who may do a lot of partying or using drugs and have mood changes — may be diagnosed quickly as bipolar if the clinician doesn’t flesh out all their substance-use issues, or if the patient doesn’t reveal them.
Also, patients who have a personality disorder are often misdiagnosed as bipolar disorder — especially something like borderline personality, where there are elements of mood elevation. They have very intense emotions that can resemble bipolar disorder.
Can you give an example or two of how a manic episode might present?
A manic episode might look like someone who one day becomes very religious. Their friends notice that the patient is talking more rapidly, and they’re staying up late. They’re sleeping less. They’re getting a lot done, but it’s kind of out of control, and they start changing their views about themselves. The patient is telling people that he is there to send a message from God. And pretty soon everyone notices that this patient is not getting his work done, not taking care of himself, looking ragged and calling people up at all hours of the night. That’s the typical bipolar I picture.
Bipolar II is similar. There’s a distinct time period when the patient has elevated energy, irritability and mood. There’s rapid thinking, rapid speech, less need for sleep and more productivity. But they’re still functional. Usually their hypomania is in the service of projects that make sense to the outside world, but it’s unusual for them.
These things are nuanced. You have to know the patient, usually more than just over the course of one hour. You have to talk to them over time to discern a pattern.
What are some of the standard treatments for bipolar, and what’s new and promising along those lines?
The standard treatment is the combination of mood stabilizers for the manic or hypomanic symptoms and antipsychotics for the depressive episodes.
Supportive cognitive behavioral psychotherapy can play a big role in helping bipolar patients be aware of their symptoms, learn how to recognize them and know how to get help when they need it. It can help them adopt good practices in their life like getting enough sleep and avoiding triggers like substances, conflicts with people or being under a lot of stress.
In general, it’s thought that people with bipolar disorder need to be on medications, whereas that may not be true for people with major depressive disorders. They often respond well to psychotherapy, exercise, changes in their circumstances, things like that.
When do you recommend transcranial magnetic stimulation (TMS) as a course of treatment for bipolar disorder?
It’s not FDA-approved for bipolar, so nobody will cover it. I’ve had people who are bipolar pay out of pocket for TMS.
I recommend it only if someone’s on a mood stabilizer. That way, I feel confident that they won’t be triggered into a manic episode, because anything that treats depression has the potential to trigger hypomania or mania.
Likewise, I wouldn’t feel comfortable giving an antidepressant to a bipolar patient without having something else on board to catch them if they become manic or hypomanic.
What are the success rates that you see in terms of treating bipolar? And what does success mean?
Success is either having a response or remission.
With the depression side, if someone has never been on medication, there’s a two-thirds chance you’ll have at least some sort of response, and half of that 67% will go into remission.
It’s the manic or hypomanic aspects that complicate things. When it comes to treatment, it’s not about whether the medications are successful, but rather the side effects you are willing to accept. I can give someone enough mood stabilizers that they’re bedbound for 16 hours. They’re not manic anymore, but they’re also not functional. People have to go along with their lives. So there’s this constant struggle of titrating their medications so they can function without having too many intrusive mood symptoms.
The other thing that people don’t talk about is that mania feels good. Hypomania feels good. People don’t necessarily want to get out of it once they’re in. It’s hard sometimes to convince them to take medication. By contrast, people who are depressed or miserable don’t want to be depressed, so they’ll take anything you give them.
It’s this complicated dance. You have to work with bipolar patients to take something that will control their symptoms but not be too intrusive on their life. There has to be a real team effort with everyone around to get treatment for the patient. ⧫
Contact us online or call (212) 731-2033 to learn more about our bipolar disorder services and take the first step toward conquering a challenging condition.
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