People with bipolar disorder often experience many forms of stigma, including stigma from healthcare providers and self-stigma. Nurse practitioners can benefit from learning how stigma can be a barrier to patients with bipolar disorder receiving appropriate diagnosis and care. This activity will dispel common myths about bipolar disorder and teach you how to correct these false beliefs to provide supportive, high-quality care for your patients.
LC: Hi, everyone! My name is Linda Cabage, and I work as a psychiatric mental health nurse practitioner in Maryville, Tennessee.
JK: I’m Joan Kitten, and I’m a nurse practitioner with Berryhill Center for Mental Health in Fort Dodge, Iowa.
Thank you for joining Linda and me today as we discuss the role of stigma as a barrier to people with bipolar disorder receiving an appropriate diagnosis. People with bipolar disorder often wait an average of 10 years from the onset of symptoms to finally receive the correct diagnosis.1
LC: One of the reasons for diagnostic delay is stigma—including stigma from society, from healthcare providers, and stigma that patients may have toward themselves.2 Stigma is a serious problem, but it’s a manageable one.
Today’s podcast will focus on the stigma that can affect bipolar disorder diagnosis specifically and how nurse practitioners can overcome this to ensure patients receive an appropriate diagnosis. Let’s start by discussing what stigma is and addressing some facts about how it plays a role in the lives of people with bipolar disorder.
Facts About Stigma in Bipolar Disorder
JK: Stigma refers to the feelings of shame and disapproval that people can have about a particular person, circumstance, or characteristic.3 Examples that most people are familiar with include stigma directed at individuals with physical disabilities or at people of diverse ethnic backgrounds. Stigma around psychiatric disorders is common and can lead to negative stereotyping, biases, and discrimination of people with mental illness.3,4 Patients with mental disorders, including those who have bipolar disorder, may experience alienation, social withdrawal, and lower quality of life as a result of stigma.4 Stigma about mental health is often the result of fear or misunderstanding. Harmful, inaccurate representations of psychiatric conditions in the media also can lead to fear and stigma.5
LC: An important aspect of stigma is that it can be self-directed. With self-stigma, patients with mental illness internalize negative beliefs and attitudes about themselves due to their illness, which can impede seeking help for their condition.3 These could be beliefs such as “I am crazy,” “I’ll never get better,” or “No one can help me.” Self-stigma is associated with several negative outcomes, such as worsening depression, lowered self-esteem and self-confidence, reduced empowerment, and an increase in perceived devaluation and discrimination.2,4
JK: What about the community or the general public’s stigmatizing attitudes and behaviors toward people with mental illness?
LC: Those too can impact patients negatively, particularly in the form of stereotypes, prejudicial thoughts and behaviors, and discrimination.4 Stereotypes are generalized beliefs about a group, ignoring individuals’ unique characteristics.6 Prejudices refer to negative emotional reactions and attitudes, such as fear or anger, that are based on one’s membership in a particular group.6 Discrimination is a behavioral response to prejudice, such as avoiding people with psychiatric disorders out of fear.6
JK: Let’s talk a little about the consequences of stigma. There’s robust literature on stigma in mental health, and we know that stigma can contribute to poorer health outcomes and increased risk of suicide in some patients with mental illness.3 The stigma toward people with bipolar disorder in particular has been associated with the loss of social support, reduced functioning, and poorer quality of life.4
One of the broad effects of stigma on bipolar disorder patients is that it can be an everyday challenge for some patients.4 Further, stigma affects the experience of illness in patients with bipolar disorder. For instance, it can lead to treatment nonadherence and result in poor symptom management.4
LC: The final form of stigma, and the one that we will discuss the most today, is stigma that comes from healthcare providers.3 I think sometimes this can be hard to talk about because as healthcare providers, we want to believe that we don’t engage in these types of beliefs or behaviors. However, we are human too, and we are vulnerable to stereotypes and biases just like anyone else. Stigma from healthcare providers can affect our ability to recognize symptoms and diagnose patients appropriately.3 This is why identifying and removing stigma among healthcare providers is so important to the care of patients with bipolar disorder.
Let’s shift the conversation and talk about common myths of bipolar disorder diagnosis that contribute to nurse practitioners’ stigma and, importantly, what we can do to combat the issue.
Myth #1: People with Bipolar Disorder Are Easy to Diagnose.
JK: One common myth about bipolar disorder is that it is easy to diagnose because patients usually present as manic, and manic episodes are highly recognizable. This is untrue and could lead to nurse practitioners being less vigilant about looking for possible bipolar disorder, especially in patients who do not appear floridly manic. At least half of patients with bipolar disorder present for care during a depressive episode, not a manic episode; as a result, patients with bipolar disorder are frequently misdiagnosed as having major depressive disorder, or MDD, instead.1 Overlooking and undertreating psychiatric illness, even if inadvertent and due to a lack of knowledge, is a subtle and unintentional form of healthcare provider stigmatization that ultimately prevents patients from receiving the care they need.3
LC: Perhaps some nurse practitioners expect patients with bipolar disorder to “stand out” somehow, maybe by behaving a certain way? In reality, though, bipolar disorder is very tricky to diagnose.
JK: That’s right, and there are several reasons for that. First, as I just said, patients typically present to healthcare settings during a depressive episode.1 A depressive episode in bipolar disorder has identical diagnostic criteria as a depressive episode in MDD, which underscores the importance of taking a thorough history for mania and hypomania.7
The NP Psych Navigator website has convenient, printable scales that can be used by healthcare providers to screen patients with depressive symptoms for bipolar disorder, as well as quick guides on how to use these scales in practice. I recommend that nurse practitioners review these scales so they are familiar with them and can integrate them into their practice when assessing patients presenting with depressive symptoms.
Another reason bipolar disorder can be so challenging to detect is that not all nurse practitioners are thoroughly familiar with the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)'s diagnostic criteria for bipolar disorder, which are lengthy. Knowing the criteria is key to making a correct diagnosis and making differential diagnoses, including knowing when a patient has experienced mixed mood episodes, as defined by the DSM-5’s “mixed features” specifier.7
Myth #2: Bipolar Disorder Is Rare and Unlikely to Be Seen in Your Practice.
LC: Another myth that affects bipolar diagnosis is that bipolar disorder is rare and not likely to be seen in your practice. This again could cause nurse practitioners to have a decreased sense of awareness for bipolar disorder in their healthcare setting, which might make them less amenable to screening patients for or asking them about their history of bipolar disorder. As we noted earlier, delayed care is a subtle form of healthcare provider stigma. I would strongly caution nurse practitioners against making this assumption, especially if you’re working in primary care or family medicine. Bipolar disorder is not uncommon, and many people with bipolar disorder present to primary care rather than to specialty care for their treatment needs.1
Furthermore, you should have an increased awareness for bipolar disorder in these settings because these patients frequently experience comorbid conditions that are also likely to appear in primary care—namely anxiety disorders and substance abuse.1,8,9 Patients presenting with such issues may benefit from evaluation for bipolar disorder.
JK: I would go a step further and say that all patients who present with depressive symptoms should be considered for a bipolar disorder diagnosis.1
LC: Can you expand on that a little more?
JK: The prevalence of patients with depression in primary care is moderately high, with an estimated range of 15% to 23% in some studies.10 Imagine how many of those patients might actually have bipolar disorder instead. In the National Institute of Mental Health’s Collaborative Depression Study, about one-quarter of patients initially diagnosed with MDD turned out to have bipolar I or bipolar II disorder.11
Patients with depressive symptoms can be further screened with a validated scale for bipolar disorder, such as the Mood Disorder Questionnaire, or MDQ.12 Although it is not diagnostic, the MDQ can alert you to a patient who should be further evaluated for a possible bipolar diagnosis. The Rapid Mood Screener, or RMS, is another validated measure that was designed specifically to screen for bipolar I disorder—especially in patients who exhibit depressive symptoms and thus may be potentially misdiagnosed with MDD instead.13
LC: I agree—and it’s not burdensome, in terms of your clinical workflow, to give patients something brief like the MDQ or RMS, each of which can take less than 5 minutes for most patients to complete themselves.
Myth #3: Patients with Bipolar Disorder Cannot Be Helped or Treated Outside of Specialty Care.
LC: This next myth is a particularly damaging one—that patients with bipolar disorder cannot be treated or helped in nonspecialty settings, such as primary care clinics. This negative belief is stigmatizing because it marginalizes people living with bipolar disorder, it undermines their ability to set and reach treatment goals, and it gives the impression that they are too difficult to manage. Although bipolar disorder is a complex condition for both nurse practitioners to manage and for patients to live with, by no means are people with bipolar disorder too complex to help. There are multiple safe, effective pharmacologic and nonpharmacologic treatments to help patients in primary care and other nonspecialty treatment settings to help manage the symptoms and improve their functioning, including medications that have been approved by the Food and Drug Administration (FDA) specifically for bipolar I depression and mania.1,12 Nonpharmacologic treatments, such as cognitive-behavioral therapy, can help patients cope more effectively with their illness, improve their symptoms, develop and maintain a support system, and enhance their quality of life.1,12
JK: That’s right. Even though there is no ‘cure’ for bipolar disorder, there are numerous tools that primary care providers and other providers not working in psychiatric clinics could use to help patients improve their symptoms and make their illness more manageable. However, when nurse practitioners buy into this myth, they may be less likely to seek out and offer patients these tools. Along those lines, there are also patient advocacy and support groups to help patients and their loved ones better understand and cope with this diagnosis.12 For instance, the National Alliance on Mental Illness and the Depression and Bipolar Support Alliance are 2 well-known patient advocacy groups that offer both patients and their loved ones access to resources and support. Again, without healthcare providers acknowledging that these resources exist and are beneficial, patients and families could be less likely to learn about and access them.
Supporting Patients and Overcoming Stigmatizing Myths
JK: Up to now, we have been focused on identifying the problem of stigma among patients with bipolar disorder, but we also need to discuss what we as nurse practitioners can do about stigma, starting with how best to support patients with bipolar disorder. What are some helpful ways you have been able to support your patients?
LC: A couple of things come to mind. First, facilitating follow-up with patients is key. This is crucial for any chronic illness, including bipolar disorder, and can reduce the risk of patients “falling through the cracks” of the healthcare system. What do I mean by facilitating follow-up? Call patients and make sure they have an appointment for a medication check. If collaboration with another colleague such as a psychiatrist is needed, and if possible, facilitate a “warm handoff” to ensure the patient gets connected with the healthcare provider rather than just giving them the provider’s phone number. Make sure the patient knows when their next appointment with you is, and emphasize the importance of keeping that appointment. Ask whether they filled the prescription you gave them, and make sure they know how to take their medication appropriately. Find out if they have any questions or concerns about the next step of care, and if they do, be sure to address those.
Next, it is helpful if you can establish ties with a network of psychiatric specialists in your area who you can refer patients to, as well as create a network of community support services you can connect patients with.1 Such services include those for collaborative management when disruptive manic behavior or suicidality is involved. In reality, this step can be difficult, especially given that some communities have scarce resources, and since the pandemic, resources in certain areas are even scarcer. However, it’s important to do what you can to connect with whatever resources you do have available so you can help patients leverage those as much as possible.
JK: That’s a good point. Resources for psychiatric consultation will probably be needed for complex cases, such as with patients who do not respond appropriately to antidepressant treatment or those with comorbid mental disorders, like substance abuse.
JK: How do you think education factors in with supporting patients?
LC: I think it plays a big role. The American Psychiatric Association recommends providing patient and family education as part of good psychiatric management in their practice guidelines for bipolar disorder.12 This education can cover things like diagnosis, prognosis, and treatment options; the fact that bipolar disorder is a chronic disease that will require long-term management; and support groups and resources for patients and their family members.12 Such materials can be found on the NP Psych Navigator website, including patient-directed education pieces that are easily understandable for non-healthcare providers.
I think supporting patients can help them overcome these stigma barriers in part, but there are specific things that healthcare providers can do to combat these myths head-on. Can you talk a little about the stigma-fighting strategies that nurse practitioners can use?
JK: Sure. I think we can make significant headway in fighting these misconceptions through 3 basic steps: know the facts, know yourself, and listen to your patients.
When I say “know the facts,” I am referring to ensuring you understand what bipolar disorder is and what it is not—all the things we have talked about here today. This also means learning about patients’ experiences with stigma and how that has impacted them, as well as knowing the facts about bipolar disorder.3 Nurse practitioners can learn more about bipolar disorder through materials on the NP Psych Navigator website and through professional development activities focused on bipolar disorder, including Continuing Medical Education programs and grand rounds lectures.
Next, I would recommend spending time getting to know yourself. Take an honest inventory of your beliefs and attitudes toward people with bipolar disorder, and be direct about any biases you hold, including implicit biases.3 There are screening tools designed to help people assess their own stigmas regarding mental disorders.
For instance, all healthcare providers can take the Attitudes to Mental Illness Questionnaire. There is also the Social Distance Scale, which is a modified version of the original from Gureje and colleagues that measures feelings toward people with mental illness.3
LC: Perfect. Our listeners should be sure to check out the links to these measures in our show notes.
JK: Lastly, I recommend that as a nurse practitioner, you spend more time learning from your patients. The more you talk with and work with patients with bipolar disorder, the more you will learn about the disease and the diversity of people living with it. This can help shut down stereotypes and bigoted beliefs about people with this condition.
LC: Also, meeting patients who are thriving is a good reminder that, for many people with bipolar disorder, managing their symptoms is possible. That’s a vital message for nurse practitioners to internalize and pass on to patients and their families, so they too can develop a sense of hope and optimism for the future.
JK: This has been a lengthy discussion, but we hope it has been an informative one and perhaps has made you think about what bipolar disorder stigmas you might currently have and how you can combat those.
LC: I think the main take-home messages from today’s discussion are that people with bipolar disorder often experience stigma from several sources, including nurse practitioners, which can lead to delayed diagnosis and treatment. Second, learning some common myths about bipolar disorder and its diagnosis can help you fight stigma and ensure patients get the care they need. Lastly, addressing your own biases and misconceptions toward these patients is a lifelong pursuit, and there are multiple strategies to help you identify and mitigate harmful beliefs and behaviors.
JK: I think that’s a great summary to end on. I’d like to thank my colleague, Linda, for joining this discussion, and thanks to all of you for listening. Take care!
Joan Kitten, ARNP
Joan Kitten received her BSN from the University of Iowa and MS from the University of Oklahoma. She has a dual certification as a psychiatric mental health nurse practitioner and as a family practice nurse practitioner. Ms Kitten has worked as a nurse practitioner in Iowa for the past 20 years. She is a former adjunct faculty member with the mental health nurse practitioner program at Allen College. Ms Kitten is an ongoing guest lecturer with Mercy Medical Center’s residency program. Ms Kitten is an assertive community treatment prescriber and works as a primary care provider embedded in community mental health. She has a special interest in the care of older adults as well as all adults with serious and persistent behavioral and physical health concerns.
Linda Cabage, APRN
Linda Cabage is a board-certified psychiatric-mental health nurse practitioner in Maryville, Tennessee, a suburb of Knoxville. After graduating from the University of Tennessee, Linda worked in community mental health before starting her own private practice, where she has continued to see patients of all ages for the past 10 years and provides medication management and psychotherapy. She worked as a registered nurse in oncology, geriatrics, and mental health before becoming a nurse practitioner. Her additional interests include complementary and alternative medicine, cultural awareness, care equity for marginalized groups, particularly LGBTQ+ populations, and academic research. She is currently a PhD candidate investigating the effects of the COVID-19 pandemic on nurse practitioners providing care to patients via telehealth. Linda enjoys gardening, cooking, reading, spending time with 2 young adult sons, traveling with her husband, and being manipulated by their 2 yellow tabby cats.
- Rolin D, Whelan J, Montano CB. Is it depression or is it bipolar depression? J Am Assoc Nurse Practit. 2020;32(10):703-713.
- Stiles BM, Fish AF, Vandermause R, Malik AM. The compelling and persistent problem of bipolar disorder disguised as major depression disorder: an integrative review. J Am Psychiatric Nurses Assoc. 2018;24(5):415-425.
- Conklin TM. Mental illness stigma: strategies to address a barrier to care. Women’s Healthcare. 2021;4(2):16-20.
- Hawke LD, Parikh SV, Michalak EE. Stigma and bipolar disorder: a review of the literature. J Affect Disord. 2013;150(2):181-191.
- American Psychiatric Association. Stigma, prejudice and discrimination against people with mental illness. 2020. Accessed September 17, 2022. https://www.psychiatry.org/patients-families/stigma-and-discrimination
- Worthy LD, Lavigna T, Romero F. Culture and Psychology: How People Shape and are Shaped by Culture. Maricopa Open Digital Press; 2020. Accessed September 17, 2022. https://open.maricopa.edu/culturepsychology/open/download?type=pdf
- Bobo WV. The diagnosis and management of bipolar I and II disorders: clinical practice update. Mayo Clin Proc. 2017;92(10):1532-1551.
- Love AS, Love R. Anxiety disorders in primary care settings. Nurs Clin North Am. 2019;54(4):473-493.
- Pace CA, Uebelacker LA. Addressing unhealthy substance use in primary care. Med Clin North Am. 2018;102(4):567-586.
- Cho SH, Crisafio A. Depression and primary care: a review of the prevalence, burden, costs, screening, and treatment strategies. J Psychiatry Behav Health Forecast. 2018;1(1):1-4.
- McIntyre RS, Calabrese JR. Bipolar depression: the clinical characteristics and unmet needs of a complex disorder. Curr Med Res Opinion. 2019;35(11):1993-2005.
- American Psychiatric Association. Practice Guideline for the Treatment of Patients with Bipolar Disorder. 2nd ed. American Psychiatric Association; 2002. Accessed September 17, 2022.
- McIntyre RS, Patel MD, Masand PS, et al. The Rapid Mood Screener (RMS): a novel and pragmatic screener for bipolar I disorder. Curr Med Res Opin. 2021;37(1):135-144.
NP Psych Navigator is sponsored by AbbVie Medical Affairs. The contributors are paid consultants for AbbVie Medical Affairs and were compensated for their time.
This resource is intended for educational purposes only and is intended for US healthcare professionals. Healthcare professionals should use independent medical judgment. All decisions regarding patient care must be handled by a healthcare professional and be made based on the unique needs of each patient.
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