Bipolar disorder is a lifelong disorder. Longitudinal studies have shown that the course of bipolar disorder tends to worsen over time and that early intervention can improve long-term outcomes. As the first step to effective treatment, an accurate diagnosis requires the identification of manic or hypomanic episodes. However, the fact that patients often do not view and recall mania or hypomania as pathological leads to missed opportunities to identify and diagnose their mania and hypomania. Bipolar disorder tends to start with depression rather than mania, so even when one accurately identifies a patient’s mania, one may miss the initial stages of bipolar disorder. With the fuller understanding of the above problems, the recognition of bipolar disorder and its precursor manifestations has been greatly improved. A, the prevalence of bipolar disorder and prevention status (a) bipolar disorder prevalence 1, foreign bipolar disorder prevalence Western developed countries in the 1970s-80s epidemiological surveys show that the lifetime prevalence of bipolar disorder is 3.0-3.4%, the 1990s rose to 5.5-7.8%, Goodwin et al (1990) reported that the prevalence of bipolar I type is 1.0% Goodwin et al. (1990) reported a prevalence of 1.0% for bipolar I, 3.0% for bipolar I combined with bipolar II, and over 4.0% if cyclothymic disorder is added. The peak age of onset of bipolar disorder is 15-19 years old, and the first episode is mostly depressive. The prevalence of bipolar disorder is similar between males and females. 25-50% of patients with bipolar disorder have experienced suicidal behavior, and 11-19% have died by suicide. 2, the epidemiological situation of bipolar disorder in China At present, there is a lack of systematic investigation on the epidemiological problems of bipolar disorder in China. From the available information, it seems that the prevalence rates obtained from epidemiological surveys of bipolar disorder in different regions of China vary widely. For example, a collaborative survey in 12 regions of mainland China (1982) found that the prevalence of bipolar disorder was only 0.042%, and a collaborative survey in 7 regions of mainland China (1993) found that the prevalence of bipolar disorder was 0.083%, while in Taiwan (1982-1987) it was between 0.7-1.6%, and in Hong Kong (1993) it was 1.5% for men and 1.6% for women. In Guangzhou (2006), the point-in-time prevalence of bipolar disorder was 0.28% and the lifetime prevalence was 0.59%. The reasons for the differences: economic and social conditions, mainly the differences in epidemiological survey methods and diagnostic concepts. (2) Current status of prevention and treatment of bipolar disorder The level of prevention and treatment of bipolar disorder has made great progress, but at present, the recognition rate and timely treatment rate of bipolar disorder are still unsatisfactory on a global scale. Statistics from Europe and the United States (Lewis, 2000) show that it takes an average of 8 years after the first definite clinical symptoms of bipolar disorder to be diagnosed; 69% of patients with current bipolar disorder have been misdiagnosed as “monophasic depression”, anxiety disorder, schizophrenia, personality disorder, and substance dependence, etc. The percentage of patients with bipolar disorder receiving treatment is very high. The treatment of patients with bipolar disorder is even less satisfactory. A statistical survey from the United States (1994) found that it took an average of 10 years after the onset of bipolar disorder for patients to receive their first treatment, and more than 50% of patients with the presenting disorder did not receive treatment for more than 5 years, and 36% of them did not receive treatment for more than 10 years. II. Considerations for diagnosing bipolar disorder (a) correctly identified mania or hypomania Finding mania or at least transient hypomania is necessary to diagnose bipolar disorder, but such mania or hypomania is often missed by clinicians or not remembered by patients as a pathological manifestation. However, someone close to the patient may recall the patient’s manic or hypomanic episodes, and those who do not remember their abnormal affective episodes may remember the consequences of these episodes. A sufficiently specific and sensitive diagnostic criterion for the diagnosis of hypomania requires an appropriate definition of the manic syndrome and an appropriate definition of the minimum duration of symptoms. the DSM-IV diagnostic criterion for the diagnosis of hypomania requires that the hypomanic syndrome last at least 4 days, but recurrent episodes of transient hypomania may be a more meaningful diagnostic criterion. If reliable subthreshold mania can be found, then subthreshold mania may be a reliable enough marker for bipolar disorder. Manic episode: A. A period of abnormally high, exuberant, or irritable state of mind lasting at least 1 week; B. During the abnormal state of mind, 3 (or more) of the following symptoms (4 required if the state of mind is only irritable) persist, and the symptoms reach a significant degree: overrated or exaggerated self-esteem, reduced need for sleep, more speech than usual or a feeling of incessant talking, drifting thoughts or subjective experience of thoughts C. The symptoms are so severe that they cause significant impairment of occupational functioning, daily social activities, or interpersonal relationships, or necessitate hospitalization to prevent harm to oneself or others, or have psychotic symptoms; D. The symptoms are not the direct physiological effects of a material or somatic condition. D. The symptoms are not the direct physiological effect of a substance or somatic condition. Mild manic episode: A. A period of abnormally high, exuberant, or irritable state of mind lasting at least 4 days; B. During the abnormal state of mind, three (or more) of the following symptoms (four are required if the state of mind is only irritable) persist, and the symptoms reach a significant degree: excessive or exaggerated self-evaluation, decreased need for sleep, increased speech than usual or a feeling of incessant talking, drifting thoughts or subjective experience of C. The episode is accompanied by definite functional changes that were not present when the patient was asymptomatic; D. The abnormal state of mind and functional changes can be observed by others; E. The episode is not severe enough to cause significant impairment of social or occupational functioning or to necessitate hospitalization; F. The episode is not severe enough to cause significant impairment of social or occupational functioning or to necessitate hospitalization. F. The symptoms are not due to the direct physiological effects of substances or somatic conditions. 1. Signs suggestive of previous manic episodes or hypomania Some signs suggestive of previous manic episodes are listed below. Patients may be able to recall behavioral changes or symptoms that occurred during a manic episode, but are less likely to recall a manic episode with clear boundaries. For example, interpersonal aberrations, including disregard for interpersonal boundaries and disregard for appropriate social limits, may be harmful manifestations of a manic episode. Therefore, clinicians should question patients about situations that are consequences of interpersonal problems, impulsivity, or impaired judgment that accompany manic episodes. Sign 1: Recurrent interpersonal conflicts; Sign 2: Extremely extroverted manner of behavior that leads to trouble; Sign 3: Legal disputes, sexual promiscuity or some other events that may be related to phase impulsivity; Sign 4: Abrupt or frequent occupational or career changes; Sign 5: Severe and/or recurrent major ups and downs in financial situation or rash decisions in financial matters. These signs should be considered in combination with a number of other previous and current clues before making a diagnosis of bipolar disorder. 2. Tools to screen for previous mania or hypomania ① Light mania inventory (HCL-32, Chinese) ② Cyclothymic temperament questionnaire (TEMPS-A, Chinese) ③ Bipolar spectrum disorder diagnostic scale (BSDS, English) ④ Mood disorder questionnaire (MDQ, Chinese) (b) Find bipolar depression Most episodes of bipolar disorder including the first episode are generally depressive in phase, but sometimes such cases of manic episodes can sometimes be missed. However, depressive episodes may be the mainstay of the pathological presentation of bipolar disorder. This section will discuss the prognostic indications for changing the diagnosis to bipolar disorder in patients initially diagnosed with recurrent depression and the differences between bipolar disorder and monophasic depression (referred to as major depressive disorder by the DSM-IV). 1. Predictors of bipolar disorder in adult patients with no known history of mania or hypomania Because depression is often the first episode form of bipolar disorder and its hypomanic episodes are often missed, patients who are initially diagnosed with major depressive disorder may have a revised diagnosis of bipolar disorder. A naturalistic chart review of patient records found that 37% of patients with bipolar disorder had been initially misdiagnosed as major depressive disorder. Two other studies compared patients with a diagnosis of bipolar disorder modified by monophasic depression with another group of patients of the same age who retained a diagnosis of monophasic depression. The authors found that those with a modified diagnosis of monophasic depression to bipolar disorder had a greater number of previous depressive episodes, were more unstable, had a younger age of onset, and had a greater degree of variability in their accompanying psychiatric problems, which they termed a “pleomorphic” form of the disorder. A retrospective study of 320 patients with bipolar disorder found that more than 50% of the patients complained that the initial episode of affective disorder was a depressive episode. Those patients who had their first episode as a manic episode had more episodes of mood disorder, higher rates of rapid cycling, and higher rates of suicidal behavior than those who had their first episode as a manic episode. It is unclear whether those patients who start with a depressive episode do so because their condition is inherently more severe or because they have been on a single antidepressant without a combination of mood stabilizers for years, all of whom have a poorer natural course. For understanding bipolar disorder, it is important to characterize the course of the illness prior to the first manic episode. One retrospective study showed that bipolar disorder starts at a young age and has a high number of depressive episodes. It was found that more than 50% of patients with bipolar disorder had at least 3 depressive episodes before their first manic episode was detected. A follow-up of 74 patients (mean age about 23 years) hospitalized for major depressive disorder after 15 years found that 46% had a manic or hypomanic episode during that time. Similarly, a poll of its members conducted by the National Depressive and Manic Depressive Association (NDPA) found that 59% of respondents had a pre-teen or teenage onset, that the most common prominent symptom was depressed mood, and that the time between the onset of the psychiatric condition and the correct There was a delay of more than 8 years between the onset of the psychiatric condition and the correct diagnosis. All of these studies suggest that bipolar disorder often begins with a depressive episode, although they may also be faulted for suggesting that the mania or hypomania that preceded their depression may have been missed. The notion that some patients with recurrent depression may have bipolar disorder is consistent with the prescient observation made by Kupfer 30 years ago that “there are two types of monophasic depression,” one of which has a family history and personality traits similar to bipolar disorder, effective lithium treatment, and poor antidepressant efficacy. The first type has a family history and personality profile similar to bipolar disorder, effective lithium treatment and poor antidepressant treatment. A recent case series found that patients with recurrent monophasic depression who had repeatedly failed to respond to antidepressant medication had good outcomes when treated with a single mood stabilizer rather than antidepressant medication. Recurrent depression with poor or inconsistent efficacy of antidepressant medication may belong to bipolar disorder. 2. Comparison of monophasic and biphasic depression Although both monophasic and biphasic depressive episodes are associated with similar melancholic syndromes, biphasic depressive episodes have more pronounced motor delays and are more prone to atypical manifestations such as excessive sleepiness and increased appetite. One study reported that 46.6% of bipolar depressed patients reported a mixed depressive state with at least 3 manic symptoms, compared to 7.1% of monophasic depressed patients. The most common manic symptoms in these patients were aggression, irritability, accelerated speech, and racing or accelerated thinking. One study found that of the study sample initially diagnosed with depression. Twenty-two percent of the patients met the diagnostic criteria for bipolar disorder, and at follow-up, it was found that 40% of this sample of patients had bipolar disorder. Characteristics that would predict a change in the diagnosis of bipolar disorder included mixed episodes, frequent episodes, and severe suicidal behavior. Clinical features of bipolar disorder compared to monophasic depression ① Characteristics of bipolar depressive episodes: greater motor retardation; more prominent atypical or reversed vegetative manifestations such as severe retardation, rejection sensitivity, excessive sleepiness, appetite and/or weight gain; mixed (depressive) episodes: three or more manic episodes during a single depressive episode symptoms; ineffective antidepressant medication or loss of initial efficacy. (2) Course characteristics of bipolar disorder: more relatives with affective disorders, especially bipolar disorder; younger age of onset; more frequent episodes of mood disorders; susceptibility to behavioral activation or mood changes during antidepressant or other medication. (iii) Pay attention to the precursors of bipolar disorder Patients with bipolar disorder may have some other psychiatric abnormalities even before the first detectable episode of bipolar disorder occurs. Early symptoms may not be specific, at least until the onset of depressive or manic symptoms. Bipolar disorder should be highly suspected if someone with recurrent depression had prominent behavioral problems, anxiety, and substance abuse in childhood and has a family history of affective disorders. This is a very useful diagnostic clue if any of the patient’s children have the same problems. 1. Early onset depressive episodes: A history of major depressive disorder before adolescence, even when not accompanied by attention deficit disorder or other comorbidities, is strongly suggestive of bipolar disorder. In one group of children aged 6 to 12 years (mean age 10 years) with major depressive disorder, 48.6% were diagnosed with bipolar disorder by their mean age 20 years (10 years of follow-up), compared to only 33% who still went on to be diagnosed with major depressive disorder. The finding that a positive family history is predictive of a diagnosis of bipolar disorder is impressive because children in this study with either attention-deficit/hyperactivity disorder or delusional depression were excluded, and both psychiatric disorders were associated with an increased risk of developing bipolar disorder later in life. Combined with the above data, this finding suggests that every 10 to 15 years, half of the patients who meet the diagnostic criteria for major depressive disorder will experience a manic or hypomanic episode, at least in early adulthood. 2, attention deficit and disruptive (disruptive) behavior disorder: Childhood adolescence mania differs from the traditional adult model and manifests as a continuous, chronic, rapid-cycling and mixed state with aggressive behavior, severe emotional outbursts and psychosocial impairment. Perhaps it is because the symptoms of mania in childhood adolescence are markedly different from those of adults, yet similar to those of attention deficit hyperactivity disorder (ADHD), that one begins to consider whether BD is somehow related to ADHD in childhood. We tried to identify the behavioral characteristics of BD patients in early childhood and their relationship with ADHD by conducting a retrospective study of adult patients with BD. In patients with ADHD, the presence of disorganized behavior or a family history of bipolar disorder were suggestive of bipolar disorder. There is a correlation between childhood disintegrative behavior disorder and the eventual development of bipolar disorder or major depressive disorder. Studies have also found a strong correlation between childhood disintegrative behavior disorder, ADHD, substance abuse, and a family history of bipolar disorder. In general, children with bipolar disorder present with symptoms of ADHD and conduct disorder similar to those of children with ADHD and conduct disorder who do not develop bipolar disorder. 3. Anxiety disorders: Bipolar disorder and anxiety disorders can co-exist with some other additional symptoms. Suicide attempts and psychotic manifestations are more common in those with both disorders than in those with either disorder alone. There is a correlation between preadolescent mood disorders and the later onset of affective disorders, with an odd ratio of 3 for major depressive disorder and 7.9 for bipolar disorder. 88% of adolescent patients with bipolar disorder have psychiatric co-morbidity, including 75% with anxiety disorders. This coexistence of multiple psychiatric disorders makes the condition more severe, and there is a correlation between anxiety disorders, bipolar disorder, and suicide attempts in adolescent patients. 4. Substance abuse: Substance abuse disorders are the most prominent Axis I co-morbidity of bipolar disorder and are associated with an earlier onset of bipolar disorder in patients. Patients with both bipolar disorder and substance abuse disorder were characterized by earlier onset, more frequent episodes, higher risk of suicidal behavior, more pronounced family history of bipolar disorder, and higher prevalence of other Axis I or Axis II psychiatric disorders compared with those with bipolar disorder only. 5. Early-onset psychotic episodes: Nearly 50% of adult manic patients have been previously diagnosed with schizophrenia. The first manic episode that occurs is most likely to be delusional, and the patient’s psychotic symptoms are more likely to be inconsistent with the state of mind than the manic episode that reappears later. For example, one study found that 77% of juvenile patients with a first manic episode had psychotic symptoms inconsistent with their state of mind, a condition that makes the possibility of misdiagnosis much higher. One study found that there was a correlation between first episodes of mood disorder with psychotic symptoms inconsistent with mood and a trend toward chronicity and poor overall outcome, and that symptoms inconsistent with mood were only a marker for more severe bipolar disorder rather than a marker for a different clinical type. Co-morbid disorders are present in 69% of patients with a first episode of bipolar disorder with psychotic symptoms, and 80% of these co-morbid disorders precede the onset of bipolar disorder with psychotic symptoms. The functional impairment in these patients is more persistent, and although it takes less than 3 months for their clinical syndrome to heal, it takes up to 6 months or more for their functional aspects to heal. (ii) Prodromal phenomena: triad: prominent behavioral problems, anxiety, and substance abuse. A hint: psychotic episodes with a family history of bipolar disorder or a history of prior depressive episodes are bipolar disorder. (iv) Note the interictal bipolar disorder characteristics In the interictal period of a bipolar disorder episode, the patient may also have residual affective symptoms or some other problems including impaired cognitive functioning or impulsivity. Compared to others, patients with bipolar disorder are also more likely to have anxiety disorders or substance abuse disorders, even during intervals without manic episodes or depressive episodes. Individuals with bipolar disorder who are in a normal state of mind or in interictal periods also differ from others without bipolar disorder in terms of personality traits or temperament characteristics. Some of the manifestations of interictal bipolar disorder are summarized below. 1. Characteristics of “euthymic” patients Bipolar disorder is associated with symptomatic functional impairment even during episodes of absence. For example, patients with bipolar disorder who are in a normal state of mind have worse feelings of well-being than patients with major depressive disorder or controls. Compared with patients with major depressive disorder or controls, patients with bipolar disorder in a normal state of mind had more frequent episodes of “sudden and brief onset” (intrusiveness of illness), especially if they had been depressed for the previous year. Among patients with bipolar I disorder, 47.3% of weeks had symptoms over a period of up to 2.8 years, using weeks as the time unit. Among them, depressive symptoms appeared almost four times more frequently than manic symptoms, with an average of six symptom transitions and three phase transitions per year. Juvenile bipolar disorder patients also had a high frequency of variable or changeable mood. In remission, patients also have impairments in executive functioning, just not as severe as those with schizophrenia. Attentional functions, including fine motor functions and reaction time, can also be impaired to some degree in patients with bipolar disorder in remission. Some studies have reported that patients in the interictal phase of bipolar disorder have more pronounced novelty seeking behavior compared to controls. Studies on the temperament of patients with bipolar disorder have found that patients in remission have a cyclothymic or affective exuberance temperament. Residual symptoms may be accompanied by interpersonal changes similar to those seen during manic episodes. Patients with bipolar disorder also have a tendency to be more impulsive in intervals than controls, which may increase their susceptibility to substance abuse and other co-morbidities. (E) Pay attention to the co-morbidity diagnosis of bipolar disorder 1. Co-morbidity with anxiety disorders Co-morbidity between bipolar disorder and anxiety disorders is the most common form of co-morbidity in patients with bipolar disorder, and existing epidemiological surveys also suggest a high incidence of co-morbidity between bipolar disorder and anxiety disorders. boylan et al. found that at least 55.8% of patients with bipolar disorder were co-morbid with at least one anxiety disorder, and about 31.8% of Among them, bipolar disorder was associated with panic disorder (PD), generalized anxiety disorder (GAD), phobia disorder, obsessive-compulsive disorder (OCD), and a variety of anxiety disorders. compulsivedisorder (OCD ), and post traumtic stress disorder (PTSD) had co-morbidity rates of 20.8%, 30%, 7.8-47.2%, 3.2-35%, and 40%, respectively. Regarding the relationship between bipolar disorder and OCD, Masi et al [2] enrolled 102 patients, including 37 patients with simple bipolar disorder, 35 patients with simple OCD, and 30 patients with bipolar disorder and OCD co-morbidity, showing that bipolar II was the most common type of co-morbidity, and the age of first onset of OCD in co-morbid patients was significantly earlier than that in patients with simple OCD, while the age of first onset of bipolar disorder The severity of the disorder was assessed by the Clinical General Impression Inventory (CGI) score, which was significantly lower in patients with simple OCD than in patients with co-morbidities at baseline, while the severity of patients with simple bipolar disorder was comparable to that of patients with co-morbidities; at the end of 3 years of follow-up, the CGI score was significantly higher in patients with co-morbidities than in patients with simple OCD and simple bipolar disorder, and the study also showed that the severity of the disorder was significantly higher in patients with co-morbidities than in patients with simple OCD. The study also showed that co-morbid patients had the same obsessive-compulsive thoughts as patients with simple OCD, and obsessive-compulsive behaviors were more common in patients with simple OCD. In our study, we found a high incidence of co-morbidity with each other, a longer duration of OCD and average treatment time in co-morbid patients than in those with simple OCD, and a high prevalence of atypical obsessive-compulsive symptoms such as miscellaneous obsessive-compulsive thoughts in co-morbid patients. It has also been noted that 21% of patients with bipolar disorder suffer from OCD, while only 12% of patients with unipolar disorder suffer from OCD, and only 6% of controls from the Epidemiological Catchment Area (ECA) database in the United States suffer from OCD. Fifteen percent of patients with OCD had bipolar disorder, and more than half of those with OCD had cyclothymic presentations. The incidence of mutual co-morbidity was high, the duration of OCD in co-morbid patients, the average duration of treatment was longer than in those with OCD alone, and atypical obsessive-compulsive symptoms such as miscellaneous obsessive-compulsive thoughts were more common in co-morbid patients. Although there are relatively few studies on the co-morbidity of bipolar disorder and social phobia, an NCS study showed that 47.2% of bipolar I disorders were co-morbid with social phobia, whereas the prevalence of social phobia in the general population was only 13.3%. In a survey of 71 patients with outpatient treatment for social phobia, Perugi et al. found that 21.1% of patients had a co-morbid bipolar II disorder. Bipolar disorder also has a high co-morbidity rate with generalized anxiety disorder. a survey by Masi et al. of 157 outpatients with generalized anxiety disorder aged between 7 and 18 years found that 18 patients had co-morbidity with bipolar disorder. another study by Masi et al. found that of 43 outpatients with bipolar disorder in children and adolescents, 8 patients had co-morbidity with generalized anxiety disorder. Regarding the relationship between bipolar disorder and panic disorder, Masi et al. conducted a cross-sectional survey and longitudinal follow-up study of 224 children and adolescents with bipolar disorder and found that 51 (2.8%) patients had lifetime co-morbidity with panic disorder, that co-morbidity between bipolar disorder and panic disorder was more common in females, and that co-morbidity was more common in patients with bipolar II disorder, and that co-morbidity was accompanied by high dissociative anxiety The results suggest that panic disorder is a common form of co-morbidity in adolescents with bipolar disorder, and that co-morbidity affects the severity, co-morbidity pattern, and course of bipolar disorder; regarding the relationship between panic attacks and bipolar disorder, it is currently believed that 26% to 80% of patients with bipolar disorder have a combination of panic attacks; in contrast, about 13% to 23% of patients with panic attacks Bipolar disorder. Family genealogy and biographical studies of the two disorders have also found a genetic correlation. Panic disorder has also been reported in 20.8% of patients with bipolar disorder, compared with 10% of patients with monophasic depression, and the onset of bipolar disorder is earlier in patients with comorbid panic disorder. Co-morbidity between bipolar disorder and anxiety disorders has a significant impact on the course of bipolar disorder, as evidenced by the fact that bipolar disorder patients with co-morbidity with anxiety disorders have a 3-4 year earlier age of onset than bipolar disorder patients without co-morbidity with anxiety disorders; co-morbidity with anxiety disorders increases the incidence of suicidal behavior and substance abuse in bipolar disorder patients; co-morbidity with anxiety disorders decreases the quality of life of bipolar disorder patients and has an impact on Co-morbidity with anxiety disorders reduces the quality of life of patients with bipolar disorder, impairs family, work, and social functioning, makes treatment more difficult, and increases the economic burden of patients. The prevalence of bipolar disorder with anxiety disorders is higher in children and adolescents, and studies of bipolar disorder patients have found that the earlier the age of onset, the higher the prevalence of comorbid anxiety disorders. Like anxiety disorders, substance-related psychiatric disorders and bipolar disorders also have a high incidence of comorbidity. Substance abuse disorders are the most prominent Axis I co-morbidity in bipolar disorder. According to the 1990 NCS study in Europe and the United States, the prevalence of substance-related psychiatric disorders was 7 times higher in patients with bipolar disorder compared to the general population. More than 60% of patients with bipolar disorder have alcohol dependence and 40% have substance dependence. Bipolar II disorder has a higher rate of co-morbidity with alcohol or drug dependence than does bipolar I disorder. Patients with both bipolar disorder and substance abuse disorders have an earlier onset, more frequent episodes, a higher risk of suicidal behavior, a more pronounced family history of bipolar disorder, and a higher prevalence of other Axis I or Axis II psychiatric disorders than those with only bipolar disorder. 3. Co-morbidity with personality disorders Personality disorders may be the result of a patient’s pathological adaptation to bipolar disorder or may represent a more chronic form of a behavioral disorder similar to bipolar disorder. Numerous studies have shown a high rate of co-morbidity between bipolar disorder and personality disorders. The prevalence of personality disorders appears to increase with the duration of the disorder, as it has been found that the prevalence of personality disorders in first-episode patients is 33%, while the prevalence of personality disorders in patients with multiple episodes reaches 65%. For example, bipolar disorder is strongly associated with borderline personality disorder (BPD), with a total of 1006 patients with BPD investigated in 8 studies and the prevalence of co-occurring BP-I found to range from 5.6% to 16.1% (median 9.2%) and 436 patients with BPD investigated in 6 studies and the prevalence of co-occurring BP-II found to range from 8% to 19% (median 10.7%). was 10.7%); in addition, in 12 studies, a total of 830 biphasic I patients were found to have co-morbid BPD between 0.5%-30% (median 10.7%), and in 3 studies, a total of 137 biphasic II patients had co-morbid BPD between 12%-23% (median 16%), and the following four hypotheses have been proposed for the high co-morbidity of BD and BPD: BPD is an atypical BD; BD is a different manifestation of BPD; BD and BPD are two independent diseases; BD and BPD have some etiological overlap. We need to explore this co-morbidity relationship in terms of the incidence of co-morbidity, phenomenology, family studies, longitudinal course, response to medication and etiology. ADHD may be the earliest clinical phase of bipolar disorder to appear during development. In the DSM-IV diagnostic criteria, bipolar disorder and ADHD share symptomatic overlap: talkativeness, inattention, and psychomotor arousal. In a four-year follow-up study of 140 children with ADHD, Biederman et al. (1996) found that 22% of the ADHD sample also met the diagnostic criteria for BD. testing 140 children with ADHD and 120 control samples without ADHD and their 822 first-degree relatives, found that ADHD and BD were more common together in the same relative than in the same relative alone. faraone et al. (1997) also found that the co-morbidity rate of BD with ADHD and the age of manic episodes was an inverse function of the co-morbidity was highest in children with manic episodes, intermediate in adolescents with manic episodes in childhood, and lowest in adolescents with manic episodes in adolescence. In this way, they suggest that ADHD is more frequently seen in childhood-onset bipolar disorder, and whether this suggests that in some cases ADHD may be a marker for early onset of bipolar disorder. III. Operational model for early identification of bipolar disorder If found Should ask about Depression Family history of bipolar disorder Irritability Behavioral problems of the patient’s children Mood volatility History of light mania that meets the criteria, brief, symptomatic or pharmacogenic Impulsivity that causes trouble Psychotic symptoms that started in childhood or adolescence, frequency of recurrent episodes, previous treatment and loss of efficacy III. Preliminary model for early diagnosis of bipolar disorder Envision 1.Screening some indicators with high sensitivity and specificity. 2.Establish predictive factors for early diagnosis of BD. 3.Establish a clinical questioning tool similar to SCID. 4.Establish a method that can diagnose bipolar disorder based on probability. 5.Develop diagnostic criteria that can be recommended for the diagnosis of BD.