Reasons for diagnostic delays in Bipolar Disorder: Systematic review and narrative synthesis

Background: Bipolar disorder is common, affecting 1% of people. The diagnosis of bipolar disorder is often delayed, which limits access to effective treatment and increases the burden of disease on individuals, families, and society. Aim: This paper investigates the individual, social, and clinical factors that contribute to delays in diagnosis for people with bipolar disorder, including delays that occur before and after a person presents to a primary care clinician. Design and setting: Systematic review and narrative synthesis. Method: Four electronic databases - Embase, Medline, PsychInfo, and Global Health - were systematically searched. This search yielded 3078 studies, 21 of which met the inclusion criteria. The data retrieved were analysed using Braun and Clarke’s Thematic Analysis to report a summary of recent research on the delays in the diagnosis of bipolar disorder. Results: Analysis of the data from the 21 studies identified five main themes as reasons for delays in diagnosis: (1)


Introduction
Bipolar disorder (BD) is a common illness, affecting 1% of people.It is a lifelong mental illness characterised by recurrent episodes of depression and (hypo)mania. [1]f BD is left untreated, it can have a negative impact on an individual's well-being -leading to impaired social, occupational, and cognitive functioning, decreased quality of life, danger to self and others, and increased mortality. [4]Delayed diagnosis can impact the recurrence of mood disturbances, which can worsen an individual's psychological well-being. [5]The misdiagnosis of BD can lead to improper treatment, worsened symptoms, and an increased risk of hospitalisation. [6]In addition, delayed treatment leads to an increase in health care costs due to higher rates of hospitalisation and increased suicide attempts. [7][8]However, when the right treatment is offered, it can help individuals minimise the burden of the illness and function better in society. [9] date, there has been limited research addressing the reasons for delays in the diagnosis of people with BD.To our knowledge, no systematic review has been conducted to systematically report reasons for these delays.In this study, we aimed to report the reasons for the delays in the diagnosis of BD and to explore these delays before and after a person presents to primary care, as well as the individual, social, and clinical factors associated with these delays.Database searches were conducted by the primary and secondary reviewers on 9th June 2022.Authors searched their own personal libraries.The review protocol was registered with PROSPERO (CRD42022313495). [10]clusion and Exclusion Criteria  [11][12] .Table 1 details the full list of the inclusion and exclusion criteria.

Search Strategy
The search strategy was developed using key terms that were built around the three main concepts: BD, delays, and diagnosis.The formation of the search terms was influenced by previous search strategies used by a systematic review that focused on BD and provided guidance on which key terms would provide relevant information for the review. [13]The database searches for Embase can be found in Supplementary Table S1.Following the search, eligible studies were transferred to EndNote (version 20.3) and de-duplicated.These libraries were then reviewed for relevant studies and information.The PRISMA flow diagram for studies selected is illustrated in Figure 1.The titles and abstract of each study were analysed by a master's student for inclusion (NM), and a second master's student (VA) reviewed 5% of the titles and abstracts of the studies.Following this, both reviewers reviewed the full text of the remaining studies.It was decided that disagreements about which studies met the inclusion criteria should be resolved by consensus or, if necessary, with the assistance of a third author (VP).In addition, a forward and backward citation search was performed using Connected Papers. [14]ality appraisal The full-text manuscripts of the selected quantitative studies were assessed using the National Institute of Health (NIH) assessment tools.The two assessment tools used were: The Quality Assessment of Case Series Studies and The Quality Assessment of Cohort and Cross-sectional Observational Studies. [15]Whereas the selected qualitative studies were assessed using the Critical Appraisal Skills Programme Tool. [16]Due to the scarcity of the studies discussed in this review, it was concluded that studies would not be excluded based on their quality assessment.Although from the assessment, none of the studies were identified as being low in quality.

Data synthesis
The data was synthesised to report the similarities and differences between studies, the observation of relationships within the data, and the strength of the findings.A thematic methodology was used to become familiar with the data extracted from the studies and to search, review, and define themes that report on the reasons for delays in the diagnosis of BD. [17] Due to the methodological and clinical diversity (e.g., heterogeneity in the participants) of the included studies, meta-analysis was not possible.

Results
Database searches retrieved 3078 studies.Following de-duplication and title and abstract screening, 145 studies were assessed in full text for eligibility.Four additional studies were identified in the co-authors' library, and no new studies were observed in the forward and backward citation searches, leading to a final total of 21 included publications (Figure 1).
Supplementary Table S2 summarises the included publications.Common themes identified In this review, there were patterns in the findings throughout the included studies that may explain the causes for delays in the diagnosis of BD, which have been translated into themes.The topics have been divided into five primary themes, each of which has been further subdivided into subthemes.Supplementary Table S3 illustrates the generation of initial codes, and Table 2 presents the identified themes.

Misdiagnosis
ealthcare challenges It was highlighted by 11 of the studies that BD patients may face challenges in accessing mental health treatments.In  [35] It was reported that troubles in finding a suitable clinician resulted in long waiting times to be seen and in being provided with limited treatments. [29][30]Moreover, it was conveyed how patients felt that clinicians were unable to make a specific diagnosis or lacked the skills to treat their condition and did not take their concerns seriously. [28][29]Along with the inability to establish stable long-term care relationships due to the constant rotation of psychiatrists in the public system. [32]ntal health stigma 8] Stigma was shown to act as a barrier for individuals to seek help from mental health services; patients expressed that the fear associated with mental health stigma discouraged them from seeking a diagnosis. [22][23]Moreover, patients would struggle to accept their diagnosis as their symptoms were different from the stereotypical ideas about what BD is.33 Moreover, patients presenting with first depressive episodes, with no history or prominent symptoms of mania or hypomania, were more likely to be misdiagnosed with MDD. [22]dividual factors 4] The studies demonstrated that socioeconomic status was linked with delays in seeking help as patients would be faced with healthcare costs. [36]Moreover, participants were reluctant to seek help for manic or hypomanic symptoms as they did not perceive them as abnormal. [30]And a lack of understanding of BD in patients, the community, and healthcare practitioners was shown to heighten these delays. [36][29]scussion Summary The literature addressing the reasons for delays in the diagnosis of BD has highlighted that individual, social, and clinical factors contribute to this delay.Available data indicate that BD is often misdiagnosed as other psychiatric disorders due to the complexity of the condition.In addition, patients are faced with barriers to accessing care due to healthcare