the misdiagnosis of bipolar disorder as major depression in the primary care setting nasa valentine,...
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The Misdiagnosis Of Bipolar Disorder As Major Depression In The Primary Care Setting
Nasa Valentine, MDWael Hamade, MDThan Luu, MD
RCRMC Department of Family Medicine
Introduction
Depression, prevalent disorder 12% annually - 20 million people
Occurs 5-10% in primary care patients Male/Female ratio 1:2 Most common: white race
Katon W Gen Hosp Psych. 1992, 14:237-47
Bhalla RN Depression. Emedicine.com. Mar 5, 2008
Major depressive episode
S leep I nterest G uilt E nergy C oncentration A ppetite P sychomotor Retardation S uicidality
Major Depression vs Bipolar Disorder
Major Depression distinguished from bipolar disorders by the fact that there is no history of ever having had a Manic, Mixed or Hypomanic Episode
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th edition.1994:345.
Bipolar Epidemiology
Peak age of onset for Bipolar symptoms is between 15-19 years; followed by 20-24 years
No race ethnicity based differences reported Incidence of Bipolar Disorder is significantly
high (11%) for patients whose first-degree relatives have a history of bipolar disorder
Rehm, L.P., Wagner, A.L., & Ivens-Tyndal, C., (2001). Mood disorders: unpopular and bipolar. In H.E. Adams & P.B. Sutker (Eds.), Comprehensive handbook of psychopathology (pp. 277-301). New York, NY: Plenum Publishers.
Unipolar vs BipolarUnipolar Bipolar References
Age of onset Later Earlier Akiskal 1995 Benazzi 2001/2003
Goldberg 2001
Recurrences (> 4)
Fewer More (BP II) Benazzi 2003
Family History
More unipolar;
fewer mood disorder
More bipolar;
more mood disorder
Akiskal 1995 Benazzi 2003
Comorbidity Less panic, GAD
More panic, GAD
Simon 2003
MEASURE resource module: Unipolar vs Bipolar Depression
Objective
To determine what percentage of the Family Care Clinic patient population diagnosed with major depression actually have bipolar disorder
Methods
Study design Adult patients in Family Care Clinic with a previous
or current diagnosis of depression are screened for bipolar disorder
Patients are either screened at their scheduled clinic appointment or called at home and interviewed
Epidemiological and clinical data were collected through interviews and medical records
Methods
Charts with ICD9 code (311) for depression for last two years pulled and reviewed (convenience sampling)
Inclusion criteria: ages>18 diagnosed with depression
Exclusion criteria: ages<18, invalid contact number, deafness, dementia, death, refusal, drug abuse
Methods
Mood Disorder Questionaire (MDQ) Screening instrument for bipolar disorder Sensitivity of 73% and specificity of 90% for a
bipolar diagnosis
Hirschfield RMA, Am J Psychiatry 2000, 157:1873-1875
Methods
MDQ positive defined as: Seven symptoms or more marked Several positive symptoms occurring over
same period of time Moderate to severe functional impairment
Methods
If patients were screened positive on the MDQ, they were interviewed further
Antidepressants halted or tapered and mood stabilizers started
Referred to Mental Health and Behavioral Health
406 Randomized charts/patients w/diagnosis of depression reviewed
246 Excluded (not eligible)
205 No valid contact number
18 Dementia
12 Refused
6 Death
3 Drugs
3 Deaf
160 Eligible
MDQ Positive MDQ Negative
Flowchart Through the Study
Results
406 patients/charts with dx of major depression interviewed/reviewed
160 patients eligible for MDQ Ages 20-70 Mean age 50.2 years at onset of study
Results
MDQ used
0
20
40
60
80
100
120
140
160
MDQ used MDQ not used
18
142
N=160
Whether MDQ Used In Original Assessment of Depressive Episode
Results
11%
89%
MDQ used
MDQ not used
Whether MDQ Used In Original Assessment of Depressive Episode
N=160
Results
26
134
0
20
40
60
80
100
120
140
160
MDQ Positive MDQ Negative
N=160
Results of those screened for bipolar disorder
Analysis of Results
Confirm that females outnumber males in
having mood disorders Confirm that caucasians outnumber other
races in having mood disorders
Analysis of Results
Primary care providers (11%) underutilize mood disorder questionnaires in the assessment of depressive episodes
16% of clinic patients diagnosed as having major depression were likely misdiagnosed
Discussion
We showed in our results that bipolar depression can be misdiagnosed as unipolar depression
Patients will report on periods of depression but neglect to report periods of elevated mood
Discussion
It is important to distinguish between the two, because treatment differs
Major depression – Antidepressant Bipolar disorder – Mood Stabilzer
Use of antidepressants in bipolar disorder
Significant risk of mania May cause rapid mood-cycling No reduction in mortality (completed
suicides) Less effective than mood stabilizers in
preventing depressive relapse
Ghaemi SN et al. Bipolar Disorders. 2003;5:421-433.
Discussion/Recommendation
There was a misdiagnosis of bipolar disorder as major depression in our clinic population.
The Mood Disorder Questionnaire (MDQ) is an easy tool to screen for bipolar disorder in the primary care setting and should be used when screening for unipolar depression and before any antidepressants are prescribed.
References
American Psychiatric Association (2000). Diagnostic and statistical manual of mental disorders (4th ed. TR). Bhalla RN Depression. Emedicine.com. Mar 5, 2008 Ghaemi SN et al. Bipolar Disorders. 2003;5:421-433. Katon W Gen Hosp Psych. 1992, 14:237-47. Kessler, R. C., et al. (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Archives of General Psychiatry, 51, 8-19. Kung H et al. National Vitals Stat Report. 2008,56, 1-120. Hirschfield RMA, Am J Psychiatry 2000, 157:1873-1875. Hirschfield RMA. J Clin Psychiatry 2002;4:9-11. MEASURE resource module 8 MEASURE resource module: Unipolar vs Bipolar Depression Rehm, L.P., Wagner, A.L., & Ivens-Tyndal, C., (2001). Mood disorders: unpopular and bipolar. In H.E. Adams & P.B. Sutker (Eds.) Comprehensive handbook of psychopathology (pp. 277-301). New York, NY: Plenum Publishers.