Academic journal article Iranian Journal of Psychiatry

Undiagnosed Bipolar Disorders in Patients with Major Depressive Episode: Iran's Part of a Multicenter Cross-Sectional Study

Academic journal article Iranian Journal of Psychiatry

Undiagnosed Bipolar Disorders in Patients with Major Depressive Episode: Iran's Part of a Multicenter Cross-Sectional Study

Article excerpt

Objective: Bipolar spectrum disorders may often go undiagnosed or unrecognized. The aim of this study was to determine the proportion of bipolar disorder symptoms in Iranian patients with a major depressive episode.

Methods: 313 patients with a current DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders 4th ed. Text rev.) diagnosed with a major depressive episode entered this cross-sectional study. Thirty two items revised Hypomania/ mania Symptoms Checklist (HCL-32) was used to determine the frequency of bipolar episodes.

Results: Considerable proportion of patients (53.9%) previously diagnosed as major depressive disorder fulfilled the criteria for bipolar disorder by Bipolarity Specifier. The Bipolarity Specifier additionally identified significant association for manic / hypomanic states during antidepressants therapy (p<0.0003) and current mixed mood symptoms (p<0.0001)

Conclusion: Bipolar symptoms meeting the criteria for bipolar disorders in depressed patients who have not been previously diagnosed with bipolar disorder are frequent. Current DSM criteria may not be sufficient to diagnose more subtle or atypical forms of bipolar disorders.

Keywords: Bipolar disorder. Major depressive disorder. Bipolar Spectrum, Mania, Hypomania, Bipolarity> Specifier

Iran J Psychiatry 2013; 8:1:1-6

(Considering the prevalence, clironicity and recurrent nature, mood disorders are amongst the most crucial topics in public and mental health issues. Major depressive disorders (MDD) are considered to be the most frequently encountered form of psychiatric problems that cause significant social and functional impairments (1).

On the basis of past hypomanic or manic features, a considerable number of patients who were initially diagnosed with major depressive disorder eventually turn out to be diagnosed with bipolar disorder (2). A misdiagnosis of unipolar depression in about 40% of bipolar patients lias been reported (3). However, bipolar disorder diagnosis in patients presenting with depressive symptoms may not be easily attained. Patients often consider their hypomanic or even manic symptoms to be normal (4), whereas depressive symptoms are distressing to them so rapidly seek treatment. Therefore, disorders with hypomanic or sub-threshold bipolar symptoms may not be recognized (5) and it may not be easy to ascertain past episodes of bipolar disorder, especially that bipolar II is a "soft" expression of the disorder (6). Hidden cases of bipolar disorders among depressive patients call for attention of clinicians to address this issue .Observations show that these patients had been visited by a mean of four physicians before receiving a definite diagnosis of bipolar disorder (7).

Some studies suggest that 50% of patients with major depressive disorder diagnosis conform to bipolar II pattern (8). Bipolar patients misdiagnosed with MDD have significantly lower quality of life and less functional outcome, having increased risk of attempting suicide, greater requirement for inpatient psychiatric care that account for higher total health care costs, and they also have more substance abuse and are more treatment refractory compared with accurately diagnosed bipolar disorder (9). Moreover, antidepressant treatment lias the potential of switching the disorder to manic or hypomanic phase (10), while mood stabilizer treatment can be more appropriate (11). According to DSM-IV-TR(Diagnostic and Statistical Manual of Mental Disorders 4th ed. Text rev.), mood disorders are classified into distinct categories of bipolar and depressive disorders. Bipolar disorders are divided into bipolar I, bipolar II, cyclothymic and bipolar NOS (Not Otherwise Specified). This categorical classification of mood disorders runs against Kraepelin's unitary classification of hypo-manic and depressive states under manic-depressive insanity. DSM-IV-TR reports that a categorical classification requires "clear boundaries" between classes. …

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