Best Practices In: Practical Treatment Strategies for the Successful Management of Bipolar Disorder
Patients with bipolar disorder present to clinicians in a wide variety of ways. Patients may complain of insomnia, irritability, low energy, or substance abuse. However, the most frequent presentation is depression. In primary care settings, more than 1 in 5 patients with depression, in fact, has bipolar disorder, often unrecognized. Unfortunately, most of these patients do not receive a correct diagnosis of bipolar disorder. This can lead to inappropriate treatment that may make the course of illness worse.
Bipolar disorders are often unrecognized even in the psychiatric setting; and when these psychiatric disorders are detected, it is often after a long delay, which stalls treatment. Mantere et al recently screened 1,630 psychiatric patients using the Mood Disorder Questionnaire (MDQ). This study identified patients with possible bipolar I and bipolar II disorders and found 90 patients with bipolar I disorder--with one quarter of these patients having been undiagnosed. Among the bipolar II disorder study population (101 patients), which included those with hypomania of 2 or 3 days or depressive mixed state (as well as those who met DSM-IV-TR criteria for bipolar II), half had not been previously diagnosed. There was a median delay of 7.8 years from first episode to diagnosis for those patients who had previously been diagnosed. Mixed episodes presented in 16.7% of patients with bipolar I disorder, and depressive mixed states presented in 25.7% of patients with bipolar II disorder. It is imperative that clinicians carefully assess patients for bipolar disorder, especially those presenting with depression.
Q: What are the strategies for improving diagnosis of bipolar disorder during the depressive phase of the illness when there is a high probability of misdiagnosis?
Dr Hirschfeld: Clinicians should ask directly whether there is a history of mania or hypomania, or whether the patient has experienced mood swings, episodes characterized by increased energy, decreased need for sleep, and altered mood.
Clinicians should ask about a family history; although patients may not know if a relative had bipolar disorder, they may have heard the phrase "manic depressive illness" or known a relative who had been admitted to a psychiatric hospital. A history of suicide or substance abuse is also suggestive of bipolar illness.
It is helpful to include family members or significant others in the evaluation process because patients with bipolar disorder often lack insight.
Administration of a screening instrument can be very helpful in identifying patients with bipolar disorder. The most widely used screening instrument is the MDQ, a self-report, single-page inventory that can be quickly and easily scored by a physician, nurse, or any trained medical staff assistant. The MDQ screens for a lifetime history of a manic or hypomanic syndrome by asking 13 yes-no questions derived from the DSM-IV criteria and from clinical experience.
Robert M.A. Hirschfeld, MD
Titus H. Harris Chair, Harry K. Davis Professor, Professor and Chair Department of Psychiatry and Behavioral Sciences The University of Texas Medical Branch Galveston, Tex.
Q: Diagnosis of bipolar disorder in the adolescent population comes with layers of complexity, including making the proper diagnosis and informing parents. How can clinicians prepare for this level of diagnostic complexity?
Dr Wagner: A clinician must conduct a comprehensive diagnostic evaluation of an adolescent to accurately diagnose bipolar disorder. The parents and adolescent should be interviewed separately during the assessment. Mood symptom onset and offset, including symptoms of mania, hypomania, depression, or mixed features, should be obtained. Any impairment associated with the mood state should be discussed. To diagnose bipolar I disorder in an adolescent, the adolescent must meet DSM-IV-TR criteria. …