The Misdiagnosis Of Bipolar Disorder As Major Depression In The Primary Care Setting Nasa Valentine, MD Wael Hamade, MD Than 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 8 letters, missing #1 Depressed mood *S Is for Sleep. Has the patient's sleep duration become shorter or longer recently? The most common manifestations are difficulty falling asleep or early-morning awakening * I Is for Interest. Also known as anhedonia, this feature is the primary flag of depression. Does the patient no longer take pleasure in activities that formerly brought enjoyment? * G Is for Guilt. Does the patient have frequent or persistent guilty thoughts or is he or she especially self-critical? Is the patient often getting down on himself? * E Is for Energy. Does the patient describe a persistent feeling of decreased energy or increased fatigue? * C Is for Concentration. Is the patient unable to focus on usual activities? Common manifestations are an inability to read an article to completion without forgetting how it began or easy distractibility. * A Is for Appetite. Has it changed? Most often appetite drops with depression, and the patient Loses weight, although weight gain is also possible. * P Is for Psychomotor Retardation. This is the most objective of the eight markers. Does the patient appear to be moving slowly and talking slowly? * S Is for Suicidality. In addition to asking about suicidal thoughts for making the diagnosis, a physician should also assess the immediacy of the threat.

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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 Criteria for Manic Episode A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary). B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree: 1.inflated self-esteem or grandiosity 2.decreased need for sleep 3.more talkative than usual or pressure to keep talking 4.flight of ideas or subjective experience that thoughts are racing 5.distractibility 6.increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation 7.excessive involvement in pleasurable activities that have a high potential for painful consequences C. The symptoms do not meet criteria for a Mixed Episode. D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features. E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatments) or a general medical condition (e.g., hyperthyroidism). 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 Bipolar Unipolar 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 This slide illustrates some of the differences between unipolar depression and bipolar disorder. Differences include Bipolar disorder is associated with an earlier onset and more recurrent episodes A family history of relatively many members with mood disorders is also associated with bipolar disorder There are also differences in psychiatric comorbidities. Panic disorder and generalized anxiety disorder (GAD) are significantly more common in patients with bipolar disorder than unipolar depression. MEASURE resource module: Unipolar vs Bipolar Depression Akiskal HA. Developmental pathways to bipolarity: are juvenile-onset depressions pre-bipolar? J Am Acad Child Adolesc Psychiatry. 1995;34:754-763. Benazzi F. Age at onset of bipolar II depressive mixed state. Psychiatry Res. 2001;103:229-235. Benazzi F. Clinical differences between bipolar II depression and unipolar major depressive disorder: lack of an effect of age. J Affect Disord. 2003;75:191-195. Goldberg JF, Harrow M, Whiteside JE. Risk for bipolar illness in patients initially hospitalized for unipolar depression. Am J Psychiatry. 2001;158:1265-1270. Simon NM, Smoller JW, Fava M, et al. Comparing anxiety disorders and anxiety-related traits in bipolar disorder and unipolar depression. J Psychiatr Res. 2003;37:187-192.

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 7 out of 10 ppl with bipolar would be correctly identified by MDQ. 9 out 10 who do not have bipolar would be accurately screened out. 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 Flowchart Through the Study 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

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 126 N=160 34

Results Gender N=160

Results N=160

Results Race N=160

Results Whether MDQ Used In Original Assessment of Depressive Episode 142 N=160 18

Results Whether MDQ Used In Original Assessment of Depressive Episode

Results Results of those screened for bipolar disorder N=160

Results Results of those screened for bipolar disorder N=160

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 Mood stabilizers esp lithium and lamotrigine have been shown to be effective in acute and prophylactic treatment of bipolar depressive episodes 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.

Limitations Sample size Retrospective study Convenience sampling

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.

© 2008 Valentine