1. 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

2. 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

3. 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.

4. Pfizer

5. 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.

6. Bipolar Epidemiology
Peak age of onset for Bipolar symptoms is between years; followed by 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 ). New York, NY: Plenum     Publishers.

7. 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:
Benazzi F. Age at onset of bipolar II depressive mixed state. Psychiatry Res. 2001;103:
Benazzi F. Clinical differences between bipolar II depression and unipolar major depressive disorder: lack of an effect of age. J Affect Disord. 2003;75:
Goldberg JF, Harrow M, Whiteside JE. Risk for bipolar illness in patients initially hospitalized for unipolar depression. Am J Psychiatry. 2001;158:
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:

8. Objective
To determine what percentage of the Family Care Clinic patient population diagnosed with major depression actually have bipolar disorder

9. 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

10. 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

11. 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:

12. Methods MDQ positive defined as: Seven symptoms or more marked
Several positive symptoms occurring over same period of time
Moderate to severe functional impairment

14. 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

15. 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
Dementia
Refused
Death
Drugs
Deaf
160 Eligible
MDQ Positive
MDQ Negative

16. 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

17. Results
126
N=160 34

18. Results
Gender
N=160

19. Results
N=160

20. Results
Race
N=160

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

22. Results Whether MDQ Used In Original Assessment of Depressive Episode

23. Results
Results of those screened for bipolar disorder
N=160

24. Results
Results of those screened for bipolar disorder
N=160

25. Analysis of Results
Confirm that females outnumber males in having mood disorders
Confirm that caucasians outnumber other races in having mood disorders

26. 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

27. 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

28. Discussion
It is important to distinguish between the two, because treatment differs
Major depression – Antidepressant
Bipolar disorder – Mood Stabilzer

29. 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:

30. 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.

31. Limitations
Sample size
Retrospective study
Convenience sampling

32. 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:
Katon W Gen Hosp Psych. 1992, 14:
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,
Hirschfield RMA, Am J Psychiatry 2000, 157:
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 ). New York,
NY: Plenum Publishers.

33. © 2008 Valentine