Download Challenges and Clinical Aspects of Diagnosing Bipolar Depression

Section 1:
Recognition and Diagnosis of
Bipolar Disorder and Its Spectrum
Spectrum of Bipolar Disorders
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Bipolar I and II
Hypomania
Bipolar NOS
Cyclothymia
Rapidly changing mood swings
Major depression with a strong family history of
bipolar disorder
• Antidepressant-induced mania and hypomania
• Secondary mania, due to other illness or drugs
Adapted from American Psychiatric Association. Practice Guideline for the
Treatment of Patients with Bipolar Disorder. 2nd ed. Washington, DC; 2002.
Bipolar Terminology
A distinct period of abnormally and persistently elevated,
expansive, or irritable mood
• Mania
– Lasting at least 1 week with a significant decline in function
• Hypomania
– Lasting at least 4 days, (clearly different from the usual nondepressed mood), but without a significant decline in
function and no psychosis
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000.
Bipolar Terminology (cont)
• Mixed Episode
– The criteria are met both for a manic episode and for a
major depressive episode (bipolar I disorder)
• Cyclothymia
– Alternating mood states that do not meet full criteria for
depressive, manic, or mixed episode for at least 2 years
• Bipolar NOS
– A mood episode that does not meet specific criteria for
any specific bipolar disorder
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000.
296.80 Bipolar Disorder NOS
The Bipolar Disorder Not Otherwise Specified category includes disorders with
bipolar features that do not meet criteria for any specific bipolar disorder.
Examples include:
1.
Very rapid alternation (over days) between manic symptoms and depressive
symptoms that meet symptom threshold criteria but not minimal duration criteria
for manic, hypomania, or major depressive episodes
2.
Recurrent hypomanic episodes without intercurrent depressive symptoms
3.
A manic or mixed episode superimposed on delusional disorder, residual
schizophrenia, or psychotic disorder not otherwise specified
4.
Hypomanic episodes, along with chronic depressive symptoms that are too
infrequent to qualify for a diagnosis of cyclothymic disorder
5.
Situations in which the clinician has concluded that bipolar disorder is present but
is unable to determine whether it is primary, due to a general medical condition, or
substance induced
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth
Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000.
Diagnostic Criteria for Major Affective Disorders
(DSM-IV)
Disorder
Depressive Episode
Manic or Mixed
Episode
Hypomanic Episodes
Bipolar I Disorder
Common but not
required
≥ 1 required
Common but not required
Bipolar II Disorder
≥ 1 required
None allowed
≥ 1 required
Bipolar Disorder
NOS*
Common but not
required
None allowed
Required, but do not meet
criteria for a specific bipolar
disorder
Cyclothymic
Disorder
Dysthymia, but not
major depression
None allowed
Numerous periods over
2 years required
Major Depressive
Disorder
≥ 1 required
None allowed
None allowed
Dysthymic Disorder
≥ 2 years required but
not major depression
None allowed
None allowed
*NOS = Not otherwise specified
Adapted from the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000:345-428.
Diagnosing Bipolar Disorder: Challenges
• Variability of age of onset and presentation
• Commonly presenting in the depressed phase and being
misdiagnosed as unipolar depression
• Prepubertal onset depression or dysthymia carries a
20–40% risk of bipolar illness
• Symptom overlap with other psychiatric conditions
• Previous misdiagnosis common
• Many clinically prominent psychiatric and medical
comorbidities
Thomas P. J Affect Disord. 2004;79(suppl 1):S3-S8.
Berk M, et al. Med J Aust. 2006;184:459-462.
The Bipolar Spectrum: Stronger
Bipolar I
 1 week
Bipolar II
 4 Days
Bipolar NOS
< 4 Days
“Bipolar III”
Antidepressant-related hypomania
Adapted from Akiskal HS, Pinto O. Psychiatr Clin North Am. 1999;22:517-534.
The Bipolar Spectrum: Weaker
Hyperthymic
“Bipolar IV”
Depressive Mixed State “IV ½”
Recurrent “Unipolar” Depression “Bipolar V”
Adapted from Akiskal HS, Pinto O. Psychiatr Clin North Am. 1999;22:517-534.
Akiskal HS, et al. J Affect Disord. 2006;96:197-205.
Bipolar “Missed States!” (Mixed States)
• Bipolar mixed states: depression and mania cooccurring
• Dysphoric mania common especially in women
• Depressive mixed states
– Core of depression, but with racing thoughts
• Mixed hypomania
Berk M, et al. Aust N Z Psych. 2005;39:215-221.
Suppes T, et al. Arch Gen Psychiatry. 2005;62:1089-1096.
Self-Rated Screening Tool:
The Mood Disorder Questionnaire (MDQ)
• Hyper or more energetic than usual
• Predominately or thematically
irritable
• Distinctly self-confident, positive
or self-assured
• Less sleep than usual
• More talkative or speaking faster
than usual
• Racing thoughts
• Easily distracted
• Problems at work and socially
• More interest in sex
• Taking unusual risks
• Excessive spending
Hirschfeld RM, et al. J Clin Psychiatry. 2003;64:53-59.
Bipolar Disorder Diagnosis
Is Often Missed
• > 85,000 US adults surveyed
• Positive screen rate for bipolar illness: 3.7%
(> 6 million people in US)
• For those with positive screen
Diagnosed with
bipolar disorder
20%
Neither bipolar
disorder nor
depression
diagnosis
49%
31%
Diagnosed with
depression
but not bipolar disorder
Only 20% of those with a positive screen had
been told by their doctors that they had bipolar disorder
Hirschfeld RM, et al. J Clin Psychiatry. 2003;64:53-59.
Unipolar Misdiagnosis May Lead
to Inappropriate Treatment
Bipolar disorder misdiagnosed as unipolar depression in 37%
of patients (N = 85)
100
Patients (%)
80
60
55%
40
23%
20
n = 38
n = 35
0
Mania/
Hypomania
Rapid
Cycling
Development of mania/hypomania or rapid cycling while taking antidepressants.
Ghaemi SN, et al. J Clin Psychiatry. 2000;61:804-808.
The Hazards of Misdiagnosis and
Delayed Diagnosis in Bipolar Disorder
Increased risk of:
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Rapid cycling or mixed features
Suicide attempts or completion
Violent behavior; impulsive behavior
Sexual and other indiscretions
Worsening substance abuse
Loss of job or significant other
Treatment resistant
Self-Report Diagnostic Tools
For Screening Bipolar Disorder
Scale
Description
Limitations
Mood Disorder
Questionnaire
(MDQ)
13 item questionnaire ( 7 is a positive
screen)
More sensitive for bipolar I than
II, should not replace a full
diagnostic interview
Bipolar Spectrum
Diagnostic Scale
(BSDS)
Screens for subtle versions of bipolar
and can rate the probability of bipolar
as high, moderate, low, or unlikely
Should not replace a full
diagnostic interview
Quick Inventory for
Depression
Symptomatology
(QIDS)
16 item inventory, each item rated 0-3
Takes an average of 15 minutes
to implement
Clinician-Administered Diagnostic Tools
For Screening Bipolar Disorder
Scale
Description
Limitations
Young Mania Rating Scale
(YMRS)
11 item scale, each with a varied
rating scale based on severity
(mania = 12, depression = 3,
euthymia = 2)
Usefulness of scale is limited in
populations with diagnoses other
than mania
Bipolarity Index
Evaluation of bipolar presentation
based on 5 “dimensions”—each
worth up to 20 points for a total of
100
Time consuming, not peer
reviewed
Hamilton Rating Scale for
Depression (HAM-D)
17-21 item scale initially intended
for identifying depressed patients
Relies heavily on clinical
interviewing skills and
experience of the rater
Montgomery-Asberg
Depression Rating Scale
(MADRS)
10 selected items are rated on a scale
of 0-6 with anchors at 2-point
intervals
Cost prohibitive and time
consuming
Subthreshold Bipolar Disorder
(The “Soft” Bipolar Spectrum)
• Boundaries of bipolarity have expanded over the past decade
• Suggest that the diagnostic criteria for hypomania need revision
• Further study is needed to evaluate the ‘hard’ and ‘soft’
definitions of bipolar II, minor bipolar disorder, and hypomania
• A more expansive definition of bipolar II yields a cumulative
prevalence rate of 10.9%, compared to 11.4% for broadly
defined major depression
Akiskal HS. Curr Psychiatry Rep. 2002;4:1-3.
Angst J, et al. J Affect Disord. 2003;73:133-146.
The Rule of 3 Hinting at Soft Bipolarity
(NOS) in a Clinically Depressed Person
• Three or more:
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Major depressive episodes
Failed marriages
Failed antidepressants trials
Distinct professions
First degree relatives (or generations) with affective illness
Fields of eminence in the family
Substances of abuse
Impulsive behaviors (gambling, car racing, sexual, etc.)
Individuals dated simultaneously
Simultaneous jobs
Languages (for US-born citizens)
Triad of past histrionic, psychopathic, or borderline diagnoses
Triad of red car, necktie, or belt
Akiskal HS. J Affect Disord. 2005;84:279-290.
Importance of Interviewing the Patient
and Their Family
• Patients admitted with major depression
– NIMH study
– Step 1: Patient screened for bipolar disorder
– Step 2: Family member interviewed (by another
investigator interested in genetics)
– Result: Twice as many bipolar I diagnoses
from interviewing both the patient and a family
member
Blehar MC, et al. Psychopharmacol Bull. 1998;34:239-243.
Physicians Must Use Patient Perspectives
to Improve Diagnosis and Care
Factors Necessary for Recovery:
1.
Communication between patient and physician: best
chance for recovery when patient feels he’s being heard;
physician must try to understand how the world looks
through patient’s eyes
2.
Treatment plans that include patient input and
preferences; physician must discuss all options so patient
has complete understanding of illness
3.
Recovery-oriented treatment based on mutually agreed
goals so patient feels like a partner in care
Lewis L, et al. Adm Policy Ment Health. 2005;32:497-503.
Take Home Messages
• Bipolar disorder can masquerade in different or
mixed mood states
• Bipolar disorder is often misdiagnosed as
depression due to the prevalence of depressive
episodes often as the presenting phase
• Misdiagnosis can have serious detrimental effects
on treatment effectiveness and outcomes