Skip to main content Accessibility help
×
×
Home

Unrecognised bipolar disorder in primary care patients with depression

  • Daniel J. Smith (a1), Emily Griffiths (a1), Mark Kelly (a2), Kerry Hood (a2), Nick Craddock (a1) and Sharon A. Simpson (a3)...
Abstract
Background

Bipolar disorder is complex and can be difficult to diagnose. It is often misdiagnosed as recurrent major depressive disorder.

Aims

We had three main aims. To estimate the proportion of primary care patients with a working diagnosis of unipolar depression who satisfy DSM–IV criteria for bipolar disorder. To test two screening instruments for bipolar disorder (the Hypomania Checklist (HCL–32) and Bipolar Spectrum Diagnostic Scale (BSDS)) within a primary care sample. To assess whether individuals with major depressive disorder with subthreshold manic symptoms differ from those individuals with major depressive disorder but with no or little history of manic symptoms in terms of clinical course, psychosocial functioning and quality of life.

Method

Two-phase screening study in primary care.

Results

Three estimates of the prevalence of undiagnosed bipolar disorder were obtained: 21.6%, 9.6% and 3.3%. The HCL–32 and BSDS questionnaires had quite low positive predictive values (50.0 and 30.1% respectively). Participants with major depressive disorder and with a history of subthreshold manic symptoms differed from those participants with no or little history of manic symptoms on several clinical features and on measures of both psychosocial functioning and quality of life.

Conclusions

Between 3.3 and 21.6% of primary care patients with unipolar depression may have an undiagnosed bipolar disorder. The HCL–32 and BSDS screening questionnaires may be more useful for detecting broader definitions of bipolar disorder than DSM–IV-defined bipolar disorder. Subdiagnostic features of bipolar disorder are relatively common in primary care patients with unipolar depression and are associated with a more morbid course of illness. Future classifications of recurrent depression should include dimensional measures of bipolar symptoms.

  • View HTML
    • Send article to Kindle

      To send this article to your Kindle, first ensure no-reply@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below. Find out more about sending to your Kindle. Find out more about sending to your Kindle.

      Note you can select to send to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be sent to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.

      Find out more about the Kindle Personal Document Service.

      Unrecognised bipolar disorder in primary care patients with depression
      Available formats
      ×
      Send article to Dropbox

      To send this article to your Dropbox account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Dropbox.

      Unrecognised bipolar disorder in primary care patients with depression
      Available formats
      ×
      Send article to Google Drive

      To send this article to your Google Drive account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you use this feature, you will be asked to authorise Cambridge Core to connect with your <service> account. Find out more about sending content to Google Drive.

      Unrecognised bipolar disorder in primary care patients with depression
      Available formats
      ×
Copyright
Corresponding author
Daniel J. Smith, MD, MRCPsych, Department of Psychological Medicine and Neurology, Cardiff University School of Medicine, Monmouth House (second floor), University Hospital of Wales, Heath Park, Cardiff, CF14 4DW, UK. Email: smithdj3@cardiff.ac.uk
Footnotes
Hide All

See editorial, pp. 3–4, this issue.

Funded by an MRC/Welsh Assembly Government Partnership Award (2008–2010). D.J.S. is funded by a Postdoctoral Fellowship from the National Institute of Health Research (NIHR).

Declaration of interest

D.J.S. has received honoraria for speaking at educational meetings organised by AstraZeneca and Lilly.

Footnotes
References
Hide All
1 Angst, J. The bipolar spectrum. Br J Psychiatry 2007; 190: 189–91.
2 Goodwin, GM, Geddes, JR. What is the heartland of psychiatry? Br J Psychiatry 2007; 191: 189–91.
3 Ghaemi, SN, Ko, JY, Goodwin, FK. Cade's Disease and beyond: misdiagnosis, antidepressant use and a proposed definition for bipolar spectrum disorder. Can J Psychiatry 2002; 47: 125–34.
4 Ghaemi, SN, Sachs, GS, Chiou, AM, Pandurangi, AK, Goodwin, K. Is bipolar disorder still underdiagnosed? Are antidepressants overutilized? J Affect Disord 1999; 52: 135–44.
5 Ghaemi, SN, Boiman, EE, Goodwin, FK. Diagnosing bipolar disorder and the effect of antidepressants: a naturalistic study. J Clin Psychiatry 2000; 61: 804–8.
6 Albanese, MJ, Clodfelter, RC Jr, Pardo, TB, Ghaemi, SN. Underdiagnosis of bipolar disorder in men with substance use disorder. J Psychiatr Pract 2006; 12: 124–7.
7 Chilakamarri, JK, Filkowski, MM, Ghaemi, SN. Misdiagnosis of bipolar disorder in children and adolescents: a comparison with ADHD and major depressive disorder. Psychiatr Ann, in press.
8 Smith, DJ, Ghaemi, N. Is underdiagnosis the main pitfall when diagnosing bipolar disorder? Yes. BMJ 2010; 340: c854.
9 Lish, JD, Dime-Meenan, S, Whybrow, PC, Price, RA, Hirschfeld, RMA. The National Depressive and Manic-depressive Association (DMDA) survey of bipolar members. J Affect Disord 1994; 31: 281–94.
10 Hirschfeld, RM, Lewis, L, Vernik, LA. Perceptions and impact of bipolar disorder: how far have we really come? Results of the National Depressive and Manic-Depressive Association 2000 survey of individuals with bipolar disorder. J Clin Psychiatry 2003; 64: 161–74.
11 Berk, M, Dodd, S, Callaly, P, Berk, L, Fitzgerald, P, de Castella, AR, et al. History of illness prior to a diagnosis of bipolar disorder or schizoaffective disorder. J Affect Disord 2007; 103: 181–6.
12 Geller, B, Zimerman, B, Williams, M, Bolhofner, K, Craney, JL. Bipolar disorder at prospective follow-up of adults who had prepubertal major depressive disorder. Am J Psychiatry 2001; 158: 125–7.
13 Smith, DJ, Harrison, N, Muir, W, Blackwood, DHR. The high prevalence of bipolar spectrum disorders in young adults with recurrent depression: toward an innovative diagnostic framework. J Affect Disord 2005; 84: 167–78.
14 Sharma, V, Khan, M, Smith, A. A closer look at treatment resistant depression: is it due to a bipolar diathesis? J Affect Disord 2005; 84: 251–7.
15 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (4th edn) (DSM–IV). APA, 1994.
16 Angst, J, Adolfsson, R, Benazzi, F, Gamma, A, Hantouche, E, Meyer, TD, et al. The HCL-32: towards a self-assessment tool for hypomanic symptoms in outpatients. J Affect Disord 200; 88: 217–33.
17 Ghaemi, SN, Miller, CJ, Berv, DA, Klugman, J, Rosenquist, KJ, Pies, RW. Sensitivity and specificity of a new bipolar spectrum diagnostic scale. J Affect Disord 2005; 84: 273–7.
18 Allen, R, Smith, DJ. Screening for bipolar disorder: strengths and limitations of currently available instruments. Prim Care Community Psychiatr 2008; 13: 4751.
19 Carta, MG, Hardoy, CM, Cadeddu, M, Murru, A, Campus, A. The accuracy of the Italian version of the Hypomania Checklist (HCL-32) for the screening of bipolar disorders and comparison with the Mood Disorder Questionnaire (MDQ) in a clinical sample. Clin Pract Epidemiol Ment Health 2006; 2: 2.
20 Vieta, E, Sanchez-Moreno, J, Bulbena, A, Chamorro, L, Ramos, JL, Artal, J, et al. Cross validation with the mood disorder questionnaire (MDQ) of an instrument for the detection of hypomania in Spanish: the 32 item hypomania symptom check list (HCL-32). J Affect Disord 2007; 101: 4355.
21 Sheehan, DV, Lecrubier, Y, Harnett-Sheehan, K, Amorim, P, Janavas, J, Weiller, E, et al. The Mini International Neuropsychitric Interview (MINI): the development and validation of a structured diagnostic psychiatric interview. J Clin Psychiatry 1998; 59 (suppl 20): 2233.
22 Snaith, RP, Harrop, FM, Newby, DA, Teale, C. Grade scores of the Montgomery–Åsberg Depression and the Clinical Anxiety Scales. Br J Psychiatry 1986; 148: 599601.
23 Young, RC, Biggs, JT, Ziegler, VE, Meyer, DA. A rating scale for mania: reliability, validity and sensitivity. Br J Psychiatry 1978; 133: 429–35.
24 Fava, M. Diagnosis and definition of treatment-resistant depression. Biol Psychiatry 2003; 53: 649–59.
25 Spitzer, RL, Gibbon, M, Williams, JBW. Global Assessment of Functioning (GAF) Scale. In Outcome Assessment in Clinical Practice (eds Sederer, LI, Dickey, B): 76–7. Williams and Wilkins.
26 Rosa, A, Sanchez-Moreno, J, Martinez-Aran, A, Salamero, M, Torrent, C, Reinares, M, et al. Validity and reliability of the Functioning Assessment Short Test (FAST) in bipolar disorder. Clin Pract Epidemiol Ment Health 2007; 3: 5.
27 World Health Organization. Development of the World Health Organization WHOQOL-BREF Quality of Life Assessment. Psychol Med 1998; 28: 551–8.
28 Dunn, G, Pickles, A, Tansella, M, Vazque-Barquero, JL. Two-phase epidemiological surveys in psychiatric research. Br J Psychiatry 1999; 174: 95100.
29 Nelson, H, Willison, J. National Adult Reading Test (2nd edn). nferNelson, 1991.
30 Angst, J. Do many patients with depression suffer from bipolar disorder? Can J Psychiatry 2006; 51: 35.
31 Smith, DJ, Thapar, A, Simpson, SA. Bipolar spectrum disorders in primary care: optimising diagnosis and treatment. Br J Gen Pract 2010; 60: 322–4.
32 Sachs, GS, Nierenberg, AA, Calabrese, JR, Marangell, LB, Wisniewski, SR, Gyulai, LF, et al. Effectiveness of adjunctive antidepressant treatment for bipolar depression. N Engl J Med 2007; 356: 1711–22.
33 Smith, DJ, Forty, L, Russell, E, Caesar, S, Walters, JT, Gordon-Smith, K, et al. Subthreshold manic symptoms in recurrent major depressive disorder are a marker for poor outcome. Acta Psychiatr Scand 2009; 119: 325–9.
34 El-Mallakh, RS, Karippot, A, Ghaemi, SN. Antidepressants in bipolar depression. In Bipolar Depression (eds El-Mallakh, RS, Ghaemi, SN): 167–83. American Psychiatric Publishing, 2006.
35 Smith, DJ, Ghaemi, SN, Craddock, N. The broad clinical spectrum of bipolar disorder: implications for research and practice. J Psychopharmacol 2008; 22: 397400.
36 Zimmermann, P, Bruckl, T, Nocon, A, Pfister, H, Lieb, R, Wittchen, H-U, et al. Heterogeneity of DSM–IV major depressive disorder as a consequence of subthreshold bipolarity. Arch Gen Psychiatry 2009; 66: 1341–52.
37 Angst, J, Gamma, A, Bennazzi, F, Ajdacic, V, Eich, D, Rossler, W. Toward a re-definition of subthreshold bipolarity: epidemiology and proposed criteria for bipolar-II, minor bipolar disorders and hypomania. J Affect Disord 2003; 73: 133–46.
38 Merikangas, KR, Akiskal, HS, Angst, J, Greenberg, PE, Hirschfeld, RMA, Petukhova, M, et al. Lifetime and 12-month prevalence of bipolar spectrum disorder in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2007; 64: 543–52.
39 Angst, J, Cui, L, Swendsen, J, Rothen, S, Cravchik, A, Kessler, R, et al. Major depressive disorder with subthreshold bipolarity in the national comorbidity survey replication. Am J Psychiatry 2010; 167: 1194–201.
Recommend this journal

Email your librarian or administrator to recommend adding this journal to your organisation's collection.

The British Journal of Psychiatry
  • ISSN: 0007-1250
  • EISSN: 1472-1465
  • URL: /core/journals/the-british-journal-of-psychiatry
Please enter your name
Please enter a valid email address
Who would you like to send this to? *
×
Type Description Title
PDF
Supplementary materials

Smith et al. supplementary material
Supplementary Table S1

 PDF (40 KB)
40 KB

Metrics

Altmetric attention score

Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed

Unrecognised bipolar disorder in primary care patients with depression

  • Daniel J. Smith (a1), Emily Griffiths (a1), Mark Kelly (a2), Kerry Hood (a2), Nick Craddock (a1) and Sharon A. Simpson (a3)...
Submit a response

eLetters

Early Diagnosis of Bipolar: "SUSPICIOUS depression"

David Horgan, Psychiatrist
21 September 2011

Many doctors worry about missing the diagnosis of bipolar disorder. Smith et al (1) have indicated that up to 21.6% of primary care patients with unipolar depression may have undiagnosed bipolar disorder. The editorial comment (2) drew attention to the therapeutic importance of early diagnosis, and the well known years of delay in many cases. Having reported on missed bipolar diagnosis in patients admitted to a prestigioustertiary psychiatric hospital (3), I have developed a mnemonic "SUSPICIOUS" to summarise the current academic and clinical expert views (4) indicating increased risk of bipolar illness in patients presenting with depression.

S - Severe

U - Under 25 at first episode

S - Short duration

P - Post-natal illness

I - Intermittent / recurrent

C - Crazy ideas (delusions, hallucinations)

I - In the family

O - Overeating / oversleeping

U - Unusually heavy limbs (psychomotor retardation)

S - Swings of mood while depressed

Yours faithfully,

David Horgan

Clinical Associate Professor of Psychiatry, University of Melbourne

Email davidhorgan@email.com

1) Smith DJ, Griffiths E, Kelly M, Hood K, Craddock N, Simpson SA. Unrecognised bipolar disorder in primary care patients with depression. BrJ Psychiatry 2011; 199, 49-56

2) Young A, MacPherson H. Detection of bipolar disorder. Br J Psychiatry 2011; 199, 3-4

3) Horgan D. Change of diagnosis to manic depressive illness . Psychol Med 1981; 11:517-523

4) Mitchell PB, Goodwin GM, Johnson GF, Hirschfeld RM. Diagnostic guidelines for bipolar depression: a probabilistic approach. Bipolar Disorders 2008; 10,144-152

... More

Conflict of interest: None declared

Write a reply

Allegiance Effects and Conclusion Fidelity

Partha Sarathi Biswas, Dr. Partha Sarathi Biswas
03 August 2011

Smith et al [1] focused on an interesting and recent dimensional model of bipolarity, which places depressed patients along a gradient instead of defining them as belonging to discrete entities. The present diagnostic systems of psychiatric illnesses are categorical. Although the dimensional approach is not beyond criticism [2], the upcoming DSM-V has aproposal to take up this approach in a hybrid of categorical classifications coupled with dimensions [3].

Smith et al [1] has compared the frequency of sub threshold features of bipolar disorder in individuals with supposed unipolar depression with some previous studies. But the results of their primary care setting should not be compared to those from secondary and tertiary care settings.The conceptualization and thus misdiagnosis of depression in terms of bipolarity can vary depending upon the training, experience, or familiarity with one approach of bipolarity dispersion than the other approach in the treating physicians of the concerned health care setting. Consequently there would be a tendency in each level of health care settings to obtain qualitative and quantitatively unique type of misdiagnosis with the approach they have primary allegiance to, than with other approaches. This allegiance effect is an important methodological confound while coming to such a conclusion.

Before making a conclusion that sub threshold features of bipolar disorder were relatively common in individuals with supposed unipolar depression in primary care settings the authors should take a sample from multiple primary health facilities from within a geographical area on a random basis especially after stratification based on the familiarity to the bipolarity concept. Moreover, frequency of bipolarity would have been batter studied in extensive epidemiological and prospective longitudinal clinical studies to make such a conclusion.

This study assessed course of depression by the variables like chronicity of illness, hospitalization, resistance to antidepressants and number of episodes. Prospective ascertaining of treatment resistance wouldhave eliminated the confounding effect of the patients' recall bias, a common methodological issue affecting this type of study relying primarilyor solely on retrospective assessments [4]. Moreover, bipolarity is a contributor to apparent treatment resistance in depression [5]. Thus had the interepisodic functioning been assessed prospectively they would have been more confident about the course. So, this study has fewer denominators to make a conclusion that subthreshold features of bipolar disorder were associated with a more severe pattern of depressive illness.

Conclusion of a research paper seems to be one of the most difficult parts in the work. Conclusion gives a sense of completeness in the reader.In an exploratory study, it should briefly restate the thesis statement which by that time would become more and more general. However, over generalization of the finding, especially where there is limited representativeness of whole population or universe may be misguiding to a broad category of readers of the journal. The issues we discussed related to the conclusion are not immutable, rather thoughtful vigilance is the best way to avoid such a skeptical conclusion.

References

1.Smith DJ, Griffiths E, Kelly M, Hood K, Craddock N, Simpson SA. Unrecognised bipolar disorder in primary care patients with depression. BrJ Psychiatry 2011; 199: 49-56.

2.Lawrie SM, Hall J, McIntosh AM, Owens DGC, Johnstone EC. The 'continuum of psychosis': scientifically unproven and clinically impractical. Br J Psychiatry 2010; 197: 423-5.

3.Young AH, MacPherson H. Detection of bipolar disorder. Br J Psychiatry 2011; 199: 3-4.

4.Fava M. Diagnosis and definition of treatment-resistant depression.Biol Psychiatry 2003; 53: 649-59.

5.Correa R, Akiskal H, Gilmer W, Nierenberg AA, Trivedi M, Zisook S. Is unrecognized bipolar disorder a frequent contributor to apparent treatment resistant depression? J Affect Disord 2010; 127: 10-15.

Authors:

Dr.Partha Sarathi Biswas* [1], Ms. Devosri Sen [2]

Address:

1.Senior Resident, Department of Psychiatry, Ranchi Institute of Neuro- Psychiatry and Allied Sciences (RINPAS), Kanke, Ranchi, India;

2.PhD Scholar, Department of Clinical Psychology, Central Institute of Psychiatry (CIP), Kanke, Ranchi, India

* Corresponding author

Declaration of interests: none

... More

Conflict of interest: None declared

Write a reply

×

Reply to: Submit a response


Your details


Conflicting interests

Do you have any conflicting interests? *