Bipolar Disorder Often Mistaken for Depression in Primary Care

Posted by: admin on: April 21, 2011

Many adults being treated for depression in primary care may have undiagnosed bipolar disorder (BD), suggests a new study

  • It’s likely, say the researchers, that many of these patients are receiving antidepressant monotherapy.
  • For people who in fact have undiagnosed bipolar disorder, these drugs may be at best unhelpful and at worst harmful.

  • BD can be difficult to diagnose and is often misdiagnosed as recurrent major depressive disorder
  • A total of 576 (18.5%) agreed to participate and completed 2 screening instruments for BD (the Hypomania Checklist [HCL-32] and the Bipolar Spectrum Diagnostic Scale [BSDS]).
  • A total of 370 of them were invited to take part in a one-on-one comprehensive diagnostic and clinical assessment, 154 agreed, and 29 (18.8%) met Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) criteria for BD.
  • The researchers generated 3 estimates of the percentage of patients in primary care with a diagnosis of unipolar depression that may, in fact, have unrecognized BD.
  • They assumed that all individuals who dropped out of the study by not completing the questionnaire or being assessed did not have BD.
  • This seems unlikely and therefore provides an extreme lower bound for the proportion of people with undiagnosed bipolar disorder in this population, the researchers write.
  • Their least conservative estimate of 21.6% assumes that all individuals who did not drop out would have responded in the same way as those who were assessed.
  • The researchers’ more conservative midestimate of undiagnosed BP in depressed primary care patients is 9.6%.
  • Therefore, between 3.3% and 21.6% of primary care patients with depression may have unrecognized BD, Dr. Smith and colleagues note.
  • “It’s therefore important,” says Dr. Smith, “that the possibility of undiagnosed bipolar disorder is given greater recognition in primary care, and that GPs [general practitioners] are supported in developing strategies to ensure that their patients with depression receive the correct diagnosis.”
  • The findings also suggest that the HCL-32 and BSDS screening questionnaires when used in primary care settings may have “limited utility” in terms of detecting DSM-IV–defined BD.
  • The positive predictive values were 50.0% and 32.1%, respectively. However, these instruments may be useful for identifying broader definitions of BD, the researchers say.
  • They also found that sub threshold features of BD were relatively common in the cohort of depressed primary care patients and were associated with a more morbid course of illness and greater psychosocial and quality-of-life impairments.
  • These findings have important implications for the classification, assessment, and treatment of large numbers of people with depression managed in both primary and secondary care settings.

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