When to suspect bipolar disorder

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Applied Evidence

When to suspect bipolar disorder

J Fam Pract. 2010 December;59(12):682-688

By

Kavita Lohano, MD

Muruga Loganathan, MD

R. Jeanie Roberts, MD

Yonglin Gao, MD

Bipolar disease is often misdiagnosed, sometimes repeatedly. The screening tool and tips you’ll find here will help you identify patients without delay.

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References

1. Hirschfeld RM, Lewis L, Vornik 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;64:161-174.

2. Stewart C, El-Mallakh RS. Is bipolar disorder over diagnosed among patients with substance abuse? Bipolar Disord. 2007;9:646-648.

3. El-Mallakh RS, Karippot A. Chronic depression in bipolar disorder. Am J Psychiatry. 2006;163:1137-1341.

4. Goodwin FK, Jamison KR. Manic-Depressive Illness: Bipolar Disorders and Recurrent Depression, 2nd ed. Oxford University Press: New York; 2007.

5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text rev (DSM-IV-TR). American Psychiatric Association: Arlington, VA; 2000.

6. Baldessarini RJ, Salvatore P, Khalsa HM, et al. Dissimilar morbidity following initial mania versus mixed-states in type-I bipolar disorder. J Affect Disord. 2010;126:299-302.

7. Kilbourne AM, Cornelius JR, Hans X, et al. Burden of general medical conditions among individuals with bipolar disorder. Bipolar Disord. 2004;6:368-373.

8. Shah A, Shen N, El-Mallakh RS. Weight gain occurs after onset of bipolar illness in overweight bipolar patients. Ann Clin Psychiatry. 2006;18:239-241.

9. Kessler RC, Nelson CB, McGonagle KA, et al. The epidemiology of co-occurring addictive and mental disorders: implications for prevention and service utilization. Am J Orthopsychiatry. 1996;66:17-31.

10. Mantere O, Melartin TK, Suominen K, et al. Differences in Axis I and II comorbidity between bipolar I and II disorders and major depressive disorder. J Clin Psychiatry. 2006;67:584-593.

11. Calabrese JR, Hirschfeld RM, Reed M, et al. Impact of bipolar disorder on a US community sample. J Clin Psychiatry. 2003;64:425-432.

12. Collins JC, McFarland BH. Divalproex, lithium and suicide among Medicaid patients with bipolar disorder. J Affect Disord. 2008;107:23-28.

13. Hirschfeld RM, Williams JB, Spitzer RL, et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Am J Psychiatry. 2000;157:1873-1875.

14. Surja AAS, Tamas RL, El-Mallakh RS. Antipsychotic medications in the treatment of bipolar disorder. Curr Drug Targets. 2006;7:1217-1224.

15. Scherk H, Pajonk FG, Leucht S. Second-generation antipsychotic agents in the treatment of acute mania: a systematic review and meta-analysis of randomized controlled trials. Arch Gen Psychiatry. 2007;64:442-455.

16. Suppes T, Vieta E, Liu S, et al; Trial 127 Investigators. Maintenance treatment for patients with bipolar I disorder: results from a North American study of quetiapine in combination with lithium or divalproex (trial 127). Am J Psychiatry. 2009;166:476-488.

17. Judd LL, Akiskal HS, Schettler PJ. The long-term natural history of the weekly symptomatic status of bipolar I disorder. Arch Gen Psychiatry. 2002;59:530-537.

18. Judd LL, Akiskal HS, Schettler PJ, et al. A prospective investigation of the natural history of the long-term weekly symptomatic status of bipolar II disorder. Arch Gen Psychiatry. 2003;60:261-269.

19. El-Mallakh RS, Karippot A. Antidepressant-associated chronic irritable dysphoria (ACID) in bipolar disorder. J Affect Disord. 2005;84:267-272.

20. Suppes T, Datto C, Minkwitz M, et al. Effectiveness of the extended release formulation of quetiapine as monotherapy for the treatment of acute bipolar depression. J Affect Disord. 2010;121:106-115.

21. Corya SA, Perlis RH, Keck PE, Jr, et al. A 24-week open-label extension study of olanzapine-fluoxetine combination and olanzapine monotherapy in the treatment of bipolar depression. J Clin Psychiatry. 2006;67:798-806.

22. Frey MA, Grunze H, Suppes T, et al. A placebo-controlled evaluation of adjunctive modafinil in the treatment of bipolar depression. Am J Psychiatry. 2007;164:1242-1249. .

23. Goldberg JF, Burdick KE, Endick CJ. Preliminary randomized, double-blind, placebo-controlled trial of pramipexole added to mood stabilizers for treatment-resistant bipolar depression. Am J Psychiatry. 2004;161:564-566.

24. Zarate CA, Jr, Payne JL, Singh J, et al. Pramipexole for bipolar II depression: a placebo-controlled proof of concept study. Biol Psychiatry. 2004;56:54-60.

25. Sienaert P, Vansteelandt K, Demyttenaere K, et al. Ultra-brief pulse ECT in bipolar and unipolar depressive disorder: differences in speed of response. Bipolar Disord. 2009;11:418-424.

26. Valenti M, Benabarre A, Garcia-Amador M, et al. Electroconvulsive therapy in the treatment of mixed states in bipolar disorder. Eur Psychiatry. 2008;23:53-56.

27. Barekatain M, Jahangard L, Haghighi M, et al. Bifrontal versus bitemporal electroconvulsive therapy in severe manic patients. J ECT. 2008;24:199-202.

28. Calabrese JR, Vieta E, El-Mallakh R, et al. Mood state at study entry as predictor of the polarity of relapse in bipolar disorder. Biol Psychiatry. 2004;56:957-963.

29. Fujiwara Y, Honda T, Tanaka Y, et al. Comparison of early- and late-onset rapid cycling affective disorders: clinical course and response to pharmacotherapy. J Clin Psychopharmacol. 1998;18:282-288.

30. Bellivier F, Golmard J, Rietschel M, et al. Age at onset in bipolar I affective disorder: further evidence for three subgroups. Am J Psychiatry. 2003;160:999-1001.

31. Thiruvengadam AP, Chandrasekaran K. Evaluating the validity of blood-based membrane potential changes for the identification of bipolar disorder I. J Affect Disord. 2007;100:75-82.

32. National Institute of Mental Health. How is bipolar disorder treated? Available at: http://www.nimh.nih.gov/health/publications/bipolar-disorder/how-is-bipolar-disorder-treated.shtml. Accessed November 9, 2010.

33. US Food and Drug Administration. FDA approves Saphris to treat schizophrenia and bipolar disorder. Aug. 14, 2009. Available at: http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm177401.htm. Accessed November 17, 2010.

PRACTICE RECOMMENDATIONS

• Before prescribing antidepressant therapy to depressed patients, screen for bipolar illness, either by taking a detailed medical and family history or by administering the Mood Disorder Questionnaire. A

• Be alert to medical and psychiatric comorbidities in patients with bipolar illness, particularly anxiety disorders and substance abuse. A

• Prescribe a mood stabilizer for acutely depressed patients with bipolar disorder; if the depression does not resolve, add an agent with relapse prevention properties. B

Strength of recommendation (SOR)

A Good-quality patient-oriented evidence
B Inconsistent or limited-quality patient-oriented evidence
C Consensus, usual practice, opinion, disease-oriented evidence, case series

As a family physician, you are better positioned than you might think to make a difference in the lives of patients with bipolar illness. Not only are you likely to be involved in monitoring such patients, but you may frequently be the first clinician patients with bipolar symptoms seek help from.

FAST TRACK

Close to one-third of patients with bipolar disorder seek medical care within a year of the onset of symptoms, but nearly 70% do not receive an accurate diagnosis until they’ve seen 4 physicians.

All it takes to provide that help is a heightened awareness of bipolar disorder, the ways in which bipolar patients present, and the signs and symptoms to look for. Yet evidence suggests that many physicians do not have adequate knowledge of this chronic and debilitating condition. While close to one-third of patients with bipolar disorder seek medical care within a year of the onset of bipolar symptoms, nearly 70% do not receive an accurate diagnosis until they have seen an average of 4 physicians.¹ Misdiagnosis—both underdetection¹ and over-inclusion²—often results in improper treatment. And even when the diagnosis is correct, patients with bipolar disease often receive inadequate or harmful treatment.³

Ongoing care for bipolar illness is best provided in collaboration with a psychiatrist. With the disorder affecting about 3% to 5% of the US population,⁴ family physicians will inevitably play a key role in diagnosis and treatment. The text, tables, and screening tool that follow will help with both.

Bipolar diagnosis hinges on this characteristic

The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) defines 4 types of bipolar illness: bipolar I, bipolar II, cyclothymia (the most mild form), and not otherwise specified (TABLE 1).⁵ The key feature of all 4 types—and the distinguishing characteristic that diagnosis typically hinges on—is a manic or hypomanic episode (TABLE 2).⁵

Although a full-blown manic episode may not be hard to identify, hypomania is easily missed. By definition, hypomania—with its heightened sense of well-being and productivity—is not problematic and is rarely a patient’s primary complaint.

Mixed mania, a feature of bipolar I, is the worst of both worlds: It is a state in which a full manic episode is superimposed on a full depressive episode—a depression with all the energy and force of a mania. Patients who have experienced one episode of mixed mania have a 12-fold increase in mixed states, 6.5 times more depression, and 1.7 times more dysthymia than those who experience manic episodes without the overlay of depression.⁶

TABLE 1
Types of bipolar disease: DSM-IV diagnoses⁵

Bipolar I	Bipolar II	Cyclothymia	Bipolar disorder not otherwise specified
≥1 manic or mixed lifetime episode, frequently accompanied by major depressive episodes	≥1 major depressive episode, accompanied by ≥1 lifetime hypomanic episode	≥2 years of numerous periods of hypomanic and subsyndromal depressive symptoms	Symptoms resemble, but do not meet, criteria for any specific bipolar disorder

TABLE 2
Mania and hypomania: DSM-IV criteria⁵

To identify an episode of mania or hypomania, all of the following criteria must be met. Of note: Hypomania has the same criteria as mania, with 2 notable exceptions: (1) the minimum duration of hypomania is 4 days, rather than 7;* and (2) hypomania is not significantly problematic.

Euphoric, expansive, or irritable mood (not due to drugs)
3 or 4 of the following (4 if irritable mood):
- – Reduced need for sleep
- – Increased goal-directed activity or agitation
- – Increased involvement in pleasurable, but potentially destructive, activity
- – Pressured speech
- – Distractibility
- – Flight of ideas/racing thoughts
- – Grandiose/increased self-esteem

*There is no maximal duration, but the average manic episode lasts 1 to 2 months.

Complicating matters: Numerous comorbidities

FAST TRACK

The vast majority (93%) of patients with bipolar I disease also suffer from an anxiety disorder, and most (71%) have a substance abuse disorder.

Bipolar illness predisposes patients to multiple medical and psychiatric comorbidities. Cardiovascular, cerebrovascular, and metabolic disorders and sleep disturbances are common in those with bipolar disorder.⁷ So is obesity, which affects about 50% of patients with bipolar disease.⁸

Bipolar patients also suffer from an extremely high rate of comorbid psychiatric conditions. Overall, 93% of those with bipolar I also have an anxiety disorder, 71% suffer from drug or alcohol dependence, and 50% suffer from dysthymia, according to the National Comorbidity Survey.⁹ In addition, about two-thirds of bipolar patients suffer from various personality disorders¹⁰—a comorbidity that is particularly disturbing because it is associated with a chronically dysfunctional pattern of problem-solving.