Even without comorbidities, the impact of bipolar disorder is significant: In a study of 1468 patients with bipolar disorder, complaints of difficulties with work, leisure activities, and family and social interactions were common.11 Women were more likely to cite disruption of social and family life, while men often reported having been convicted of crimes. Younger patients reported a greater number of symptomatic days compared with their older counterparts.11
Suicide risk. Patients with bipolar disorder also face an increased risk of suicide, particularly in the depressive phase of the illness. Among 12,662 Oregon Medicaid patients diagnosed with, and treated for, bipolar disorder between 1998 and 2003, there were 11 deaths by suicide and 79 significant suicide attempts.12
Suspect bipolar disorder?
One of the best ways by which family physicians can speed up and improve the accuracy of bipolar diagnosis is to utilize the Mood Disorder Questionnaire (MDQ) (TABLE 3).13 Patients with any mood complaint are its target population. Within that group, the MDQ has been found to have excellent specificity (0.90) and acceptable sensitivity (0.73).13 (For more on identifying patients with bipolar disease, see “A blood test for bipolar disorder?”.)
TABLE 3
The Mood Disorder Questionnaire bipolar screening tool
| Please answer each question to the best of your ability. | ||
| 1. Has there ever been a period of time when you were not your usual self and … | ||
| YES | NO | |
| you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble? | ||
| you were so irritable that you shouted at people or started fights or arguments? | ||
| you felt much more self-confident than usual? | ||
| you got much less sleep than usual and found you didn’t really miss it? | ||
| you were much more talkative or spoke much faster than usual? | ||
| thoughts raced through your head or you couldn’t slow your mind down? | ||
| you were so easily distracted by things around you that you had trouble concentrating or staying on track? | ||
| you had much more energy than usual? | ||
| you were much more active or did many more things than usual? | ||
| you were much more social or outgoing than usual; for example, you telephoned friends in the middle of the night? | ||
| you were much more interested in sex than usual? | ||
| you did things that were unusual for you or that other people might have thought were excessive, foolish, or risky? | ||
| spending money got you or your family into trouble? | ||
| 2. If you checked YES to more than one of the above, have several of these ever happened during the same period of time? | ||
3. How much of a problem did any of these cause you—like being unable to work; having family, money, or legal troubles; getting into arguments or fights? Please circle one response only.
| ||
| Have any of your blood relatives (ie, children, siblings, parents, grandparents, aunts, uncles) had manic-depressive illness or bipolar disorder? | ||
| For a positive screen, 7 of the 13 items in No. 1 must be Yes, No. 2 must be Yes, and No. 3 must be moderate or serious. Source: Hirschfeld RM, et al. Am J Psychiatry. 2000.13 Reprinted with permission. | ||
When to administer the MDQ
Because patients with bipolar disease are more likely to seek help when they are suffering from a depressive episode, it is important to maintain a high index of suspicion. Before ruling out bipolar disease, take a complete medical history, inquiring about comorbidities, family history, and whether the patient can recall any episodes of agitation, intense irritation, or other manifestations of mania or hypomania (TABLE 2).5 If, based on the history, you continue to suspect bipolar disorder, administer the MDQ.
If the patient has a positive screen, your next step would be to initiate treatment for bipolar disorder, even if depression is the presenting symptom. A referral to a psychiatrist would be indicated, as well.
Complexities of bipolar treatment
In recent years, numerous agents have been approved by the US Food and Drug Administration (FDA) for the treatment of bipolar illness in general, and for acute mania in particular. Nearly all of the second-generation, or atypical, antipsychotics have been approved for use in acute mania.14 (Mixed states should be treated the same as mania.) Most of these agents have also been found to be useful as maintenance medications, to prevent relapse (TABLE 4).