Prevalence and characteristics of undiagnosed bipolar disorders in patients with a major depressive episode: The BRIDGE Study

The University of Texas Health Science Center, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA.
Archives of general psychiatry (Impact Factor: 14.48). 08/2011; 68(8):791-8. DOI: 10.1001/archgenpsychiatry.2011.87
Source: PubMed


Major depressive disorder, the most common psychiatric illness, is often chronic and a major cause of disability. Many patients with major depressive episodes who have an underlying but unrecognized bipolar disorder receive pharmacologic treatment with ineffective regimens that do not include mood stabilizers.
To determine the frequency of bipolar disorder symptoms in patients seeking treatment for a major depressive episode.
Multicenter, multinational, transcultural, cross-sectional, diagnostic study. The study arose from the initiative Bipolar Disorders: Improving Diagnosis, Guidance and Education (BRIDGE).
Community and hospital psychiatry departments.
Participants included 5635 adults with an ongoing major depressive episode.
The frequency of bipolar disorder was determined by applying both DSM-IV-TR criteria and previously described bipolarity specifier criteria. Variables associated with bipolarity were assessed using logistic regression.
A total of 903 patients fulfilled DSM-IV-TR criteria for bipolar disorder (16.0%; 95% confidence interval, 15.1%-17.0%), whereas 2647 (47.0%; 95% confidence interval, 45.7%-48.3%) met the bipolarity specifier criteria. Using both definitions, significant associations (odds ratio > 2; P < .001) with bipolarity were observed for family history of mania/hypomania and multiple past mood episodes. The bipolarity specifier additionally identified significant associations for manic/hypomanic states during antidepressant therapy, current mixed mood symptoms, and comorbid substance use disorder.
The bipolar-specifier criteria in comparison with DSM-IV-TR criteria were valid and identified an additional 31% of patients with major depressive episodes who scored positive on the bipolarity criteria. Family history, illness course, and clinical status, in addition to DSM-IV-TR criteria, may provide useful information for physicians when assessing evidence of bipolarity in patients with major depressive episodes. Such an assessment is recommended before deciding on treatment.

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    • "The onset of BD reportedly involves a major depressive episode in approximately half of BD type I patients, and three-quarters of BD type II patients (Baldessarini et al., 2013). Variable proportions of BD patients present two or more episodes of depression before manifesting a (hypo)manic or mixed episode, required for diagnosis of BD (Angst et al., 2011). The observed interval from an initial episode of depression to clinical diagnosis of bipolar disorder typically is from 5 to 15 years (Angst et al., 2005; Fiedorowicz et al., 2011). "
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    ABSTRACT: Background: Growing interest has been given to the construct of Duration of untreated illness (DUI) on the outcome of bipolar disorder (BD), due to its potentially modifiable nature. The aim of this study was to identify possible clinical correlates of DUI in a sample of BD patients. Method: 119 BD spectrum patients included. DUI rate was calculated and dichotomized into short DUI and long DUI subgroups, cut-off 24 months. These subgroups were compared for socio-demographic and clinical variables. Significant results were included into direct logistic regressions to assess their impact on the likelihood of presenting with long DUI. Results: Mean DUI±SD was 75.6±98.3 months. Short DUI subgroup comprised 56 (47.1%), long DUI 60 (52.9%) patients. Age at onset of BD was lower in the long DUI subgroup (p=0.021), illness duration longer (p=0.011). Long DUI subgroup showed significantly more comorbidity with Axis I (p=0.002) and personality disorders (p=0.017), less interepisodic recovery (p<0.001) and less Manic Predominant Polarity (p=0.009). Direct logistic regression as a full model was significant, correctly classifying 76.7% of cases. A unique statistically significant contribution was made by: Manic Predominant Polarity, Personality Disorder Comorbidity, and Total Changes in Medications. Limitations: Partial retrospective data, cross sectional study. Conclusions: DUI was longer than 24 months in half of the sample. Psychotic /Manic onset contributed to a quick diagnostic classification. Personality disorders in depressed patients could delay a correct diagnosis of BD, factors associated with an increased likelihood of BD must be considered. More research on personality disorder comorbidities is needed.
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    • "Depression is also a risk factor for somatic diseases such as cardiovascular disease (Lin et al., 2014), and maternal depression has been shown to affect child development (Ohoka et al., 2014). Approximately 16% of patients seeking treatment for a major depressive episode have bipolar disorder (Angst et al., 2011). Bipolar disorder is characterized by recurrent depressive and (hypo)manic episodes. "
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    • "There is also some evidence that MAO inhibitors may have a relatively low risk of inducing mood-switching (Himmelhoch et al., 1991 ; Tondo et al., 2010). The presence of unrecognized initial subsyndromal hypomanic symptoms may contribute to poor responses to antidepressant treatment, even in patients diagnosed with unipolar depression (Ghaemi et al., 2003 ; Post et al., 2003b ; Sharma et al., 2005 ; Calabrese et al., 2006 ; Goldberg et al., 2007 ; Sachs et al., 2007 ; O'Donovan et al., 2008 ; Phelps et al., 2008 ; Frye et al., 2009 ; Baldessarini et al., 2010d ; Correa et al., 2010 ; Angst et al., 2011 ; Pacchiarotti et al., 2011b ; Perlis et al., 2011 ; Rihmer and Gonda, 2011 ; Rybakowski, 2012). This hypothesis parallels the view that bipolar depression is less treatmentresponsive than unipolar depression – a conclusion that can be questioned based on the present findings (Table 2). "

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