Diagnostic errors and temporal stability in bipolar disorder
The diagnosis of bipolar disorder is frequently modified during the course of the illness.
Diagnostic changes and associated errors are described for 1,153 patients diagnosed as bipolar disorder, aged over 18 years and with at least ten follow-up visits. Data was extracted from a clinical registry of out-patient care specialized in Psychiatry and psychiatric hospitalizations of 25,152 patients representative of an urban area of 240,000 inhabitants. Limit for diagnostic stability was established as the maintenance of the bipolar disorder diagnosis in at least 75% of the visits.
A total of 158 (46.1 %) out of 342 patients diagnosed as having a bipolar disorders in the first visit kept this diagnostic constant in subsequent evaluations. Infradiagnostic initial error was committed with 108 stable patients who were not diagnosed in the first visit. 184 patients diagnosed in the first visit with bipolar disorder had less than 75 % concordant diagnosis along the follow-up and could be considered as initial overdiagnosis. Two hundred and nine out of the 443 patients who were diagnosed as bipolar disorder in their last visit did not keep stability criteria in their follow-up and could be considered therefore as final overdiagnosis. Thirty two stable patients not diagnosed in their last visit could be considered as infradiagnosis final error. Diagnosis from schizophrenia spectrum (F2) appears in one of every four psychiatric visits of the patients included in this study. Overlap was seen in three other categories: anxiety disorders (F4), personality disorders (F6) and substance abuse disorders.
Initial course of bipolar disorder causes difficulties in the diagnosis.
Available from: Sidney H Kennedy
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ABSTRACT: The Canadian Network for Mood and Anxiety Treatments (CANMAT) published guidelines for the management of bipolar disorder in 2005, with a 2007 update. This second update, in conjunction with the International Society for Bipolar Disorders (ISBD), reviews new evidence and is designed to be used in conjunction with the previous publications. The recommendations for the management of acute mania remain mostly unchanged. Lithium, valproate, and several atypical antipsychotics continue to be first-line treatments for acute mania. Tamoxifen is now suggested as a third-line augmentation option. The combination of olanzapine and carbamazepine is not recommended. For the management of bipolar depression, lithium, lamotrigine, and quetiapine monotherapy, olanzapine plus selective serotonin reuptake inhibitor (SSRI), and lithium or divalproex plus SSRI/bupropion remain first-line options. New data support the use of adjunctive modafinil as a second-line option, but also indicate that aripiprazole should not be used as monotherapy for bipolar depression. Lithium, lamotrigine, valproate, and olanzapine continue to be first-line options for maintenance treatment of bipolar disorder. New data support the use of quetiapine monotherapy and adjunctive therapy for the prevention of manic and depressive events, aripiprazole monotherapy for the prevention of manic events, and risperidone long-acting injection monotherapy and adjunctive therapy, and adjunctive ziprasidone for the prevention of mood events. Bipolar II disorder is frequently overlooked in treatment guidelines, but has an important clinical impact on patients' lives. This update provides an expanded look at bipolar II disorder.
Bipolar Disorders 06/2009; 11(3):225-55. DOI:10.1111/j.1399-5618.2009.00672.x · 4.97 Impact Factor
Available from: ncbi.nlm.nih.gov
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ABSTRACT: Objective To describe the prevalence of patients who screen positive for symptoms of bipolar disorder in primary care practice using the validated Mood Disorders Questionnaire (MDQ). Design Prevalence survey. Setting Fifty-four primary care practices across Canada. Participants Adult patients presenting to their primary care practitioners for any cause and reporting, during the course of their visits, current or previous symptoms of depression, anxiety, substance use disorders, or attention deficit hyperactivity disorder. Main outcome measures Subjects were screened for symptoms suggestive of bipolar disorder using the MDQ. Health-related quality of life, functional impairment, and work productivity were evaluated using the 12-Item Short-Form Health Survey and Sheehan Disability Scale. Results A total of 1416 patients were approached to participate in this study, and 1304 completed the survey. Of these, 27.9% screened positive for symptoms of bipolar disorder. All 13 items of the MDQ were significantly associated with screening positive for bipolar disorder (P < .05). Patients screening positive were significantly more likely to report depression, anxiety, substance use, attention deficit hyperactivity disorder, family history of bipolar disorder, or suicide attempts than patients screening negative were (P < .001). Health-related quality of life, work or school productivity, and social and family functioning were all significantly worse in patients who screened positive (P < .001). Conclusion This prevalence survey suggests that more than a quarter of patients presenting to primary care with past or current psychiatric indices are at risk of bipolar disorder. Patients exhibiting a cluster of these symptoms should be further questioned on family history of bipolar disorder and suicide attempts, and selectively screened for symptoms suggestive of bipolar disorder using the quick and high-yielding MDQ.
Canadian family physician Medecin de famille canadien 02/2011; 57(2):e58-67. · 1.34 Impact Factor
Available from: Ricardo Sánchez
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ABSTRACT: Introducción. La escala para manías de la Universidad Nacional de Colombia es un instrumento diseñado para medir la gravedad de la sintomatología maníaca y sólo ha sido validada utilizando técnicas de teoría psicométrica clásica. Objetivos. Determinar las propiedades psicométricas y las características, como instrumento de medición, de la escala para manías mediante análisis basados en la teoría de respuesta al ítem. Materiales y métodos. Se evaluaron 264 pacientes con diagnóstico de episodio maníaco, hipomaníaco o mixto, usando la escala para manías. Se analizaron las características psicométricas del instrumento utilizando un modelo de Rasch de crédito parcial para datos politómicos. Resultados. El análisis mostró que, en contraste con los ítems, los índices de separación y la confiabilidad para personas fueron bajos, lo cual sugiere una posible representación reducida del constructo evaluado en esta muestra. La disminución de la necesidad de dormir fue el ítem más fácilmente detectable en los pacientes maníacos. La mayoría de ítems se ajustó a las expectativas del modelo (excepto el afecto depresivo y la capacidad de distraerse). El diagnóstico de la escala de puntuación mostró que las medidas promedio se incrementan monotónicamente a través de la escala. Dos ítems mostraron redundancia y podrían omitirse en versiones futuras de la escala. El mapa persona-ítem sugiere que el síndrome no queda completamente evaluado por la escala, probablemente debido a que algunos síntomas depresivos no se incluyeron en ella. Conclusiones. En este primer estudio de la escala para manías usando el análisis de Rasch, se detectó mal ajuste y redundancia de algunos ítems. El síndrome maníaco no queda completamente evaluado por la escala. El instrumento podría mejorarse agregando síntomas depresivos. Palabras clave: escalas de valoración psiquiátrica, estudios de validación, trastorno bipolar/diagnóstico, psicometría/estadísticas y datos numéricos, reproducibilidad de resultados, entrevista psicológica. Validation by Rasch analysis of the Mania Scale (EMUN) for measuring manic symptions Introduction. The Mania Scale (EMUN) developed at the Universidad Nacional de Colombia was designed to measure the severity of manic symptoms, but has been validated only using classical psychometric theory. Objectives. The psychometric properties and measuring characteristics of the EMUN scale were determined using an analysis based on item response theory. Materials and methods. Two hundred sixty-four patients with manic, hypomanic or mixed episode symptoms were assessed using the EMUN scale. The psychometric characteristics of the scale were analyzed using a Rasch model for partial credit scoring. Results. The analysis based on the item response theory showed that reliability and separation indexes for persons are low in contrast to items. This suggested a narrow representation of the construct evaluated in this sample. Reduced need to sleep has been the most easily detectable symptom in mania. Excepting depressive affect and distractibility, the majority of items fit the model's expectation The rating scale diagnostics showed that the average measures increase monotonically across the rating scale. Two items showed redundancy and can be omitted in future versions of the scale. The person-item map suggested that the syndrome is not fully evaluated by the scale, probably because some depressive symptoms are not included. Conclusion. In this first study to use Rasch analysis to assess the psychometric properties of the EMUN scale, misfit and redundancy of items have been detected. The manic syndrome is not fully evaluated by the scale. The instrument can be improved by adding depressive symptoms.
Biomédica: revista del Instituto Nacional de Salud 03/2011; 31(3). DOI:10.7705/biomedica.v31i3.385 · 0.55 Impact Factor
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