Practical Clues to Early Recognition of Bipolar Disorder: A Primary Care Approach.

Department of Psychiatry, University of Texas Health Science Center at Houston, Houston
The Primary Care Companion to The Journal of Clinical Psychiatry 02/2005; 7(1):15-21.
Source: PubMed


Early treatment can favorably impact the course of bipolar disorder, a lifelong illness. Because bipolar disorder can masquerade as various mental and physical illnesses-primarily major depressive disorder-patients with this condition frequently go unrecognized for years. During this recognition lag, such patients may present to their primary care physician on multiple occasions. Accordingly, primary care physicians would benefit from knowing the "clues" to early recognition of the disorder, because early recognition and management can reduce disability, improve social and employment stability, and result in improved functional outcomes. This review describes 3 pathways to the diagnosis of bipolar disorder relevant to the primary care setting: detection of mania or hypomania, differential diagnosis of recurrent depressive episodes, and identification of interepisode disorder and its comorbidities. We summarize these pathways in terms of a practical tool that a primary care physician can use to trigger further evaluation or referral.

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    • "Because of the important treatment implications of this differential diagnosis, efforts have been made to improve initial identification of bipolar disorder and differentiate it from unipolar depression. Review articles have described the subtle clinical characteristics that differentiate not-yet-recognized bipolar disorder from unipolar depression [13,14]. In addition, screening tools for bipolar disorder, such as the MDQ [15] and a claims-based screening algorithm [16], have been developed to help identify unrecognized bipolar disorder. "
    [Show abstract] [Hide abstract] ABSTRACT: Previous research has documented that the symptoms of bipolar disorder are often mistaken for unipolar depression prior to a patient's first bipolar diagnosis. The assumption has been that once a patient receives a bipolar diagnosis they will no longer be given a misdiagnosis of depression. The objectives of this study were 1) to assess the rate of subsequent unipolar depression diagnosis in individuals with a history of bipolar disorder and 2) to assess the increased cost associated with this potential misdiagnosis. This study utilized a retrospective cohort design using administrative claims data from 2002 and 2003. Patient inclusion criteria for the study were 1) at least 2 bipolar diagnoses in 2002, 2) continuous enrollment during 2002 and 2003, 3) a pharmacy benefit, and 4) age 18 to 64. Patients with at least 2 unipolar depression diagnoses in 2003 were categorized as having an incongruent diagnosis of unipolar depression. We used propensity scoring to control for selection bias. Utilization was evaluated using negative binomial models. We evaluated cost differences between patient cohorts using generalized linear models. Of the 7981 patients who met all inclusion criteria for the analysis, 17.5% (1400) had an incongruent depression diagnosis (IDD). After controlling for background differences, individuals who received an IDD had higher rates of inpatient and outpatient psychiatric utilization and cost, on average, an additional $1641 per year compared to individuals without an IDD. A strikingly high proportion of bipolar patients are given the differential diagnosis of unipolar depression after being identified as having bipolar disorder. Individuals with an IDD had increased acute psychiatric care services, suggesting higher levels of relapses, and were at risk for inappropriate treatment, as antidepressant therapy without a concomitant mood-stabilizing medication is contraindicated in bipolar disorder. Further prospective research is needed to validate the findings from this retrospective administrative claims-based analysis.
    Full-text · Article · Jun 2010 · BMC Psychiatry
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    • "Bipolar disorder (BD) is a psychiatric disease that is characterized by mood alteration associated with recurrent depression and mania in lifetime (Swann et al., 2005). The elucidation of etiology and pathophysiology of this disease is extremely important to establish treatment and prevention strategy (Mamdani et al., 2003; Murray et al., 2004). "
    [Show abstract] [Hide abstract] ABSTRACT: We investigated the effect of polymorphic variants of c.1298A>C (Glu429Ala) and c.677C>T (Ala222Val) in methylenetetrahydrofolate (MTHFR) gene on the total homocysteine (tHcy), folate and B12 levels in patients with bipolar disorder, first-degree relatives of patients, and controls. The c.677C>T and c.1298A>C polymorphisms in MTHFR were determined by polymerase chain reaction-restriction fragment length polymorphism in 197 bipolar patients, 278 relatives and 238 controls. tHcy and folate and vitamin B12 levels were measured by Fluorescence Polarization Immunoassay and Electrochemiluminescence, respectively. The tHcy was significantly increased in patients and relatives. In contrast, folate and B12 were significantly lower in patients and relatives. Gender was not considered as a significant determinant in the multivariate analysis. Genotypes of c.1298A>C and c.677C>T were correlated with tHcy, folate and B12. Patients and relatives carrying TT and/or AA and AC genotypes had elevated tHcy and reduced folate and B12 levels. High tHcy but low folate and vitamin B12 levels may be a risk factor for development of bipolar disorder.
    Full-text · Article · Aug 2008 · Progress in Neuro-Psychopharmacology and Biological Psychiatry
  • [Show abstract] [Hide abstract] ABSTRACT: Bipolar disorder has a lifelong course. Our understanding of the illness is not complete enough to detect it before the first manic or hypomanic episode. Treatment of bipolar disorder has three phases. The continuation phase comprises the transition between symptomatic improvement after correct diagnosis and effective treatment of an episode and functional recovery. This phase requires continuation of effective pharmacologic treatments combined with nonpharmacologic treatments that will provide the basis for education, monitoring, and anticipation of relapse. The maintenance phase begins when pre-episode function has been regained. Placebo-controlled data for mania support lithium, olanzapine, and divalproex in patients whose most recent episode responded to one of these treatments. Carbamazepine lacks placebo-controlled studies but appears to have response predictors that are complementary to those of lithium. For prevention of depressive episodes, which are at least twice as frequent as mania, placebo-controlled data support lithium, lamotrigine, and divalproex. Treatment response may depend upon the course of illness. There are relatively little data about long-term treatment response in bipolar II disorder or rapid-cycling. Although current treatments are effective, especially when combined with appropriate nonpharmacologic treatments, more definitive strategies require a better understanding of the physiologic processes underlying the recurrent nature of bipolar disorder.
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