Research reportIs bipolar disorder still underdiagnosed? Are antidepressants overutilized?
Introduction
The diagnosis and treatment of bipolar disorder is often difficult. In the recent past, it was recognized that patients with bipolar disorder were often confused diagnostically with schizophrenia (Pope and Lipinski, 1978). With DSM-III and the adoption of neo-Kraepelinian nosology, this differential diagnosis was more carefully defined, and by DSM-IV, a broad consensus appeared to be reached in differentiating bipolar disorder from schizophrenia clinically (Goodwin and Jamison, 1990). However, since the introduction of newer safer antidepressant agents in the past decade, there may have been an increase in the diagnosis and treatment of major depression, perhaps in part related to the introduction of treatments for the diagnosis (“treatment-oriented observation bias” or Klerman's “pharmacocentric view of the world”) (Stoll et al., 1993). While this factor is only one of a variety of possible explanations for this cohort effect, the move towards more aggressive diagnosis and treatment of depression may explain reports of possible overutilization of antidepressants in the treatment of bipolar disorder (Wehr and Goodwin, 1987; Sachs, 1996). This overutilization of antidepressants has been associated with increased risk of drug-induced mania (30–70% of patients with bipolar disorder treated with antidepressants alone) (Goodwin and Jamison, 1990) and possible worsening of the long-term course of bipolar disorder by the induction of treatment-resistant rapid-cycling episodes (26–51% of patients with bipolar disorder treated with antidepressants chronically) (Kukopulos et al., 1983; Wehr and Goodwin, 1987; Altshuler et al., 1995; Kukopulos et al., 1980; Quitkin et al., 1981). There is some evidence that patients with milder variations of bipolar disorder, such as type II, may be at more risk of misdiagnosis as unipolar major depressive disorder and overtreatment with antidepressants resulting in a worsened rapid-cycling course (Altshuler et al., 1995).
Experts in the treatment of bipolar disorder have thus recommended careful diagnosis and avoidance of antidepressant treatment except in the brief short-term treatment of severe acute bipolar depression in conjunction with mood-stabilizing agents (Goodwin and Jamison, 1990; Stoll et al., 1993; Sachs, 1996). We wished to assess the standard of care in one community for the diagnosis and treatment of bipolar disorder, with special attention to the above recommendations. We asked the following questions: Is bipolar disorder underdiagnosed, and if so, is it frequently mistaken for unipolar major depressive disorder? Are antidepressants utilized more frequently than necessary and prudent? To what extent are mood-stabilizing agents used? Can the acute major depressive episode in bipolar disorder be effectively treated with mood-stabilizing agents alone without using antidepressant agents? Can the use of antidepressants be minimized by the aggressive utilization of mood-stabilizing agents and other adjuncts for the treatment of bipolar disorder (particularly, typical and atypical neuroleptic agents, and clonazepam)?
Section snippets
Methods
Charts of all consecutive patients with the hospital diagnosis of bipolar disorder, type I (n=50) or schizoaffective disorder, bipolar type (n=5) hospitalized on an affective disorders unit over 12 months in an urban academic hospital were reviewed. Seven patients were excluded from further analysis due to experiencing a first manic episode (n=2) or not previously seeking psychiatric treatment (n=5). The final sample thus consisted of 48 patients, 44 with bipolar disorder, type I and four with
Results
Clinical and demographic characteristics of the sample are provided in Table 1.
Table 2 describes the diagnostic and treatment characteristics of the sample. Most patients were not previously diagnosed with bipolar or schizoaffective disorder. The most common previous diagnosis was unipolar major depressive disorder. The majority of patients were not receiving treatment with mood-stabilizing agents, 1/3 were receiving treatment with antidepressant agents, often without mood-stabilizing agents.
Discussion
These results support the suggestion that bipolar disorder is underdiagnosed. 40% of those patients who were diagnosed with bipolar disorder in this study had not been previously diagnosed with it (excluding first episode patients and those who did not seek previous treatment), and all of them were previously diagnosed with unipolar major depressive disorder. In those who were diagnosed with conditions other than bipolar disorder, about 7.5 years elapsed from their first mental health
Conclusions
These results support the conclusion that bipolar disorder is underdiagnosed and frequently misdiagnosed as unipolar major depressive disorder. If not diagnosed early, patients with bipolar disorder remain undiagnosed for 7.5 years. Patients with bipolar disorder are not adequately treated with mood stabilizers in the community, and appear over-treated with antidepressant medications. Aggressive use of mood stabilizing agents produced acute response rates that were as good for depression, mixed
Acknowledgements
This study was supported by a grant from Abbott Laboratories.
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