Coming as a surprise to more than a few mental health professionals, a new study out today suggests that bipolar disorder is often missed in patients who present only with major depression. The study examined 5,635 adults seen at community and hospital psychiatry departments in a number of different countries.
The discrepancy was reported because of the use of “bipolarity specifier criteria” that are broader than the DSM-IV criteria, the standard for diagnosis of mental disorders by mental health professionals.
Using the broader bipolar criteria developed by the researchers found an additional 31 percent of patients who could have been diagnosed with bipolar disorder.
So what’s really going on here? Are professionals really “missing” bipolar disorder? Or have the researchers stacked the deck in this study simply to suggest it is so?
Here are the findings, according to the news article reporting on the study:
DSM-IV-TR criteria for bipolar disorder were met by 903 patients (16.0%; 95% confidence interval [CI], 15.1% – 17.0%), and bipolarity specifier criteria were met by 2647 patients (47.0%; 95% CI, 45.7% – 48.3%). When both sets of criteria were applied, there were significant associations with bipolarity for a family history of mania or hypomania and multiple past mood episodes. When only the bipolarity specifier was used, there were also significant associations for manic/hypomanic states during treatment with antidepressant drugs, current mixed mood symptoms, and comorbid substance use disorder.
The obvious question to me is, what the heck are these “bipolarity specifier criteria” mentioned by the researchers? Why haven’t most professionals ever heard of these criteria before?
These sub-threshold bipolar criteria were first proposed by Angst et al. in 2003 (coincidentally the lead researcher in the new study) and take the following form:
This bipolarity specifier attributes a diagnosis of bipolar disorder in patients who experienced an episode of elevated mood, an episode of irritable mood, or an episode of increased activity with at least 3 of the symptoms listed under Criterion B of the DSM-IV-TR associated with at least 1 of the 3 following consequences: (1) unequivocal and observable change in functioning uncharacteristic of the person’s usual behavior, (2) marked impairment in social or occupational functioning observable by others, or (3) requiring hospitalization or outpatient treatment. No minimum duration of symptoms was required and no exclusion criteria were applied.
In other words, the researchers have re-written the DSM bipolar disorder criteria to rope in people who wouldn’t ordinarily qualify for the diagnosis. They’ve set the threshold lower, making it a “sub-threshold” diagnosis.
One could argue that all of the criteria in the DSM are somewhat arbitrary. For instance, why do you need to meet five criteria for depression? Why not 4? Or 3? Sure, there’s data to suggest five is a good compromise in terms of ensuring you catch legitimate clinical depression in people, without roping in people who don’t actually have it.
But in this case, I have to wonder. A single case of irritable mood along with the very subjective observation of an “unequivocal and observable change in functioning uncharacteristic of the person’s usual behavior” hardly seems sufficient to qualify a person to be characterized as having “bipolar disorder.” It seems like you could classify significant portion of the population with these two characteristics combined.
So why would you want to propose a set of sub-threshold criteria for bipolar disorder that would, by their very design, include a lot more people? If professionals were to adopt these criteria, more people could ostensibly be diagnosed with bipolar disorder… and then need treatment.
What kind of treatment would they need? Why, bipolar medications, of course. And who makes a medication for bipolar disorder? The study’s primary sponsor — sanofi-aventis:
Financial Disclosure: All investigators recruited received fees, on a per patient basis, from sanofi-aventis in recognition of their participation in the study.
Role of the Sponsors: The sponsor of this study (sanofi-aventis) was involved in the study design, conduct, monitoring, data analysis, and preparation of the report. The study sponsor funded an independent contract research organization (SYLIA-STAT; Bourg-la-Reine, France) to collect and analyze the data and to generate the statistical report.
So sanofi-aventis designed the study, and was involved in every aspect of the study’s implementation, data collection and final analysis. Huh.
Certainly some people who present with major depression can be mis-diagnosied with depression when they actually have bipolar disorder. It does happen, since sometimes a clinician may not ask the right questions to determine the presence of an earlier bipolar episode. But it’s not such a problem as these researchers would suggest, missing an entire swath of 30 percent more people.
Needless to say, you can take this study’s findings with a big grain of salt.
Read the full article: Bipolar Disorder Underlying Major Depression May Be Missed
12 comments
it is perhaps not such a bad thing….particularly when you consider the number of deaths which occur when antidepressants are given to people with bipolar without mood stabilising drugs……and the withdrawal issues common with antidepressants to boot…..the current average duration for someone to be diagnosed with Bipolar in this country is 15 years with misdiagnosis as Major Depression the most common cause of this.
it is needing the extensive history which fits the diagnostic criteria which the full criteria could take in excess of a decade to present….meanwhile a person struggles repeatedly telling their physicians that their treatment is not working….they may be suicidal but it isn’t “working” something is still wrong….while they drop out of university jump between jobs and go from crisis to crisis until someone eventually does a full history rather than going along with the original assumption simply because the history simply hadn’t past yet in order to fit the diagnostic criteria……a list with which you could more readily differentiate Bipolar from Major depression at the earliest stages prior to the first major manic undeniable break….could save lives….literally not just reduce the number of tombstones but prevent lives being eaten up by decades of instability while they wait for the professionals to take another look.
I’m going to be celebraing my 50th shortly, and was diagnosed as a child with (what eventually became) ADD/ADHD depending on the therapist, then a few years ago – after over 30 years of a variety of behavioral and medicinal therapies, ‘special’ school (NY Hospital – Cornell Medical Center, White Plains NY), and one suicide attempt 10 years ago – I was finally given a diagnosis of something along the lines of “Bipolar Disorder – Major Depressive” (still can’t find the DSM-IV code for that one – Anyone? Anyone? Bueller?).
Basically, if one’s bipolar swings are to be viewed something like a sine wave with the median in the middle (1/3 manic, 1/3 depressive, 1/3 ‘normal’), mine’s more like one with the median towards the top (manic) side. My “highs” aren’t ‘that’ high – I don’t go climbing on rooftops thinking I’m God, more like I get super-obsessed with a ‘brilliant idea’ only to come down later, but my lows are very low (poor description, maybe, I grant you – visualize with me.)
But when I finally realized that I DO in fact have a form of Bipolar Disorder, however masked in depression it is, my life changed. Permanently, I trust.
With apologies to G.I. Joe, “Knowledge is half the battle.” Knowing, finally, that I could grasp the concept of what was really happening in my brain, and – granted – being ‘properly medicated’ (No, I won’t tell you what it is, but it’s not inhibiting my ability to tell you this, is it?), I have been able to work thru these issues and contribute once again.
And that, in a nutshell, is that. Dunno if that helps anyone, angers anyone, or whatever…don’t care, either. It’s my story. And thankfully, I’m here to tell it. My 19 yr old son was diagnosed early on with Asperger’s Syndrome – maybe I have it too. Don’t care about that either.
Point is, don’t give up in your search for the right answer…don’t just accept the first ‘diagnosis’ as the right one, or jump to medication (Lithium was the worst thing ever prescribed to me) without knowing why you’re doing it. If you can’t decide, get a loved one to really LOOK at it.
It’s your life. Mine has been reclaimed. I hope yours will be too.
Blessings,
Flyback
My partner was misdiagnosed for over 18 years…..exactly the above happened….
he was midway through his 30’s before the drugs caused such a serious psychotic break and doctors refusing to listen we were that desperate that we would have traveled any distance for decent care. it cost our insurance $20 000 for him to be base lined for full diagnosis and a full history to be done….it was missed for so long because he had No idea what Mania was, no one ever asked him, no one ever explained that auditory and visual hallucinations are still hallucinations if they do not present exactly as the example they provide during questions…..
the check lists currently used are inadequate and leave too many holes…..yes I believe close to 30% would be falling through the cracks…..maybe not in the US but certainly in Australia. it is a serious problem and one acknowledged by mental health foundations here and they at least are bothering to find ways to change that and take such efforts seriously…..
these are not people who would be otherwise not diagnosed with a mental illness…..this is differentiating between bipolar and major depression.
Looking for red flags amongst the sea of common symptoms of the disorders…of those who are seriously mentally ill….not just walking in off the street.
sorry but to some extent I find your dismissal of it disgusting….they are trying to detect early the more complicated disorder which is often missed….not completely rewrite the criteria…it makes a difference with treatment…it has a big difference of effectiveness of those treatments to get it right the first time.
Doc, I could send you to support and recovery sites where people will tell you they never had an episode of manic or even depression prior to being prescribed AD’s. It would be hard to determine criteria IF the drug being used to treat OCD is causing bipolar.
My ex never had anything that remotely resembled the behaviors that came 6 months after taking Prozac. Pull up your list of symptoms for mania and put a check mark next to every one of them. And they lasted for at least 6 months.
I will add this. It is not such a dire consequence giving and AD to a patient that may end up being bipolar (or its little brother borderline). What most prescribing physicians fail is to follow the protocol to “maintain close contact with the patients immediate care givers to observe for drastic behavioral changes”. Her doctor wouldn’t and couldn’t see me due to privacy laws. However, I derived a letter describing her threat of suicide, harming the baby, assault and arrest on me, and increased extra marital activity. Her doctors response was to double from 10 to 20 mgs and put this patient who had never been on a BC in 15 years on one. That was the GP’s response. I thought I had seen “crazy” until the behavior that proceeded that. We are creating some of these monsters.
Dear Doctor,
YOU are so right! I have been treated for 5 years for “depression” and have been taking all these anti-depressants. I still did not feel well. I moved out of State and had to change doctors. At first he kept me on the same medications. I kept telling him that I did not feel well and could not sleep, had all these thoughts racing through my mind, I was confused, kept talking about different things, was very creative and could not stop thinking. He said, “We can stop that.” He ordered risperidone but did not tell me much more. It has been a total change! My mind has calmed down, and I don’t skip around talking about different subjects on and on and on.
Unfortunately, the other doctor had misdiagnosed me as just “depressed” but missed the target completely.
Thank you for bringing this to the forefront. Maybe doctors will consider taking a good look at their patients when they still do not feel well.
I was diagnosed with depression,anxiety,OCD and since the age of nine, for 18years I’m now having to be re diagnosed because my mood swings were not acknowledged nor were the hallucinations. My psychiatrist has made me wait 4 months to complete a mood diary before he will see me again which is not great when your suicidal. My own doctor has practically begged for me to be seen sooner with no avail,and is still giving me anti depressents that I feel are making me worse with episodes occuring more frequently.
This new revision and change to the criteria regarding the number of symptoms needed to be present in a bipolar diagnosis is an excellent development in mental health,particularly if the psychiatrists and psychologists in the UK actually take note!
However the only down side would be the over diagnosis of bipolar in depressed patients.
I was surprised by your introductory paragraph because almost all the bipolar people I know were initially misdiagnosed with only depression, and my doctors have told me that’s really common, yet you state it as a surprise discovery.
I was diagnosed as depressed because my primary symptom is severe depression. After 24 years of taking the wrong medication and getting worse and more unstable (and also not less depressed), I was finally diagnosed as having Bipolar II. Now I take a mood stabilizer and, although still depressed, I am not unstable and erratic and alienating friends and getting laid off from work all the time.
Bipolar disorder — sometimes called manic-depressive disorder — causes mood swings that range from of the lows of depression to the highs of mania.
I have personally treated two patients without any history of mania…any my histories are thorough/include several family members, etc…with antidepressants who then developed full blown mania, and there is no good literature identifying this phenomenon as merely “substance induced” vs “unmasking a primary bipolar disorder.” I agree with Dr. Grohol’s skepticism, but do wonder if it is appropriate to loosen or broaden the “criteria”. One thing that I am finding very strange and no one has mentioned this…Sanofi manufactures Depakote, a medication that went generic a long time ago. I’m not sure this warrents such a large scale study as the drug will not be hugely profitable to the company forever…So, the real question I think is…what does Sanofi have in the pipeline right now?
perhaps introduction of amisulpride to the American market following significant international success…just a thought
I looked into the portfolio of Sanofi Aventis R&D, and found nothing of interest concerning bipolarity. As previously stated, their sole contribution appears to be valproate (Depakote in the US). If they are funding this study for their own gain, the question is more complex.
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