Transcript PRESENTATION NAME - RCRMC Family Medicine Residency

The Misdiagnosis Of Bipolar Disorder As
Major Depression In The Primary Care
Setting
Nasa Valentine, MD
Wael Hamade, MD
Than Luu, MD
RCRMC Department of Family Medicine
Introduction
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Depression, prevalent disorder 12% annually
- 20 million people
Occurs 5-10% in primary care patients
Male/Female ratio 1:2
Most common: white race
Katon W Gen Hosp Psych. 1992, 14:237-47
Bhalla RN Depression. Emedicine.com. Mar 5, 2008
Major depressive episode
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S leep
I nterest
G uilt
E nergy
C oncentration
A ppetite
P sychomotor Retardation
S uicidality
Pfizer
Major Depression vs Bipolar Disorder
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Major Depression distinguished from bipolar
disorders by the fact that there is no history
of ever having had a Manic, Mixed or
Hypomanic Episode
American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th edition.1994:345.
Bipolar Epidemiology
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Peak age of onset for Bipolar symptoms is
between 15-19 years; followed by 20-24
years
No race ethnicity based differences reported
Incidence of Bipolar Disorder is significantly
high (11%) for patients whose first-degree
relatives have a history of bipolar disorder
Rehm, L.P., Wagner, A.L., & Ivens-Tyndal, C., (2001). Mood disorders: unpopular and bipolar. In H.E. Adams
& P.B. Sutker (Eds.), Comprehensive handbook of psychopathology (pp. 277-301). New York, NY: Plenum
Publishers.
Unipolar vs Bipolar
Unipolar
Age of onset Later
Bipolar
References
Earlier
Akiskal 1995
Benazzi
2001/2003
Goldberg 2001
More (BP II)
Recurrences Fewer
(> 4)
More unipolar; More bipolar;
Family
fewer mood
more mood
History
Comorbidity
disorder
disorder
Less panic,
GAD
More panic,
GAD
MEASURE resource module: Unipolar vs Bipolar Depression
Benazzi 2003
Akiskal 1995
Benazzi 2003
Simon 2003
Objective
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To determine what percentage of the Family
Care Clinic patient population diagnosed with
major depression actually have bipolar disorder
Methods
Study design
 Adult patients in Family Care Clinic with a previous
or current diagnosis of depression are screened for
bipolar disorder
 Patients are either screened at their scheduled clinic
appointment or called at home and interviewed
 Epidemiological and clinical data were collected
through interviews and medical records
Methods
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Charts with ICD9 code (311) for depression
for last two years pulled and reviewed
(convenience sampling)
Inclusion criteria: ages>18 diagnosed with
depression
Exclusion criteria: ages<18, invalid contact
number, deafness, dementia, death, refusal,
drug abuse
Methods
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Mood Disorder Questionaire (MDQ)
Screening instrument for bipolar disorder
Sensitivity of 73% and specificity of 90% for a
bipolar diagnosis
Hirschfield RMA, Am J Psychiatry 2000, 157:1873-1875
Methods
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MDQ positive defined as:
Seven symptoms or more marked
Several positive symptoms occurring over
same period of time
Moderate to severe functional impairment
Methods
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If patients were screened positive on the
MDQ, they were interviewed further
Antidepressants halted or tapered and mood
stabilizers started
Referred to Mental Health and Behavioral
Health
406 Randomized charts/patients
Flowchart Through the Study
w/diagnosis of depression reviewed
246 Excluded (not eligible)
205
18
12
6
3
3
No valid contact number
Dementia
Refused
Death
Drugs
Deaf
160 Eligible
MDQ Positive
MDQ Negative
Results
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406 patients/charts with dx of major
depression interviewed/reviewed
160 patients eligible for MDQ
Ages 20-70
Mean age 50.2 years at onset of study
Results
Gender
140
126
120
100
80
N=160
60
40
34
20
0
M
F
Results
Gender
M
21%
N=160
M
F
F
79%
Results
Race
90
80
80
70
60
54
50
N=160
40
30
20
20
10
6
0
Asian
Black
Hispanic
White
Results
Race
Asian, 4%
Black, 12%
N=160
Asian
Black
White, 50%
Hispanic
Hispanic ,
34%
White
Results
Whether MDQ Used In Original Assessment of Depressive Episode
MDQ used
160
142
140
120
N=160
100
80
60
40
18
20
0
MDQ used
MDQ not used
Results
Whether MDQ Used In Original Assessment of Depressive Episode
11%
N=160
MDQ used
MDQ not used
89%
Results
Results of those screened for bipolar disorder
160
134
140
120
100
80
N=160
60
40
26
20
0
MDQ Positive
MDQ Negative
Results
Results of those screened for bipolar disorder
16%
MDQ Positive
MDQ Negative
84%
N=160
Analysis of Results
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Confirm that females outnumber males in
having mood disorders
Confirm that caucasians outnumber other
races in having mood disorders
Analysis of Results
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Primary care providers (11%) underutilize
mood disorder questionnaires in the
assessment of depressive episodes
16% of clinic patients diagnosed as having
major depression were likely misdiagnosed
Discussion
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We showed in our results that bipolar
depression can be misdiagnosed as unipolar
depression
Patients will report on periods of depression
but neglect to report periods of elevated
mood
Discussion
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It is important to distinguish between the two,
because treatment differs
Major depression – Antidepressant
Bipolar disorder – Mood Stabilzer
Use of antidepressants in bipolar
disorder
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Significant risk of mania
May cause rapid mood-cycling
No reduction in mortality (completed
suicides)
Less effective than mood stabilizers in
preventing depressive relapse
Ghaemi SN et al. Bipolar Disorders. 2003;5:421-433.
Discussion/Recommendation
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There was a misdiagnosis of bipolar disorder
as major depression in our clinic population.
The Mood Disorder Questionnaire (MDQ) is
an easy tool to screen for bipolar disorder in
the primary care setting and should be used
when screening for unipolar depression and
before any antidepressants are prescribed.
Limitations
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Sample size
Retrospective study
Convenience sampling
References
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American Psychiatric Association (2000). Diagnostic and statistical
manual of mental disorders (4th ed. TR).
Bhalla RN Depression. Emedicine.com. Mar 5, 2008
Ghaemi SN et al. Bipolar Disorders. 2003;5:421-433.
Katon W Gen Hosp Psych. 1992, 14:237-47.
Kessler, R. C., et al. (1994). Lifetime and 12-month prevalence of DSM-III-R
psychiatric disorders in the United States. Archives of General
Psychiatry, 51, 8-19.
Kung H et al. National Vitals Stat Report. 2008,56, 1-120.
Hirschfield RMA, Am J Psychiatry 2000, 157:1873-1875.
Hirschfield RMA. J Clin Psychiatry 2002;4:9-11.
MEASURE resource module 8
MEASURE resource module: Unipolar vs Bipolar Depression
Rehm, L.P., Wagner, A.L., & Ivens-Tyndal, C., (2001). Mood disorders:
unpopular and bipolar. In H.E. Adams & P.B. Sutker (Eds.)
Comprehensive handbook of psychopathology (pp. 277-301). New York,
NY: Plenum Publishers.
© 2008 Valentine