The_Misdiagnosis_of_Bipolar_Disorder_as_Major_Depression (1).ppt

Major Depressive Disorder (MDD) is a serious mental health condition characterized by persistent feelings of sadness, hopelessness, and a lack of interest or pleasure in activities once enjoyed. Symptoms often interfere with daily functioning and can include:

- **Emotional symptoms:** Deep sadness, irritability, feelings of worthlessness or guilt.
- **Cognitive symptoms:** Difficulty concentrating, indecisiveness, or recurrent thoughts of death or suicide.
- **Physical symptoms:** Changes in appetite or weight, sleep disturbances (insomnia or hypersomnia), fatigue, and psychomotor agitation or retardation.

The exact cause of MDD is complex, involving a combination of genetic, biological, environmental, and psychological factors. Diagnosis typically involves a comprehensive assessment by a mental health professional, and treatment often includes therapy, medication, or a combination of both.

MDD can significantly impact relationships, work, and overall quality of life, but with appropriate treatment, many individuals experience improvement and can lead fulfilling lives. If you or someone you know is struggling, seeking help from a healthcare provider is crucial.

1. 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

2. Introduction
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

3. Major depressive episode
S leep
I nterest
G uilt
E nergy
C oncentration
A ppetite
P sychomotor Retardation
S uicidality

4. Pfizer

5. Major Depression vs Bipolar Disorder
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.

6. Bipolar Epidemiology
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.

7. Unipolar vs Bipolar
UnipolarBipolar References
Age of onsetLater Earlier Akiskal 1995
Benazzi
2001/2003
Goldberg 2001
Recurrences
(> 4)
Fewer More (BP II)Benazzi 2003
Family
History
More unipolar;
fewer mood
disorder
More bipolar;
more mood
disorder
Akiskal 1995
Benazzi 2003
ComorbidityLess panic,
GAD
More panic,
GAD
Simon 2003
MEASURE resource module: Unipolar vs Bipolar Depression

8. Objective
To determine what percentage of the Family
Care Clinic patient population diagnosed with
major depression actually have bipolar disorder

9. 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

10. Methods
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

11. Methods
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

12. Methods
MDQ positive defined as:
Seven symptoms or more marked
Several positive symptoms occurring over
same period of time
Moderate to severe functional impairment

14. Methods
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

15. 406 Randomized charts/patients
w/diagnosis of depression reviewed
246 Excluded (not eligible)
205 No valid contact number
18 Dementia
12 Refused
6 Death
3 Drugs
3 Deaf
160 Eligible
MDQ Positive MDQ Negative
Flowchart Through the Study

16. Results
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

17. Gender
0
20
40
60
80
100
120
140
M F
Results
34
126
N=160

18. Results
M
21%
F
79%
M
F
N=160
Gender

19. Results
Race
6
20
54
80
0
10
20
30
40
50
60
70
80
90
Asian Black Hispanic White
N=160

20. Results
Asian, 4%
Black, 12%
Hispanic ,
34%
White, 50%
Asian
Black
Hispanic
White
N=160
Race

21. Results
MDQ used
0
20
40
60
80
100
120
140
160
MDQ used MDQ not used
18
142
N=160
Whether MDQ Used In Original Assessment of Depressive Episode

22. Results
11%
89%
MDQ used
MDQ not used
Whether MDQ Used In Original Assessment of Depressive Episode
N=160

23. Results
26
134
0
20
40
60
80
100
120
140
160
MDQ Positive MDQ Negative
N=160
Results of those screened for bipolar disorder

24. Results
16%
84%
MDQ Positive
MDQ Negative
N=160
Results of those screened for bipolar disorder

25. Analysis of Results

Confirm that females outnumber males in
having mood disorders
Confirm that caucasians outnumber other
races in having mood disorders

26. Analysis of Results
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

27. Discussion
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

28. Discussion
It is important to distinguish between the two,
because treatment differs
Major depression – Antidepressant
Bipolar disorder – Mood Stabilzer

29. Use of antidepressants in bipolar
disorder
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.

30. Discussion/Recommendation
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.

31. Limitations
Sample size
Retrospective study
Convenience sampling

32. References
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.

33. © 2008 Valentine