Improving Diagnostic Accuracy of Bipolar Disorder

A key clinical challenge in the mood disorders is to determine whether patients with depression actually have a diagnosis of bipolar disorder.  This can be quite difficult as patients may have limited insight while suffering a manic episode.  They may have impairments in memory during manic episodes that reduce their ability to provide an accurate psychiatric history.

The symptoms of mania are outlined in the Diagnostic and Statitistical Manual-Fourth Edition, Text Revision (DSM-IVTR) and include:

A. A distinct period of elevated, expansive or irritable mood lasting at least one week

B. Presence of three of the following symptoms or signs (four if irritable mood is assessed)

• inflated self esteem or grandiosity
• decreased need for sleep
• hypertalkative
• flight of ideas (moving quickly from one subject to another), racing thoughts
• distractibility
• increase in goal-directed activity or psychomotor agitation
• engagement in pleasurable activities with high risk for adverse out, i.e. gambling

C. Not accompanied by current symptoms of depression in which case a mixed episode is diagnosed

D. Significant impairment or psychotic symptoms or need for hospitalization

E.  Not better accounted by drug use, i.e amphetamines, a medical condition, or caused by a medical treatment for depression, i.e. antidepressants

Jules Angst and colleagues from the BRIDGE study group have recently published a study suggesting additional criteria may be helpful in diagnosing bipolar disorder in those with a history of depression.  Angst has previously proposed a bipolar specifier in depression populations that includes presence of a family history of bipolar disorder and an early-onset of illness with multiple mood episodes.

Using a international sample of over 5000 adults with ongoing major depression, Angst and his team closely examined a series of variables and determined the correlation with DSM-IV TR bipolar disorder diagnosis as well as the broader specifier criteria criteria.

The study found that a family history of mania or hypomania and multiple episodes of mood disorder did highly correlate with both DSM-IV criteria of mania.  Additionally, manic or hypomanic states during antidepressant therapy, presence of mixed mood disorder and comorbid substance abuse correlated with his bipolar specifier definition.

Using the limited DSM-IV TR mania/hypmanic criteria classifed 16% of the depressed sample as bipolar, while using the bipolar specifier increased this proportion to 47% of the sample.

The are significant clinical implications if this larger estimate of the percentage of individuals with depression meeting a bipolar variant is correct.  It would support greater use of mood stabilizers such as lithium, greater use of atypical antipsychotics such as aripiprazole and reduced use of the standard antidepressant class of drugs.  Antidepressants appear to have adverse effects on the long-term course of some individuals with the bipolar variant of mood disorder.

Dr. Gary Sachs of Harvard has also done work looking a similar expanded Bipolarity Index classification of mood disorder provided with this link.

Photo of Juno Beach sunrise using a pixelation filter from the author's collection.

Angst J, Azorin JM, Bowden CL, Perugi G, Vieta E, Gamma A, Young AH, & for the BRIDGE Study Group (2011). Prevalence and Characteristics of Undiagnosed Bipolar Disorders in Patients With a Major Depressive Episode: The BRIDGE Study. Archives of general psychiatry, 68 (8), 791-798 PMID: 21810644