Is Your Depressed Patient Bipolar?

Neil S. Kaye, MD, DFAPA

J Am Board Fam Med. 2005;18(4):271-281.

Consequences of Misdiagnosis

Missing the diagnosis of a bipolar disorder could have serious and even occasionally fatal consequences for a person with the illness. Lifetime risk of suicide attempts among patients with bipolar disorders ranges from 25% to 50%,^[32] and estimates of completed suicide in persons with a bipolar disorder diagnosis are between 10% and 15%.^[7] Epidemiologic data also reveal that suicide attempts occur 30 times more frequently during depressive episodes than during manic or hypomanic states.^[4]

Misdiagnosis and inappropriate treatment can also prolong suffering and contribute to worsening occupational, family, and social problems. The situation is particularly concerning because the use of antidepressants in bipolar depression, especially without the concomitant use of a mood stabilizer, may actually worsen the course of the disease. Antidepressants have been shown to contribute to rapid cycling,^[28,33]in which patients experience more mood swings than are normally seen, with at least 4 episodes of mania/hypomania and/or depression over a 1 year period. Rapid-cycling patients experience more episodes of illness, with progressively shorter periods of wellness and a diminished response to medication.^[34] At the present time, it is unclear whether the use of mood stabilizers in conjunction with an antidepressant protects against the development of rapid cycling.

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Table 4. Features Indicative of Bipolar Disorders
	Bipolar	Unipolar
Substance abuse	Very high	Moderate
Family history	Almost uniform	Sometimes
Seasonality	Common	Occasional
First episode <25 years	Very common	Sometimes
Postpartum illness	Very common	Sometimes
Psychotic features <35 years	Highly predictive	Uncommon
Atypical features	Common	Occasional
Rapid on/off pattern	Typical	Unusual
Recurrent major depressive episodes (>3)	Common	Unusual
Antidepressant-induced mania or hypomania	Predictive	Uncommon
Brief major depressive episodes (avg <3 months)	Suggestive	Unusual (episode duration usually >3 months)
Wearing off of antidepressant efficacy	Suggestive	Uncommon
Mixed depression (presence of hypomanic features within the depressive episode)	Predictive	Rare

Data from refs. [7], [50], [54] (p. 114-9, 200-2), [51], [65], and [70].

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