The Year in Psychiatry: Studies Not to Miss From 2011

Christoph U. Correll, MD; Maren Carbon, MD


November 23, 2011

In This Article

How Often Is Bipolar Disorder Disguised as Depression?

Angst J, Azorin JM, Bowden CL, et al; BRIDGE Study Group. Prevalence and characteristics of undiagnosed bipolar disorders in patients with a major depressive episode: the BRIDGE study. Arch Gen Psychiatry 2011;68:791-798.

Recurrent major depressive episodes define major depressive disorder, but they also occur in bipolar disorder. Because these depressive episodes are typically perceived as more impairing than hypomanic episodes, hypomania often goes unnoted by patients and their treating clinicians. Nevertheless, treatment regimens in bipolar disorder and major depressive disorder clearly differ, as patients with bipolar disorder do not respond adequately to antidepressant treatment alone. To the contrary, antidepressants may worsen bipolar symptoms, "roughen" the illness course, or trigger a manic/hypomanic episode. Thus, disentangling these entities in each affected individual is an important diagnostic goal. In earlier studies, Angst and colleagues have developed "bipolar specifier" criteria to increase the sensitivity for identifying bipolar disorder relative to the more narrowly defined DSM-IV-based diagnosis of bipolar disorder. The "bipolar specifier" is applied in patients with at least 1 episode of elevated mood, 1 episode of irritable mood, or 1 episode of increased goal-directed activity with concurrent evidence of at least 3 DSM-IV B criteria for bipolar mania. In addition, at least 1 of the following 3 consequences have to be present: (1) unequivocal and observable change in the person's behavior that is uncharacteristic for the person; (2) marked impairment in social or educational/vocational functioning observable by others; or (3) requiring hospitalization or outpatient treatment.

In this multicenter study across Asia, Africa, and Europe, the investigators aimed to validate the bipolar specifier concept by determining the frequency of bipolar symptoms in patients consulting a psychiatrist for a current major depressive episode. Bipolarity was defined on the basis of the DSM-IV-TR criteria and by the bipolarity specifier criteria. Among 5635 patients with a major depressive episode, bipolar disorder was diagnosed in 903 patients (16%) using only DSM-IV-TR criteria, while 2647 (47.0%) met the bipolarity specifier criteria. Combining both definitions, significant associations (odds ratio > 2; P < .001) with bipolarity were found for family history of mania/hypomania and multiple past mood episodes. In addition, the bipolarity specifier identified significant associations for manic/hypomanic states during antidepressant therapy, current mixed mood symptoms, and comorbid substance-use disorder. These data question the current, narrow diagnostic criteria for bipolarity implemented in the DSM-IV and have relevance for the discussions about defining and demarcating the bipolar spectrum in DSM-V. Of note, this study argues for heightened attention regarding aspects of bipolarity before establishing a treatment regimen in every patient presenting with a major depressive episode. Because (hypo)manic symptomatology may be underreported particularly during a depressive episode, informant and good historical healthcare information are crucial for making the most accurate diagnosis and developing a treatment plan.


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