8 Controversies in Bipolar Disorder Addressed

Nassir Ghaemi, MD, MPH; Stephen M. Strakowski, MD


June 30, 2016

Controversy 6: Underdiagnosed or Overdiagnosed?

Is BD underdiagnosed, overdiagnosed, both, or neither?

Dr Ghaemi: The usual reply is to say "both," but one could say that about any condition, because all conditions involve some mistakes, some misdiagnoses. The real question is which is more predominant: Do misdiagnoses tend to go in the direction of missing BD when it is present, or mistakenly diagnosing BD when it is absent?

As a matter of percentages, the answer is that multiple studies have found that BD is predominantly missed when it is present, hence it is underdiagnosed. The rates tend to be about 30%-40%, even in studies by those who claim overdiagnosis. The rate at which BD is mistakenly diagnosed when it is not present has never been shown to be more than 13%, even in studies that claim overdiagnosis.

A common error is to mistake unreliability for overdiagnosis. The mistaken studies claiming overdiagnosis do so because they report that about 50% of patients diagnosed by clinicians with BD do not have it when reinterviewed by researchers. But this is not over- or underdiagnosis; this is simply unreliability. The same rates can be found with every psychiatric illness, and in fact with many other medical diagnoses. The kappa value for major depressive disorder (MDD) in the DSM-5 field trials was about 0.3—which means that more than 50% of the time, when clinicians would diagnose MDD, they were wrong. This isn't systematic overdiagnosis of any single condition, but rather unreliability of all psychiatric diagnosis.

Dr Strakowski: My prediction is that there are small subgroups around the world in which BD is overdiagnosed for a variety of reasons, but as Dr Ghaemi points out, the preponderance of evidence continues to suggest that the condition is too often missed. Some data suggest that it still takes multiple physician visits and up to 7 years to finally land on a (correct) BD diagnosis.

Within certain ethnic groups, namely African Americans, people with BD are very commonly misdiagnosed, in this case with schizophrenia. In fact, it appears that if you are African American and have a mood disorder, you have a nine times greater risk of being misdiagnosed with schizophrenia than a similar white patient.

Our research suggests that in African American patients, mood symptoms are either not identified or minimized; it is critical to remember that schizophrenia is a diagnosis of exclusion in all patients, but especially in this population at risk for misdiagnosis.


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