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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 Medic

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

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Page 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

The Misdiagnosis Of Bipolar Disorder As Major Depression In The Primary Care Setting

Nasa Valentine, MDWael Hamade, MDThan Luu, MD

RCRMC Department of Family Medicine

Page 2: 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

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

Page 3: 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

Major depressive episode

S leep I nterest G uilt E nergy C oncentration A ppetite P sychomotor Retardation S uicidality

Page 4: 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

Pfizer

Page 5: 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

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.

Page 6: 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

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.

Page 7: 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

Unipolar vs BipolarUnipolar Bipolar References

Age of onset Later 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

Comorbidity Less panic, GAD

More panic, GAD

Simon 2003

MEASURE resource module: Unipolar vs Bipolar Depression

Page 8: 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

Objective

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

Page 9: 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

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

Page 10: 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

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

Page 11: 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

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

Page 12: 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

Methods

MDQ positive defined as: Seven symptoms or more marked Several positive symptoms occurring over

same period of time Moderate to severe functional impairment

Page 13: 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
Page 14: 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

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

Page 15: 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

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

Page 16: 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

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

Page 17: 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

Gender

0

20

40

60

80

100

120

140

M F

Results

34

126

N=160

Page 18: 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

Results

M21%

F79%

M

F

N=160

Gender

Page 19: 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

Results

Race

6

20

54

80

0

10

20

30

40

50

60

70

80

90

Asian Black Hispanic White

N=160

Page 20: 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

Results

Asian, 4%

Black, 12%

Hispanic , 34%

White, 50%

Asian

Black

Hispanic

White

N=160

Race

Page 21: 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

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

Page 22: 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

Results

11%

89%

MDQ used

MDQ not used

Whether MDQ Used In Original Assessment of Depressive Episode

N=160

Page 23: 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

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

Page 24: 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

Results

16%

84%

MDQ PositiveMDQ Negative N=160

Results of those screened for bipolar disorder

Page 25: 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

Analysis of Results

Confirm that females outnumber males in

having mood disorders Confirm that caucasians outnumber other

races in having mood disorders

Page 26: 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

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

Page 27: 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

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

Page 28: 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

Discussion

It is important to distinguish between the two, because treatment differs

Major depression – Antidepressant Bipolar disorder – Mood Stabilzer

Page 29: 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

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.

Page 30: 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

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.

Page 31: 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

Limitations

Sample size Retrospective study Convenience sampling

Page 32: 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

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.

Page 33: 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

© 2008 Valentine


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