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Screening For Bipolar Disorder in Primary Care Setting

written by: GiangNguyen • edited by: Paul Arnold • updated: 12/5/2008

Bipolar disorder is often misdiagnosed as depressive disorder, particularly in primary care settings. This article discusses the use of a simple screening methodology to improve detection rate for bipolar disorder in primary care setting.

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    Bipolar disorder spans a broad spectrum ranging from bipolar I disorder, bipolar II disorder, to cyclothymia. A patient is diagnosed with bipolar disorder if she or he had one or more episodes of manic symptoms such as euphoric, racing thoughts, a decrease need for sleep, talkativeness. One of the challenges associated with diagnosing bipolar disorder is to distinguish whether depressive symptoms are part of a depressive disorder or bipolar disorder. Failure to diagnose bipolar disorder correctly will lead to the use of unopposed antidepressants to improve depressive symptoms, hence, increase the risk of mania, hypomania, mixed affective states and rapid cycling between mania and depression.

    One of the main tools used for screening bipolar disorder is the Mood Disorder Questionnaire (MDQ), which is a 15-item self-report, single-page, paper-and-pencil assessment of lifetime bipolar disorder. The questionnaire was developed based on Diagnostic and Statistical Manual of MentalDisorders, Fourth Edition (DSM-IV) criteria. The MDQ screens for history of a manic or hypomanic syndrome. A score of 7 indicates elevated risk for bipolar disorder.The MDQ has a sensitivity of 0.28 and a specificity of 0.97 in a community sample; a sensitivity of 0.73 and a specificity of 0.90 in an outpatient psychiatric sample.

    Das et al. (2005) conducted a community-wide study to examine the effectiveness of screening for bipolar disorder. Participants in the study were recruited from adult patients seeking primary care. Participants were asked to complete the Mood Disorder Questionnaire (MDQ). They were also asked about the age of symptoms onset and whether they consulted health care professional about the symptoms.

    Das et al.(2005) found that roughly 10% of the participants had a positive screen for a lifetime history of bipolar disorder. The most common symptoms for mania are irritability or hyperness. About 10% of participants reported an onset at age 18 or younger whereas ~40% reported an age of onset at age 40 or older. Gender, age, race/ethnicity, marital status, and level of educational achievement do not affect the prevalence of screening positive for bipolar disorder. About one-in-every five people screened positive for bipolar disorder had suicidal thoughts at least some days during the previous two weeks. This rate is about six times higher than those who screened negatively for bipolar disorder. The reported prevalence in this study is 10-15 higher in comparison to other studies. This is probably due to the low socioeconomic status of the population participated in the study.

    The study emphasizes the importance for screening for bipolar disorder in primary care serving poor populations. Low-income people are less likely to receive proper treatment or any treatment at all. Low-income people are also more likely to rely on primary care. Using effective screening techniques, primary care professionals will help to improve the rate of detection for bipolar disorders and the chance that patients with bipolar disorder will receive proper treatment. There is a growing risk that misdiagnosed cases of bipolar disorder in primary care will receive antidepressants (which might have adverse effects on bipolar patients) rather than mood stabilizers.

    References

    Hirschfeld RM, Williams JB, Spitzer RL, et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Am J Psychiatry. 2000;157:1873-1875.

    Screening for Bipolar Disorder in a Primary Care Practice, Amar K. Das, et al JAMA. 2005;293:956-963.