The Misdiagnosis Of Bipolar Disorder As Major Depression In The Primary Care Setting Nasa Valentine, md

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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 Medicine


  • Depression, prevalent disorder 12% annually - 20 million people

  • Occurs 5-10% in primary care patients

  • Male/Female ratio 1:2

  • Most common: white race

Major depressive episode

  • S leep

  • I nterest

  • G uilt

  • E nergy

  • C oncentration

  • A ppetite

  • P sychomotor Retardation

  • S uicidality

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

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

Unipolar vs Bipolar



  • 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


  • 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


  • Mood Disorder Questionaire (MDQ)

  • Screening instrument for bipolar disorder

  • Sensitivity of 73% and specificity of 90% for a bipolar diagnosis


  • MDQ positive defined as:

  • Seven symptoms or more marked

  • Several positive symptoms occurring over same period of time

  • Moderate to severe functional impairment


  • 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


  • 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









Analysis of Results

  • Confirm that females outnumber males in having mood disorders

  • Confirm that caucasians outnumber other races in having mood disorders

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


  • 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


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

  • Major depression – Antidepressant

  • Bipolar disorder – Mood Stabilzer

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


  • 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.

  • Sample size

  • Retrospective study

  • Convenience sampling

American Psychiatric Association (2000). Diagnostic and statistical

  • American Psychiatric Association (2000). Diagnostic and statistical

  • manual of mental disorders (4th ed. TR).

  • Bhalla RN Depression. 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.

© 2008 Valentine

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