The very fact that bipolar disorder has a history of being underdiagnosed may be sensitizing clinicians to avoid missing the diagnosis altogether. This is resulting in an equal if not greater problem of overdiagnosis, according to a recent study published in the Journal of Clinical Psychiatry.
Lead author Mark Zimmerman, M.D., reports that fewer than half the patients in the study who were previously diagnosed with bipolar disorder received their diagnosis based on the Structured Clinical Interview for DSM-IV (SCID). Of those who had, there was a significantly higher risk of bipolar disorder in first degree relatives.
Overdiagnosis raises some serious questions about the ‘alternative’ diagnosis that may have been missed. I put this question to Dr Zimmerman who replied, “I would hypothesize that a number of patients with major depressive disorder and comorbid personality disorder (especially borderline personality disorder) are overrepresented in the overdiagnosis group.”
Side effects of medication are an additional concern. Mood stabilizers, invariably prescribed for bipolar disorder, can have some serious side effects and may also affect renal, endocrine, liver, immunologic and metabolic functions.
Once a diagnosis of bipolar disorder is made no further checks and balances, for example being re-interviewed at a later date, are made to ensure accuracy of diagnosis. When I asked Dr Zimmerman why this is the case, his response points out something of the clinical dilemma facing the clinician:
“ . . . if they [the patient] do not experience additional episodes after beginning treatment this could (rightfully) be interpreted as successful treatment. The method of verifying diagnostic validity in such a case could mean tapering down medication to see if a new episode occurs. Some patients may elect to do this because they are hesitant to stay on medication for the rest of their lives until convinced it is necessary, whereas others may be unwilling to risk another episode of illness.”
In a previous interview, Dr Zimmerman speculated that the increased availability of medications for bipolar disorder, reinforced by messages from pharmaceutical companies which emphasize underrecognition and avoiding treatment delay, is influencing clinicians to err on the side of diagnosing the disorder that is responsive to medication. Zimmerman recommends that clinicians use a standardized, validated method in diagnosing bipolar disorder.
Dr Mark Zimmerman is director of outpatient psychiatry at Rhode Island Hospital and an associate professor of psychiatry and human behavior at the Warren Alpert Medical School of Brown University. The report is from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS).
Published On: May 12, 2008
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