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Study: bipolar
disorder over diagnosed
(August/September
2008 Issue)
By Pamela Berard
A recent study suggests that bipolar disorder is over diagnosed.
In the study, less than half of those people previously diagnosed
with bipolar disorder met the diagnostic criteria for it when assessed
by the Structured Clinical Interview for DSM-IV (SCID). The 700
psychiatric outpatients who participated completed a self-administered
questionnaire that asked whether they had been previously diagnosed
with bipolar or manic depressive disorder by a health care professional.
Family history information was obtained by the patient. Of the
700 patients, 145 said they had been previously diagnosed as having
bipolar disorder. But based on the SCID, fewer than half of those
145 patients (43.4 percent) were diagnosed with bipolar disorder.
Additionally, patients diagnosed with bipolar disorder based on
the SCID had a higher morbid risk of bipolar disorder in first-degree
relatives than did those who were not diagnosed with bipolar disorder
according to the SCID interview.
Study author Mark Zimmerman, M.D., director of outpatient psychiatry
at Rhode Island Hospital and associate professor of psychiatry and
human behavior at Brown University, says under diagnosis remains
a concern with bipolar disorder, but he hoped to highlight the issue
that "it has swung the other way," and over diagnosis also represents
a problem.
A number of significant clinical repercussions of over diagnosis
exist, he says. Among them, "some patients are being treated needlessly
with medications. They are being exposed to potential side effects
they otherwise would not be," Zimmerman says. Also, some individuals
may put too much of their identity in the diagnosis. "You need
to work with them and suggest there is no magic pill out there.
There are other issues they need to work on."
Participants in the study who reported being previously diagnosed
were diagnosed from a variety of sources, including therapists and
primary care physicians.
Vermont psychologist Kirke McVay, M.A., who has a part-time private
practice and does disability review for Social Security, says many
people who come in for a review have been inaccurately diagnosed
with bipolar disorder. "A lot of the diagnosis is made by primary
care providers," McVay says. "If people have depression or irritability,
they just get labeled as bipolar."
He says many primary care physicians aren't aware of intermittent
explosive disorders and other disorders in the spectrum.
McVay says he believes bipolar disorder is over diagnosed, although
he isn't sure it causes a great deal of harm. "In most cases, there
is no harm because in terms of medication, you're probably going
to do the same thing," whether it's bipolar disorder or a similar
diagnosis, he says.
Zimmerman's study was published online by the Journal of Clinical
Psychiatry and he presented the findings at the annual meeting of
the American Psychiatric Association.
Psychologist Susan Sanders, Ph.D., of the Morning Bridge Center
in Phillips, Maine, says that making use of the current diagnostic
criteria, the research makes sense. "However, the current understanding
and criteria leave out a significant number of individuals who suffer
with dysregulated moods, as they do not meet full criteria and are
often missed.
"For example, many people with what appears to be anxiety-driven
depression fare better when treated by a mood stabilizer rather
than an anti-depressant. How can one tell the difference? Often
the key is racing thoughts or too many thoughts. This is merely
one symptom, however, in an entire symptom picture," she says.
What becomes more important than stating that bipolar is over or
under diagnosed is the type of treatment that is most effective
regardless of what you call it, according to Sanders.
"Many people suffer with an anxiety that is more like hypomania,
yet they do not necessarily lose up to four days of sleep. They
just may sleep restlessly or a few hours periodically. Often they
display obsessive compulsive behaviors. Yet they seem to fare far
better when treated with a mood stabilizer rather than an antidepressant,"
she says.
"Therefore, the real question is not whether it is under or over
diagnosed; the real question is about the current paradigm. A mood
spectrum paradigm works better when choosing medical treatment,"
she adds.
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