During the past few years, many experts have suggested that bipolar disorder — a serious illness resulting in significant psychosocial morbidity and excess mortality — is under-recognized, particularly in patients with major depression. Even patients who are diagnosed with bipolar disorder often wait more than 10 years after initially seeking treatment for the correct diagnosis to be made.
The clinical implications of the failure to recognize bipolar disorder in depressed patients include the under-prescription of mood-stabilizing medications, and an increased risk of rapid “cycling” — swings between manic and depressive phases. But, perhaps as a consequence of concerted efforts to improve the recognition of bipolar disorder, during the past few years we have observed the emergence of an opposite phenomenon — overdiagnosis.
In my own practice, my colleagues and I have encountered patients who reported that they were previously diagnosed with bipolar disorder, despite lacking a history of manic or hypomanic episodes. To be sure, we have also seen patients seeking treatment for depression who really did have bipolar disorder. However, there seemed to be more overdiagnosis than underdiagnosis.
We therefore conducted a study to examine empirically how often bipolar disorder might be over- and under-diagnosed. Seven hundred psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV (SCID) and completed a self-administered questionnaire that asked whether they had been previously diagnosed by a health-care professional with bipolar or manic-depressive disorder. Family history information was obtained from the patient regarding their immediate relatives.
Slightly more than 20 percent (145 patients) in our sample reported that they had been previously diagnosed as having bipolar disorder, significantly higher than the 12.9 percent rate based on the SCID. Less than half of those who reported that they had been previously diagnosed with bipolar disorder were diagnosed with bipolar disorder based on the SCID. Patients with SCID-diagnosed bipolar disorder had a significantly higher risk of bipolar disorder in their immediate family members than patients who self-reported a previous diagnosis of bipolar disorder that was not confirmed by the SCID. Patients who self-reported a previous diagnosis of bipolar disorder that was not confirmed by the SCID did not have a significantly higher risk for bipolar disorder than the patients who were negative for bipolar disorder by self-report and the SCID. Our findings, validated by family history, thus suggest that bipolar disorder was overdiagnosed.
Any study seeking to determine whether a psychiatric disorder is over-diagnosed will find that some patients with the condition do not have it upon re-interview. Such is the nature of the imperfect reliability of psychiatric diagnosis. The question, then, is not whether some patients previously given a diagnosis do not seem to have it upon re-interview, but rather how many . How high the percentage should be before claiming over-diagnosis is a significant problem and a value judgment. But we think that an over-diagnosis rate of more than 50 percent crosses the clinical significance threshold.
Over-diagnosis of bipolar disorder has costs. Mood stabilizers are the treatment of choice, and, depending on the medication, they can produce potentially significant health complications affecting renal, endocrine, hepatic, immunologic, or metabolic function.
The impact of marketing efforts by pharmaceutical companies and publicity probably plays a role in the emerging tendency to over-diagnose bipolar disorder. Direct-to-consumer advertisements that refer individuals to screening questionnaires can result in patients suggesting to their doctors that they have bipolar disorder. We have seen evidence of this in our practice. This does not necessarily reflect a problem with the performance of a screening questionnaire, but rather how these scales are used. Screening questionnaires maximize sensitivity, at a cost of false positives, because it is presumed that they are followed by expert clinical evaluation. But insufficient diagnostic rigor can result in overdiagnosis.
Clinicians are inclined to diagnose disorders that they feel more comfortable treating. We believe that the increased availability of medications that have been approved for the treatment of bipolar disorder might be influencing clinicians who are unsure whether or not a patient has bipolar disorder or borderline personality disorder to err on the side of diagnosing the disorder that is responsive to medication.
This bias is reinforced by the marketing of pharmaceutical companies to physicians, which has emphasized research on delayed diagnosis and under-recognition of bipolar disorder, possibly sensitizing clinicians accordingly. The campaign against under-recognition has probably resulted in some anxious, agitated and/or irritable depressed patients who complain of insomnia and “racing thoughts” being misdiagnosed with bipolar disorder.
The results of our study are consistent with prior studies suggesting possible problems with the diagnosis of bipolar disorder. With the greater number of medications approved for the treatment of bipolar disorder, along with multiple reports cautioning clinicians against underdiagnosis, it appears that overdiagnosis has become a greater problem than underdiagnosis. Both can have negative consequences.
Mark Zimmerman is associate professor of psychiatry and human behavior at Brown Medical School.
COPYRIGHT: PROJECT SYNDICATE
Former president Ma Ying-jeou (馬英九) in recent days was the focus of the media due to his role in arranging a Chinese “student” group to visit Taiwan. While his team defends the visit as friendly, civilized and apolitical, the general impression is that it was a political stunt orchestrated as part of Chinese Communist Party (CCP) propaganda, as its members were mainly young communists or university graduates who speak of a future of a unified country. While Ma lived in Taiwan almost his entire life — except during his early childhood in Hong Kong and student years in the US —
Chinese Nationalist Party (KMT) lawmakers on Monday unilaterally passed a preliminary review of proposed amendments to the Public Officers Election and Recall Act (公職人員選罷法) in just one minute, while Democratic Progressive Party (DPP) legislators, government officials and the media were locked out. The hasty and discourteous move — the doors of the Internal Administration Committee chamber were locked and sealed with plastic wrap before the preliminary review meeting began — was a great setback for Taiwan’s democracy. Without any legislative discussion or public witnesses, KMT Legislator Hsu Hsin-ying (徐欣瑩), the committee’s convener, began the meeting at 9am and announced passage of the
Prior to marrying a Taiwanese and moving to Taiwan, a Chinese woman, surnamed Zhang (張), used her elder sister’s identity to deceive Chinese officials and obtain a resident identity card in China. After marrying a Taiwanese, surnamed Chen (陳) and applying to move to Taiwan, Zhang continued to impersonate her sister to obtain a Republic of China ID card. She used the false identity in Taiwan for 18 years. However, a judge ruled that her case does not constitute forgery and acquitted her. Does this mean that — as long as a sibling agrees — people can impersonate others to alter, forge
In response to a failure to understand the “good intentions” behind the use of the term “motherland,” a professor from China’s Fudan University recklessly claimed that Taiwan used to be a colony, so all it needs is a “good beating.” Such logic is risible. The Central Plains people in China were once colonized by the Mongolians, the Manchus and other foreign peoples — does that mean they also deserve a “good beating?” According to the professor, having been ruled by the Cheng Dynasty — named after its founder, Ming-loyalist Cheng Cheng-kung (鄭成功, also known as Koxinga) — as the Kingdom of Tungning,
RSS