What do Jean-Claude Van Damme
and Carrie Fisher (aka Princess Leia) have in common?
Both suffer from bipolar disorder and both have been successfully
treated. How many of your patients suffer from this condition?
It could be as many as one in 10, according to a study
published in the February 23 issue of the Journal of the
American Medical Association (JAMA). The study
also finds an alarming treatment gap, with many patients
receiving prescriptions that could worsen their condition.
BALANCING
ACT
The problem is that bipolar disorder isn't helped by
antidepressants alone. Such meds can provoke the manic
phase and produce what the study's authors, headed by
Dr Amar Das of the New York Psychiatric Institute, euphemistically
called "adverse events," unless combined with a mood
stabilizer such as lithium.
It's generally been assumed that
mental illnesses other than depression are rare enough
to be left to the specialists, but the JAMA study
casts doubt on that cosy assumption. Of 1,157 patients
between the ages of 18 and 70 who were seeking primary
care at an urban general medicine clinic, 9.8% screened
positive for bipolar disorder. The prevalence was the
same across all categories of age, sex and race.
DIAGNOSIS
DILEMmA
Surprisingly, nearly three-quarters of these bipolar
patients had sought medical help for their psychiatric
symptoms. Primary care physicians had recorded diagnoses
of current depression for 49% of these patients, but
none made any mention of bipolar disorder. Out of a
total of 107 patients with bipolar disorder, only nine
had a correct diagnosis, and a measly seven had taken
mood-stabilizing drugs in the previous month.
There are potential questions over
the methodology of the research, which diagnosed bipolar
disorder using a mix of standardized questionnaires,
data on past mental health treatments, and reviews of
medical records. The rate of bipolar disorder found,
at nearly 10%, is almost twice as high as the best existing
research would suggest.
A 2002 study by the American Psychiatric
Association (APA) revealed a national bipolar disorder
rate of 3.4%, which even then was three times higher
than most experts believed. Some might wryly attribute
the extraordinarily high rate of mental illness among
the JAMA study patients to the fact that they
live in New York City. However, the APA's 2002 survey
showed that rates were highest in rural areas and small
towns. Nevertheless, the authors do believe that environment
played a role in the high burden of bipolar disorder
in these patients.
"The high estimated prevalence
in this clinical setting," they presumed in the paper,
"may be related to the low socioeconomic status of the
population. In a national study, lifetime prevalence
of bipolar disorder was highest (5.7%) among participants
with the lowest annual household income (less than $20,000/year)."
FP
EFFORT
As to the misdiagnoses, it's known that patients with
bipolar disorder seldom seek medical help during their
manic phases, but are likely to look for antidepressant
therapy during their 'down' cycle. Any assessment based
purely on their presenting symptoms will therefore generally
lead to a diagnosis of unipolar depression. The solution
to the problem, according to the JAMA researchers,
is for primary care physicians to screen depressive
patients for past instances of mania or hypomania (mild
mania). They concluded with the psychiatrist's eternal
mantra: "further efforts are needed by primary care
physicians."
JAMA Feb 23, 2005;293:956-63
|
