Unrecognized bipolar disorder in patients with a diagnosis of unipolar depression

David L.DUBBER

Unrecognized bipolar disorder in patients with a diagnosis of unipolar depression

David L.DUBBER

The diagnosis of bipolar rather than unipolar depression is currently a clinical diagnosis w hich cannot be validated by specific biological measures,such as laboratory tests.Certainly the characteristics of bipolar depression frequently differ from unipolar major depression in that patients with bipolar depression generally have an earlier age of onset and more frequent episodes than individuals with unipolar major depression［1］. Some,but not all,studies support an increase in suicidal behaviors among bipolar as com pared with unipolar major depression［2］,and"atypical features"such as hypersomnia and hyperphagia also may be found more frequently among individuals with bipolar depression.Furthermore family histories of subjects with bipolar disorders more frequently reveal relatives with bipolar disorder.In contrast,relatives of patients with unipolar depression’s family history generally reflects major depression butnotbipolar disorder［3］.One clinical clue to a diagnosis of bipolar disorder is having more than one major depressive episode per year.W e found only a few individuals with such histories who do not have bipolar disorder［4］.

The study by Chen and colleagues in this issue of the Shanghai Archives of Psychiatry finds that the distinguishing characteristics of bipolar depression versus unipolar major depression found elsewhere are also present in Chinese patients.The rate of misdiagnosis of bipolar disorder versus major depression in this sample is consistent with the rates of misdiagnosis found in studies from other cultures.Chen and coworkers used an interesting combined methodology of self-administered rating scales and a diagnostic interview（the M IBI）to document the presumed correct diagnosis.It is of interest that some of the subjects clinically diagnosed as having major depression met criteria of current hypomania during the research assessment and, thus,were diagnosed as bipolar.

A correct diagnosis of bipolar disorder will likely lead to more appropriate treatment,as the treatment for bipolar depression is at variance with the treatment of major depression.Antidepressant treatment of individuals with bipolar depression may result in switches into mania or hypomania and more frequent depressive episodes whereas antidepressant monotherapy for individuals with major depression is likely to alleviate the depression.Furthermore,treatment for bipolar depression with certain atypical antipsychotics, lithium or lamotrigine may be of benefit whereas these treatments are less likely to be successful when used as monotherapy for individuals with major depression.

Most clinicians do not use structured assessments to make a diagnosis but instead rely on clinical interview ing skills they have learned through their residency and enhanced over time with clinical experience. However,rating scales and structured interview s such as the M IBI or the Structured Clinical Interview for DSM-IV（SCID）are likely to be better in ascertaining bipolar conditions and in detecting histories of mania and hypomania than clinical interview s alone.Very experienced clinicians using sem i-structured interview techniques may more accurately distinguish unipolar depression from bipolar depression than non-clinicians using the M IBIor the SCID［5］.How ever,most clinicians do not have this degree of expertise so it would be helpful for clinicians to adopt rating scales and structured interview techniques for their clinical practice,especially in the differential diagnosis of major depressive episodes［6-8］.This is perhaps the most important finding of the study by Chen and colleagues:the diagnosis of bipolar depression was considerably enhanced by the use of screening rating scales and structured interviewing techniques.

Psychiatry would benefit greatly by the development of laboratory tests which would validate our clinical diagnoses.However,such laboratory tests seem to be far in the future and for the time being w e as clinicians need to rely on clinical interview ing skills.

1. Dunner D l,Dw yer T,Fieve RR.Depressive symptoms in patients with unipolar and bipolar affective disorder.Compr Psychiatry,1976,17: 447-451.

2. Stallone F,Dunner DL,Ahearn J,Fieve RR.Statistical predictions of suicide in depressives.Compr Psychiatry,1980,21:381-387.

3. Dunner DL.A review of the diagnostic status of"Bipolar II"for the DSM-IV work group on mood disorders.Depression,1993,1:2-10.

4. Tay LK,Dunner DL.A report on three patients with"rapid cycling"unipolar depression.Com pr Psychiatry,1992,33:253-255.

5. Dunner DL,Tay LK.Diagnostic reliability of the history of hypomania in bipolar IIpatients and patients with major depression.Compr Psychiatry,1993,34:303-307.

6. Dunner DL.Diagnostic assessment.Psychiatr Clin Borth Am,1993,16:431-441.

7. Ghaem i SB,Bauer M,Cassidy F,Malhi GS,M itchell P,Phelps I,etal.Diagnostic guidelines for bipolar disordere:a summary of the International Society for Bipolar Disorders Diagnostic Guidelines Task Force Report.Bipolar Disord,2008,110:117-128.

（David L.DUNNER,MD,FACPsych.Director,Center for Anxiety and Depression,Mercer lsland,WA,USA；Professor Emeritus,Department of Psychiatry and Behavioral Sciences；University of W ashington,Seattle,USA. E-mail：dldunner@com cast.net）

环太平洋精神病学家学会“精神医学领导能力”研讨与培训项目招生通知

我国目前精神疾病负担逐年上升，预计到2020年将占全部疾病负担的1/5，位列第一。为了加强国内外交流与合作，提升精神医学专业及领导能力，环太平洋精神病学家学会（Pacific-Rim College of Psychiatrists,PRCP）将与中国医院协会精神病医院管理分会、上海市医院协会精神卫生中心管理委员会、上海市精神卫生中心联合举办“精神医学领导能力”研讨与培训项目，旨在培养医教研三方面结合的具有领导能力的复合型精神医学专业人才，创建一个与国内外专家直接交流的平台，同时亦建立学术的联系，拓展和加深更多合作的机会。

参加对象：本次培训主要针对领导能力进行培训，建议精神病专科医院医疗、科研、教学管理人员、高年资精神科医生、科主任等相关专业人员参加。

项目形式：授课和工作坊

特邀专家：将邀请十几位国内外精神病学领域知名专家来参加本次研讨及培训项目，主要专家如下。

瑞典大学Borman Sartorius教授，前世界卫生组织精神卫生处主任、世界精神医学会主席；新加坡国立大学Kua Ee Heok教授、环太平洋精神病学家学会主席、亚太精神病学杂志主编、新加坡老年学协会主席；上海交通大学医学院附属精神卫生中心肖泽萍教授、环太平洋精神病学家学会副主席、中国医院协会精神病医院管理分会主任委员，上海心理卫生学会理事长；美国路易维尔大学医学Allan Tasman教授；墨尔本大学医学Edmond Chiu教授；美国亚利桑那州立大学Paul Leung教授；新西兰奥克兰大学医学系Graham Mellsop教授；英国哥伦比亚大学医学系Hiram Mok教授；新加坡国立大学Tan Chay Hoon教授；北京医科大学精神卫生研究所于欣教授。

时间：2011年10月14日-15日；地点：详见第二轮通知；费用：980元/人，统一安排食宿，费用自理。

报名方式：学员以自愿报名、单位同意为宜。截止日期：2011年8月4日。为保证培训质量，将严格控制名额，报名从速。

地址：上海市宛平南路600号，邮政编码200030，上海市精神卫生中心科研科（收）

电话：021-34289888转3010/3239；传真：021-64387986

或E-mail至shivayaya2011@gmail.com,联系人：邬佳艳。

环太平洋精神医学协会

中国医院协会精神病医院管理分会

上海市医院协会精神卫生中心管理委员会

上海市精神卫生中心

2011年4月8日

10.3969/j.issn.1002-0829.2011.02.006