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）

環太平洋精神病學家學會“精神醫學領導能力”研討與培訓項目招生通知

我國目前精神疾病負擔逐年上升，預計到2020年將占全部疾病負擔的1/5，位列第一。為了加強國內外交流與合作，提升精神醫學專業及領導能力，環太平洋精神病學家學會（Pacific-Rim College of Psychiatrists,PRCP）將與中國醫院協會精神病醫院管理分會、上海市醫院協會精神衛生中心管理委員會、上海市精神衛生中心聯合舉辦“精神醫學領導能力”研討與培訓項目，旨在培養醫教研三方面結合的具有領導能力的復合型精神醫學專業人才，創建一個與國內外專家直接交流的平臺，同時亦建立學術的聯系，拓展和加深更多合作的機會。

參加對象：本次培訓主要針對領導能力進行培訓，建議精神病專科醫院醫療、科研、教學管理人員、高年資精神科醫生、科主任等相關專業人員參加。

項目形式：授課和工作坊

特邀專家：將邀請十幾位國內外精神病學領域知名專家來參加本次研討及培訓項目，主要專家如下。

瑞典大學Borman Sartorius教授，前世界衛生組織精神衛生處主任、世界精神醫學會主席；新加坡國立大學Kua Ee Heok教授、環太平洋精神病學家學會主席、亞太精神病學雜志主編、新加坡老年學協會主席；上海交通大學醫學院附屬精神衛生中心肖澤萍教授、環太平洋精神病學家學會副主席、中國醫院協會精神病醫院管理分會主任委員，上海心理衛生學會理事長；美國路易維爾大學醫學Allan Tasman教授；墨爾本大學醫學Edmond Chiu教授；美國亞利桑那州立大學Paul Leung教授；新西蘭奧克蘭大學醫學系Graham Mellsop教授；英國哥倫比亞大學醫學系Hiram Mok教授；新加坡國立大學Tan Chay Hoon教授；北京醫科大學精神衛生研究所于欣教授。

時間：2011年10月14日-15日；地點：詳見第二輪通知；費用：980元/人，統一安排食宿，費用自理。

報名方式：學員以自愿報名、單位同意為宜。截止日期：2011年8月4日。為保證培訓質量，將嚴格控制名額，報名從速。

地址：上海市宛平南路600號，郵政編碼200030，上海市精神衛生中心科研科（收）

電話：021-34289888轉3010/3239；傳真：021-64387986

或E-mail至shivayaya2011@gmail.com,聯系人：鄔佳艷。

環太平洋精神醫學協會

中國醫院協會精神病醫院管理分會

上海市醫院協會精神衛生中心管理委員會

上海市精神衛生中心

2011年4月8日

10.3969/j.issn.1002-0829.2011.02.006