Predicting lifetime mood elevation in primary care patients and psychiatric patients

Unrecognized bipolar disorder in patients with depression managed in primary care: A systematic review and meta-analysis

PURPOSE

Bipolar disorder is a common, severe mental health condition and a major financial burden for healthcare systems across the globe. There is some evidence that unrecognized bipolar disorder is prevalent amongst patients with depression in primary care which can lead to non-optimal treatment. However, a systematic synthesis of this literature is lacking. We aimed to determine the percentage of primary care patients who are diagnosed with depression that have unrecognized bipolar disorder.

METHODS

Medline, Embase, Cochrane and PsycINFO were searched to January 2019. We included quantitative observational studies. Risk of bias was assessed using the Newcastle Ottawa cohort scale. Analyses were performed using random-effects models, heterogeneity was quantified using I² and formal tests of publication bias were undertaken.

RESULTS

Ten studies with 3803 participants with depression in primary care were included. The pooled prevalence of bipolar disorder in those with depression was 17% (95% CI = 12 to 22). The prevalence of unrecognized bipolar depression was higher in studies which used questionnaires as assessment tools for bipolar disorder compared to studies which used clinical interviews but this difference was not significant (14%, 95% CI = 8 to 20 versus 22%, 95% CI = 16 to 28, Q = 1.27, p = 0.12). The prevalence of unrecognized bipolar disorder was not significantly affected by study-level variations in the risk of bias and we found no evidence for publication bias.

CONCLUSION

Over 3 in 20 patients with depression have unrecognized bipolar disorder in primary care which can lead to harmful patient outcomes. Increased awareness of unrecognition of bipolar disorder in primary care patients with depression and efficient assessment strategies in primary care are warranted.

Instruments that prospectively predict bipolar disorder - A systematic review

BACKGROUND

Identification of earlier stages of Bipolar Disorder (BD), even prior to the first manic episode, may help develop interventions to prevent or delay the onset of BD. However, reliable and valid instruments are necessary to ascertain such earlier stages of BD. The aim of the current review was to identify instruments that had predictive validity and utility for BD for use in early intervention (EI) settings for the prevention of BD.

METHODS

We undertook a systematic examination of studies that examined participants without BD I or II at baseline and prospectively explored the predictive abilities of instruments for BD onset over a period of 6 months or more. The instruments and the studies were rated with respect to their relative validity and utility predicting onset of BD for prevention or early intervention. Odds ratios and area under the curve (AUC) values were derived when not reported.

RESULTS

Six studies were included, identifying five instruments that examined sub-threshold symptoms, family history, temperament and behavioral regulation. Though none of the identified instruments had been examined in high-quality replicated studies for predicting BD, two instruments, namely the Child Behavioral Checklist - Pediatric BD phenotype (CBCL-PBD) and the General Behavioral Inventory - Revised (GBI-R), had greater levels of validity and utility.

LIMITATION

Non-inclusion of studies and instruments that incidentally identified BD on follow-up limited the breadth of the review.

CONCLUSION

Instruments that test domains such as subthreshold symptoms, behavioral regulation, family history, and temperament hold promise in predicting BD onset.

Screening for bipolar depression in family medicine practices: prevalence and clinical correlates

BACKGROUND

To compare individuals in primary care (PC) who screen positive for bipolar depression to those who screened positive for unipolar depression on mental health care ouctomes, PC service utilization, medical comorbidities, suicidal ideation, health-related quality of life (HRQoL) and psychosocial functioning.

METHODS

In this cross-sectional study, participants (N=1197) answered self-reported measures of depressive symptoms (Center for epidemiologic studies depression scale), HRQoL (World Health Organization Quality of Life instrument-Abbreviated version), medical comorbidity (functional comorbidity index) and functioning (Functional Assessment Short test). Participants were partitioned into 'bipolar' and 'unipolar' depression groups based on a predefined cutoff on the Brazilian mood disorder questionnaire.

RESULTS

The prevalence of bipolar depression was in PC was 4.6% (95% CI: 3.4-5.8). Participants with bipolar depression were more likely to endorse suicidal ideation, present with more medical comorbidities, report a worse physical HRQoL and have a higher rate of PC services utilization as compared to participants who screened positive for unipolar depression. Only six (10.9%) participants were recognized by the general practitioner as having a diagnosis of bipolar depression.

LIMITATIONS

The cross-sectional design prevents firm causal inferences from being drawn. A positive screen for BD does not substantiate the actual diagnosis. Co-morbid mental disorders were not accessed.

CONCLUSIONS

Bipolar depression is common and under-recognized in Brazilian PC services. A positive screen for bipolar depression was associated with worse clinical outcomes and greater PC service utilization.

The prevalence of bipolar disorder in primary care patients with depression or other psychiatric complaints: a systematic review

BACKGROUND

Bipolar disorder prevalence in primary care patients with depression or other psychiatric complaints has been measured in several studies but has not been systematically reviewed.

OBJECTIVE

To systematically review studies measuring bipolar disorder prevalence in primary care patients with depression or other psychiatric complaints.

METHODS

We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method in January 2013. We searched 7 databases using a comprehensive list of search terms. Included articles had a sample size of 200 patients or more and assessed bipolar disorder using a structured clinical interview or bipolar screening questionnaire in adult primary care patients with a prior diagnosis of depression or had an alternate psychiatric complaint.

RESULTS

Our search yielded 5595 unique records. Seven cross-sectional studies met our inclusion criteria. The percentage of primary care patients with bipolar disorder was measured in 4 studies of patients with depression, 1 study of patients with trauma exposure, 1 study of patients with any psychiatric complaint, and 1 study of patients with medically unexplained symptoms. The percentage of patients with bipolar disorder ranged from 3.4%-9% in studies using structured clinical interviews and from 20.9%-30.8% in studies using screening measures.

CONCLUSIONS

Bipolar disorder likely occurs in 3%-9% of primary care patients with depression, a trauma exposure, medically unexplained symptoms, or a psychiatric complaint. Screening measures used for bipolar disorder detection overestimate the occurrence of bipolar disorder in primary care owing to false positives.