Misdiagnosis of Bipolar Disorder With Unipolar Depression

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Bipolar disorder, formerly known as manic depression, is a mental illness that causes shifts in mood and energy and interferes with the ability to carry out day-to-day tasks. All types of bipolar disorder have an unknown cause but researchers know that there is a relationship between genetic and environmental factors. It is suspected that people are born ‘vulnerable’ to the disorder and huge stressors such as death, trauma, or alcohol/drug abuse can trigger it.

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Researchers also suggest that bipolar disorder is due to abnormalities in the way the brain functions with neurotransmitters that then results in communication problems within the brain.

There are four types of bipolar disorder: Bipolar I, Bipolar II, Cyclothymia, and Bipolar Disorder Not Otherwise Specified (NOS). All four types include two types of episodes, manic and depressive. Manic episodes are considered to be periods of energized behavior, while depressive episodes are feelings of extreme sadness and hopelessness. To specify the type of bipolar disorder a person may have normally depends on the period of time that the individual experiences the manic and depressive episodes and the severity of them. Bipolar I disorder is the most severe of the four and is a combination of extreme manic episodes that will last at least one week and depressive episodes that last at least two weeks. The other type of bipolar disorder, cyclothymia, is a milder and chronic form. Those with cyclothymia experience brief periods of hypomania and mild depression that are ongoing for at least two years in adults and one year in children. Cyclothymia can also be prevented from developing into a more severe form of bipolar if treatment is sought out. The last type of bipolar disorder that a patient may be diagnosed with, bipolar disorder not otherwise specified, is when the symptoms do not exactly match any of the other three types. Those with bipolar disorder not otherwise specified still experience days of manic and depressive episodes, but these episodes rapidly alternate over a few days and the symptoms of the episodes are different than the other three. Bipolar II disorder is considered to be a milder form of bipolar I disorder that consists of a combination of depressive and hypomanic episodes that last one to three days. Hypomanic episodes have the same symptoms as a manic episode, but are less severe and do not last as long. This type of bipolar is also most commonly misdiagnosed as unipolar depression because it is harder to determine a state of hypomania in an individual as it doesn’t typically impair day-to-day functioning, therefore focusing on the depressive episodes, hence the misdiagnosis.

In today’s society, the desire for optimum health is unparalleled to any other time period in U.S. history. Americans are continuously bombarded with groundbreaking medical technology, fitness promotions, and the overwhelming vision of improved quality/availability of healthcare. However, despite extensive investments, attitude changes, and development of new policies, these notable health contributions have fallen flat. It is striking to add that mental health, mood disorders such as bipolar disorder and depression, are among the most prevalent and costly problems in the U.S (Shippee et al., 2011). The Stigma associated with mental illness creates health inequity for the mentally ill population, in general, by preventing them from achieving optimal health and creating preventable differences in managing these diseases. More specifically, the examination of the misdiagnosis of bipolar disorder (BD) and unipolar depression (UD) as a health disparity is defined by differences in both populations in terms of socioeconomic status, employment, social inclusiveness of the affected/misdiagnosed population.

The differences between bipolar disorder and unipolar depression are significant and a misdiagnosis can result in suboptimal symptom resolution, induction of manic switch, mixed state, or accelerated cycling. According to Nisha er al.(2015), 40% of patients are misdiagnosed with unipolar depression. His study concluded that accurate bipolar disorder diagnosis is hindered by three major factors- assumptions of similar phenomenology, failure for therapist to note previous hypomanic symptoms, and failure for patient to report them ( Nisha et al., 2015). When considering the socioeconomic status and employment status, both bipolar disorder and unipolar depression groups, 56.7% and 53.3%, belonged to lower middle class status, while 16.7% bipolar disorder groups were also unemployed ( Nisha et al., 2015). The overrepresentation of the lower middle class indicated that both mood disorders are unevenly distributed in the general population. It coincides with what is typically true; low socioeconomic status is a predictor for low anticipation for good general health. Higher unemployment rates and the build of chronic stress has also been associated with worse health outcomes, and in this case, leads to the loss of productivity, a sense of inclusiveness, and significantly worse symptom resolution for both bipolar disorder and unipolar depression. Nathan D. Shippee, assessed the financial limitations and subsequent inequity between being misdiagnosed with either bipolar or unipolar depression. Results showed that generally high unemployment rates of both populations are due to disabelment in social, cognitive, and work limitations (2011). Although unemployment rates are noted for both bipolar disorder and unipolar depression, it is significantly higher for those with bipolar, which has created a larger gap between availability of social and financial resources ( Shippee et al., 2011). The isolation due to the stigma of mental health disorders infringes on the idea that these individuals are treated equally and are in fact more vulnerable in the workforce than both non-mood disorder and unipolar depression groups. Termination of their employment increases limitation to resources, especially, social capital and emotional support systems which are crucial in proper psychological health. Professor Barr states, in addition to demonstrable effects on physical health, those with more regular social engagement also tend to display better mental health (2014). The misdiagnosis of bipolar disorder and unipolar depression create stark inequities in several unique aspects of each of the affected populations, such as low socioeconomic status, high unemployment, and harsh limitation of social capital. It is imperative that health professionals embrace this public health issue and attempt to close the gap of inequity between misdiagnosis of both mood disorders and address mental health as a whole, and allow these preventable burdens to be solved.

When looking at health disparities in misdiagnosed bipolar patients, it was found that some of those disparities are due to race and gender/marital status. First, looking at race in misdiagnosed bipolar disorder patients it can be seen that between African Americans individuals and white individuals, there was a higher rate of African Americans being initially diagnosed with something other than bipolar disorder. This misdiagnosis delays the individual from getting the proper treatment which can directly address illness morbidity (Akinhanmi, Margaret 2018). The Depression Bipolar Support Alliance conducted a survey in 1994 and again 10 years later that showed a delay in getting accurately diagnosed with bipolar disorder. This finding is important because most of the time patients get misdiagnosed with unipolar major depressive disorder instead of bipolar disorder. Research shows that being treated for unipolar depression by taking antidepressants would increase the likelihood of treatment nonresponse or antidepressant induced mania/mood destabilization (Akinhanmi, Margaret 2018).

In a study reported in 2002, the study showed that 24 African-Americans with bipolar I disorder received antipsychotics at a greater percentage of follow-up visits (44%/70 visits) that 34 white individuals (40%/34 visits) (Akinhanmi, Margaret 2018). In a similar study with 34 bipolar patients taking lithium carbonate demonstrated African-Americans had a higher mean lithium red blood cell to plasma ratio than white patients even though the dosage was the same for the two races.During another similar study researchers did take into account that symptoms reports during the clinical assessments from some African-Americans may be misattributed to psychopathology instead of sociocultural background. When taking sociocultural into consideration researchers found that they may have been able to more accurately diagnose the patient. Based on this study culturally competent treatment in populations of different sociocultural background may help address racial bias and decrease the misdiagnosis rate.

A different disparity to consider when looking at bipolar disorder is gender and marital status. Bipolar disorder was found to be more common among individuals who were never-married. Among the married bipolar individuals’ marital functions were said to be impaired. In a 2-year study conducted with 282 bipolar individuals, the study showed that bipolar women were more likely to be married. The study also showed that married women had fewer episode of depression than non-married women. When looking at men the data showed that never-married men were more likely to have an earlier age of onset bipolar I disorder in comparison to married men (Lieberman, Daniel 2010).

Based on the study conducted by Lieberman, it showed that more men were diagnosed with bipolar I in comparison to women and more women were diagnosed with bipolar II in comparison to men. Another interesting factor was that women in this study who were married had usually completed fewer years. All other demographics in this study seemed to have been the same for both men and women. A study in Denmark found that after an individual’s first mood episode, never-married bipolar individuals were at risk of recurrence about 3 times greater than individuals who were married, divorced, or widowed (Lieberman, Daniel 2010).

As stated previously, there is obviously a health disparity for bipolar disorder sufferers being misdiagnosed with unipolar depression. Fortunately, there is hope on the horizon for better diagnostic procedures. There have been changes made to the DSM-5 to help better identify and differentiate bipolar disorder and unipolar depression. These changes include separating bipolar disorder and related conditions into their own chapters and the criteria necessary to diagnose bipolar disorder (changes in mood and changes in activity or energy are now included). The criteria needed to diagnose a mixed mood episode has also been changed. According to Kupfer and Philips, Previously, the diagnosis of a mixed mood episode required a patient to simultaneously meet the full criteria for both mania and major depression-however there is a new specifier that allows clinicians to report up to three manic symptoms during a depressive episode. These changes to the DSM-5 indicate good test-retest reliability of adult bipolar disorder type I, suggesting that DSM-5 could be a positive step towards improved accuracy of bipolar disorder (Kupfer, Phillips 2013).

A new way of diagnosing bipolar disorder takes a biological approach. Scientists are using neuroimaging to look for differentiation with biomarkers between bipolar disorder and unipolar depression. These images look for any abnormality in the brain regarding white matter connectivity, grey matter, and functional abnormalities in neural circuitry (Kupfer, Phillips 2013). Research has also taken an integrative approach to tackling this issue. According to Kupfer and Phillips, this integrative approach has the greatest potential to identify biological targets for personalised treatment and new treatment developments for all such illnesses. This integrative approach looks at genetic, molecular, cellular, neural circuitry, and behavioral measures. By combining all of these different factors, Integration across these scales could thus yield different biosignatures that represent dimensions of underlying pathophysiological process in bipolar disorder and other affective disorders (Kupfer, Phillips 2013).

In 2018 a new study actually identified a difference in neural activity between patients with bipolar disorder and those suffering from depression. The scientists who conducted this study looked at amygdala activation while patients were processing facial expressions. According to the study, patients who had bipolar disorder had lower activation in the left amygdala in comparison to patients who had depression (Korgaonkar, et al., 2018). Based on this information there is definitely progress being made to help accurately diagnose those suffering from bipolar disorder.

In conclusion, bipolar disorder is a major public health issue that involves extreme mood swings from mania to deep depression. Bipolar disorder II is more commonly misdiagnosed as unipolar depression because it is hard to distinguish a state of hypomania in these individuals.

When considering the disparities, it can be seen that race, socioeconomic status, and gender/marital status do play a role in diagnosing an individual with bipolar disorder. Looking at these individuals it was noticeable that individuals who are minorities are for the most part misdiagnosed when compared to non-minorities. Also, looking at socioeconomic status one notices that individuals of a lower socioeconomic status were more likely to be misdiagnosed than those higher on the socioeconomic scale. However, individuals with from a higher socioeconomic status tend to be diagnosed with bipolar disorder more often than those of lower socioeconomic status. Finally, looking at marital status/gender studies conducted showed that bipolar disorder was more prominent in individuals who were never-married compared to married individuals. However, the study also showed that bipolar women were more likely to be married.

Bipolar disorder has no cure but with proper diagnosis the individual can start taking steps to develop insight as to when they might be having an episode and receiving the correct treatment. This is why it is important for mental illnesses to be taken seriously and for more research to be conducted so that the gap in misdiagnoses can be lessened, especially when misdiagnosing could hinder the individual’s treatment response. Luckily, there are many improvements and changes happening so that individuals can be diagnosed properly.

References

Akinhanmi, Margaret O, et al. Racial Disparities in Bipolar Disorder Treatment and Research: a Call to Action. Bipolar Disorders, vol. 20, no. 6, Sept. 2018, pp. 506“14, doi:10.1111/bdi.12638.

Barr, D. A. (2014). Health disparities in the United States: Social class, race, ethnicity, and health. Baltimore, MD: Johns Hopkins University Press.Bipolar Disorder. (n.d.). Retrieved from https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml

Hook, D. B. (2018, April 30). The Different Types of Bipolar Disorder, Including Cyclothymia | Everyday Health (K. Keegan MD, Ed.). Retrieved from https://www.everydayhealth.com/cyclothymia/

Kaye, N. S., MD. (2005). Is Your Depressed Patient Bipolar? The Journal of the American Board of Family Medicine,18(4), 271-281. doi:10.3122/jabfm.18.4.271

Korgaonkar, M. S., Erlinger, M., Breukelaar, I. A., Boyce, P., Hazell, P., Antees, C., . . . Malhi, G. S. (2018). Amygdala Activation and Connectivity to Emotional Processing Distinguishes Asymptomatic Patients With Bipolar Disorders and Unipolar Depression. Society of Biological Psychiatry, 10. doi: 10.1016/j.bpsc.2018.08.012

Kupfer, D. J., & Phillips, M. L. (2013). Bipolar disorder diagnosis: Challenges and future directions. The Lancet, 381(9878), 2nd ser., 1663-1671. doi:10.1016/S0140-6736(13)60989-7

Leahy, R. L. (2007). Bipolar disorder: Causes, contexts, and treatments. Journal of Clinical Psychology,63(5), 417-424. doi:10.1002/jclp.20360

Lieberman, D., Massey, S., & Goodwin, F. (2010). The role of gender in single vs married individuals with bipolar disorder. Comprehensive Psychiatry, 51(4), 380“385. https://doi.org/10.1016/j.comppsych.2009.10.004

M. (2017, February). Bipolar Disorder: What causes bipolar disorder? Retrieved from https://www.heretohelp.bc.ca/factsheet/bipolar-disorder-what-causes-bipolar-disorder

Nisha, A., Sathesh, V., Punnoose, V. P., & Varghese, P. J. (2015). A comparative study on psycho-socio-demographic and clinical profile of patients with bipolar versus unipolar depression. Indian journal of psychiatry, 57(4), 392-6

Omrin, D., Kirilenko, D., Timmins, V., & Goldstein, B. (2016). 5.12 CORRELATES OF SOCIOECONOMIC STATUS AMONG ADOLESCENTS WITH BIPOLAR DISORDER. Journal of the American Academy of Child & Adolescent Psychiatry, 55(10), S187“S187. https://doi.org/10.1016/j.jaac.2016.09.271

Shippee, N. D., Shah, N. D., Williams, M. D., Moriarty, J. P., Frye, M. A., & Ziegenfuss, J. Y. (2011). Differences in demographic composition and in work, social, and functional limitations among the populations with unipolar depression and bipolar disorder: results from a nationally representative sample. Health and quality of life outcomes, 9, 90. doi:10.1186/1477-7525-9-90.

Singh, T., & Rajput, M. (2006). Misdiagnosis of bipolar disorder. Psychiatry (Edgmont (Pa. : Township)), 3(10), 57-63.

Smith, K., PhD. (2018, February 13). Causes of Bipolar Disorder: Understanding the Risk Factors. Retrieved from https://www.psycom.net/bipolar-disorder-causes

Towbin, K., Axelson, D., Leibenluft, E., & Birmaher, B. (2013). Differentiating bipolar disorder-not otherwise specified and severe mood dysregulation. Journal of the American Academy of Child and Adolescent Psychiatry, 52(5), 466-81.

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