Undiagnosed Bipolar Depression Linked to Reduced Quality of Life, High Economic Costs

Bipolar spectrum disorders are commonly misdiagnosed and inappropriately or inadequately treated. During a presentation given by Roger S. McIntyre, MD, FRCPC, a professor in the Departments of Psychiatry and Pharmacology at the University of Toronto, at the Neuroscience Education Institute Max! Virtual Meeting, he reviewed symptoms, history, and risk factors that are important for diagnosis, as well as evidence-based treatment guidelines for bipolar depression and mania.

Patients with bipolar disorder usually seek help during depressive rather than manic episodes, as hypomania is often pleasant for patients, so they may not seek treatment. This makes accurately diagnosing bipolar depression so difficult.

“The majority of people with bipolar disorder are not diagnosed,” said Dr. McIntyre, noting that some people are undiagnosed for up to 10 years since disease onset. The longer patients are undiagnosed and untreated, the less likely treatments and therapy are to work.

The inability to identify bipolar depression early on has several consequences, including worse quality of life, inaccurate and potentially harmful treatment, increased cycling and risk of relapse, reduced treatment response, increased risk of suicide, increased subsequent morbidity, and high economic costs.

The overall mortality rate for bipolar disorder is more than 2.5 times higher than the general population. Women with bipolar disorder have three times greater odds of medical comorbidities and 2.5 greater odds of psychiatric comorbidities compared with men. Medical comorbidities with immune dysfunction that have shown to be correlated with bipolar disorder can include Crohn’s disease, multiple sclerosis, rheumatoid arthritis, psoriasis, obesity, and type 2 diabetes. Up to 90% of people with bipolar disorder have at least one comorbidity, according to Dr. McIntyre.

Nearly 30% of patients with bipolar disorder attempt suicide at least once in their life, and suicide mortality is 20 times more likely for patients with bipolar disorder than the general population.

Up to 60% of patients with bipolar disorder are first diagnosed as unipolar, as only 20% of patients are correctly diagnosed with bipolar disorder. Several features are more common in bipolar disorder versus unipolar depression, including psychotic symptoms, shorter depressive episodes, restlessness, early age of onset (<25 years), early morning insomnia, irritability, feelings of guilt, and more. Neurobiological markers differentiate unipolar from bipolar disorder.

While a majority of patients with bipolar disorder do not have a family history, it is a robust and reliable risk for this condition, he said, as those with a first-degree relative with bipolar disorder have an eight times greater risk of developing the condition.

Dr. McIntyre said one of the most important questions to ask every patient with depression is, “Do you have manic/hypomania symptoms and/or a family history of bipolar disorder?” He advised to screen for bipolarity in these patients.

There are currently no mood stabilizers approved for use in bipolar depression, although some data have demonstrated efficacy of lamotrigine for treating bipolar depression. There are various atypical antipsychotics approved for bipolar disorder, and they are the most frequently prescribed agents in the United States for this condition; a few of these agents have been approved for bipolar depression (cariprazine, lurasidone, olanzapine with fluoxetine, and quetiapine).

Antidepressants could be used, but there are certain patients in whom they should be avoided, including those with a history of past mania, hypomania, or mixed episodes emerging during antidepressant treatment; in patients with high mood instability; those with predominantly mixed states; and others.

Psychotherapy is a component of bipolar disorder treatment, as it increases adherence to medication, enhances social and occupational function, decreases denial and trauma, and decreases the risk of recurrence. “These patients often need help with interpersonal and psychosocial function,” Dr. McIntyre noted.

Patients with bipolar disorder have a “staggering” rate of obesity, according to Dr. McIntyre, noting that much of this is related to the medications patients are on. Patients with bipolar disorder are three times more likely to have metabolic syndrome, so diet and lifestyle should also be addressed. Cardiovascular disease (CVD) and hypertension also occur more frequently in patients with bipolar I disorder, so patients should be monitored for CVD.

Presentation: Bipolar Disorder: A Spectrum Disorder with a Spectrum of Treatments. Presented at the Neuroscience Education Institute Max! Virtual Meeting, Nov. 5-8, 2020.