Bipolar Disorder in Primary Care Part 1 7/13/2017

Primary care providers may often be the first point of contact for persons with bipolar disorder, and about 25% of patients with bipolar disorder receive their mental health care predominantly through the primary care setting. PCPs are in a unique position to be the first clinicians to be able to recognize bipolar symptoms early in the course of the illness. It is therefore important for providers to feel comfortable with assessing patients for potential bipolar illness, to avoid missed or delayed diagnosis, in order to help improve outcomes.

Bipolar Disorder is a mood disorder defined by episodes of mania or hypomania associated with major depression. The symptoms have to cause impairment in social or occupational functioning and cannot be attributed to the effects of substances or medications or another medical condition.

  1. Manic episode is defined as: at least one week of abnormally and continually elevated, expansive, or irritable mood and increased activity or energy accompanied by at least 3 of the following symptoms: inflated self-esteem, decreased need for sleep, increased talkativeness, flight of ideas or racing thoughts, marked distractibility, increased goal directed activity, agitation and excessive involvement in dangerous or high-risk activities. In manic states there is typically a marked level of impairment, typically associated with psychotic features and often requiring hospitalization or intensive emergency service intervention.
  2. Hypomanic episode is defined as: at least 4 days of the elevated mood, that is observable by others but does not have to lead to the level of impairment as seen in a manic episode, and at least 3 of the associated symptoms noted above.
  3. Major depressive episode is defined by the presence of at least 5 of 9 of the following symptoms for a minimum of 2 weeks associated with a decline in functioning: depressed mood, markedly decreased interest in activities, significant change in weight or appetite, insomnia or hypersomnia, psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or excessive guilt, decreased ability to think or concentrate or indecisiveness, and recurrent thoughts of death or suicidality (at least one of the symptoms must be depressed mood or anhedonia).

Patients with Bipolar I Disorder have had at least one manic episode and typically have multiple hypomanic and depressive episodes. Patients with Bipolar II Disorder have had at least one hypomanic episode and at least one depressive episode, and by definition have not had a manic episode. Some patients with Bipolar Disorder may present with a mixed state with symptoms including periods of irritability, increased energy and sleeplessness occurring in conjunction with depressive symptom features.   It should be recognized that most patients with bipolar disorder spend most of their life in a euthymic or depressive state.

The lifetime prevalence of bipolar disorder is 4% and it affects men and women equally. The age of onset is typically under age 25 and most people first present with a depressive episode. Therefore it is not uncommon for patients to first be diagnosed with Major Depression and then the diagnosis to change to a bipolar disorder diagnosis after a manic or hypomanic episode. It is thought that 20% of adolescents that are diagnosed with a bona fide Major Depression Disorder eventually develop a bipolar disorder. It is important to screen for current and past history of manic and hypomanic symptoms in patients presenting with depressive, mood and anxiety complaints. It is also important to ask for a thorough family history of mood disorders.

Comorbid issues related to bipolar disorder include alcohol abuse and other substance abuse; increase in suicidal thinking and suicide attempts and completed suicides; and anxiety disorders. Social history may reveal relationship and marital issues, financial problems, difficulty maintaining employment and legal problems.

There are some medical conditions that can mimic bipolar disorder. These include neurologic conditions (partial seizures, neoplasm, strokes, delirium) and endocrines disorders (hyperthyroidism, Cushing disease) and vitamin deficiencies (B12, folate, niacin, thiamine). Drug and substance misuse (including antidepressants and stimulants) should be ruled out.

A widely used instrument that has been validated for screening for bipolar disorder is the MDQ (Mood Disorder Questionnaire) available at MDQ. While this is a good screening tool (sensitivity of 73% and specificity of 90%), it is not sufficient to establish a diagnosis of bipolar disorder. A positive screen should be followed up with a thorough assessment including clinical interview, physical and neurological exam and relevant lab testing.

The second part of this series will address treatment for bipolar disorder in the primary care setting.


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