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Bipolar disorder: Epidemiology and diagnosis

INTRODUCTION

Bipolar disorder is an illness characterized by periods of mood elevation. Patients with bipolar I disorder have episodes of sustained mania, and often experience depressive episodes. Patients with bipolar II disorder have one or more major depressive episodes, with at least one hypomanic episode.

Recognition of bipolar disorder is important; untreated it is associated with substantial morbidity and mortality, and treatment differs from that of unipolar depression. It is not uncommon for bipolar disorder to be underdetected. Patients may present with symptoms of depression, especially in the primary care setting, but a careful history may find evidence of prior manic episodes [1].

This discussion will address the epidemiology, clinical manifestations, and diagnosis of bipolar disorder. Issues related to acute treatment and maintenance therapy for bipolar disorder are discussed separately. (See "Bipolar disorder: Treatment".)

EPIDEMIOLOGY AND PATHOGENESIS

The lifetime prevalence of bipolar disorder has traditionally been estimated as about one percent [2]. More recently, a spectrum of bipolar conditions has been proposed [3], including subthreshold bipolar disorder, with a higher prevalence (2.6 to 6.5 percent) [4-7]. The World Health Organization identified bipolar disorder as the sixth leading cause of disability-adjusted life years worldwide among people ages 15 to 44 years [2].

The true prevalence of bipolar disorder is uncertain; the diagnosis is likely to be missed when patients are seen with depression and not specifically asked about symptoms suggesting prior episodes of mania or hypomania [4,8]. In a study of outpatients being treated for depression in a family medicine clinic, a screening questionnaire for bipolar disorder (the Mood Disorder Questionnaire or MDQ [9]) was positive in 21.3 percent; two thirds of those screening positive had never been diagnosed with bipolar disorder [8]. The sensitivity and specificity of the MDQ in this population was 0.6 and 0.9 respectively, when results of screening were compared to DSM-IV criteria as determined by the Structured Clinical Interview.
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