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Is underdiagnosis the main pitfall when diagnosing bipolar disorder? Yes

BMJ 2010; 340 doi: (Published 22 February 2010) Cite this as: BMJ 2010;340:c854
  1. Daniel J Smith, clinical senior lecturer in psychiatry1,
  2. Nassir Ghaemi, professor of psychiatry2
  1. 1Cardiff University School of Medicine, Cardiff
  2. 2Tufts University School of Medicine, Boston, Massachusetts, USA
  1. Correspondence to: D J Smith smithdj3{at}

    Daniel Smith and Nassir Ghaemi believe that many people with bipolar disorder remain undiagnosed, but Mark Zimmerman (doi:10.1136/bmj.c855) argues that overdiagnosis is the bigger problem

    Bipolar disorder is a complex condition, and patients can present with the entire range of psychiatric symptoms.1 Its underdiagnosis has always been, and continues to be, a major problem.

    Ever since Emil Kraepelin defined manic depressive insanity as recurrent mood episodes (either mania or depression, but not necessarily requiring mania) in 1898,2 the condition has been underdiagnosed. For almost a century it was commonly misdiagnosed as schizophrenia.3 In 1980, the American Diagnostic and Statistical Manual (DSM-III) narrowed the definition of schizophrenia and divided manic depressive insanity into two groups: broadly defined major depressive disorder and narrowly defined bipolar disorder.4 Reasons for underdiagnosis since then include lack of insight into mania by patients, lack of systematic assessment of mania by clinicians, stigma, and the aggressive marketing of antidepressants. The broadening of the definition of bipolar disorder to include hypomania in 1994 and marketing of new drugs have begun …

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