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Is underdiagnosis the main pitfall in diagnosing bipolar disorder? No

BMJ 2010; 340 doi: (Published 22 February 2010) Cite this as: BMJ 2010;340:c855
  1. Mark Zimmerman, director, outpatient psychiatry
  1. 1Rhode Island Hospital, Bayside Medical Building, 235 Plain Street, Providence, RI 02905, USA
  1. mzimmerman{at}

    Daniel Smith and Nassir Ghaemi (doi:10.1136/bmj.c854) believe that many people with bipolar disorder remain undiagnosed, but Mark Zimmerman argues that overdiagnosis is the bigger problem

    Bipolar disorder is a serious illness resulting in significant psychosocial morbidity and excess mortality. Research reports, reviews, and commentaries have suggested that bipolar disorder is under-recognised, and that many depressed patients have, in fact, bipolar disorder.1 2 3 4 The treatment and clinical implications of the failure to recognise bipolar disorder in depressed patients include the underprescription of mood stabilising drugs, an increased risk of rapid cycling, and increased costs of care.5 6 7 8

    During the past decade, my hospital has introduced semistructured diagnostic interviews into outpatient clinical practice. Use of these interviews initially documented underdetection of psychiatric comorbidity,9 10 11 and these findings were replicated in other settings.12 13 14 However, in recent years, we observed the emergence of an opposite phenomenon in bipolar disorder —clinician overdiagnosis in patients without a history of a manic or hypomanic episode.

    Overdiagnosis is the bigger problem

    We therefore conducted a study to determine how often bipolar disorder might …

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