Introduction: A Focus on Differential Diagnoses, Comorbidity, and Suicide Risk

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Depressive disorders and bipolar and related disorders have their own chapters in DSM-5, but the challenges for diagnosing and treating these disorders remain the same. Some of the most common challenges include the diagnosis of a mood disorder, especially a bipolar disorder, and the assessment and management of comorbidities and suicidalities in patients with a mood disorder. In this Special Report on mood disorders, the authors of the 3 articles have attempted to address these issues. The article on comorbid ADHD and depression by W. Burleson Daviss, MD, and Joseph B. Bond, MD, appears here and will be published in the September issue of Psychiatric Times.

As with any illness, a correct diagnosis is the first step toward treatment success. However, the same presentations of depressive symptoms with MDD (unipolar depression) and with bipolar disorder (bipolar depression) pose challenges for clinicians to differentiate unipolar depression from bipolar depression. Misdiagnosis of bipolar depression as unipolar depression is problematic.^1,2 Although manic/hypomanic symptoms are prerequisites for diagnosing bipolar disorder, in some cases, the manic/hypomanic symptoms might not be obvious or straightforward.

Clinicians should help patients understand the presentations of manic/hypomanic symptoms to uncover any manic/hypomanic episode(s). A complete psychiatric interview with a longitudinal perspective is essential. Collateral information from family members and/or friends may be necessary to make a correct diagnosis for those who don’t have much insight into their illness or who are unwilling to share their manic/hypomanic experiences. Screening tools such as the Mood Disorder Questionnaire and Hypomania Checklist-32 item may be useful to uncover manic/hypomanic symptoms.^3,4

Among all the psychiatric conditions, bipolar disorder has the highest risk for suicide and suicide attempts.

In the article on the phenotypic boundaries of bipolar disorder, Dean F. MacKinnon, MD, uses 2 patients as examples to illustrate phenotypic differences in bipolar disorders. He concludes “soft” symptoms are not easily discerned. Clinicians should pay close attention to the “soft” symptoms during interviews.

The co-occurrence of other psychiatric disorders with mood disorders is the rule rather than the exception.^5,6 A systematic diagnostic interview is essential to assess psychiatric comorbidities. Comorbid anxiety and substance use disorders are most prevalent, especially in patients with a bipolar disorder.⁶ However, a significant number of patients with a mood disorder, especially those with bipolar I disorder, also have ADHD.^5,6 Commonly used medications for ADHD have the potential to worsen anxiety symptoms and provoke mania or hypomania.

In their (online) article on comorbid ADHD and depression, W. Burleson Daviss, MD, and Joseph B. Bond, MD, review the prevalence, assessment, and treatment of comorbid ADHD and depression. Their review not only provides an update on this important topic, but also helps clinicians understand the challenges and unmet needs in this population.

Mood disorders are risk factors for suicide and suicide attempts. Among all the psychiatric conditions, bipolar disorder has the highest risk for suicide and suicide attempts. To reduce deaths by suicide in patients with bipolar disorder, the International Society for Bipolar Disorder Task Force on Suicide Risk and Prevention in Bipolar Disorder made a collaborative effort to study the risk factors for suicide and suicide attempt and to develop strategies to assess and manage suicide risk.^7,8

In their article on suicide risk and prevention in bipolar disorder, Ayal Schaffer, MD, and Manuel Sanchez De Carmona, MD, share some findings from this collaboration. The authors first review the prevalence of suicide and suicide attempt and summarize the risk factors for suicide. They also provide a specific clinical model for bipolar disorder suicide risk assessment, and propose strategies for managing suicide risk.

In summary, these articles provide important clinically relevant information for diagnosing mood disorders, especially bipolar disorder, and assessing and managing comorbid ADHD in depression and suicide risk in bipolar disorder.

Disclosures:

Dr. Gao is Professor of Psychiatry, Department of Psychiatry, Case Western Reserve University School of Medicine; Clinical Director of Mood Disorders Program, University Hospitals Case Medical Center, Cleveland, OH. He reports that he has received grant support from AstraZeneca, the Brain and Behavior Foundation, and the Cleveland Foundation; he is on the Speakers Bureau and Advisory Board for Sunovion.

References:

1. Hirschfeld RM, Lewis L, Vornik LA. Perceptions and impact of bipolar disorder: how far have we really come? Results of the National Depressive and Manic-Depressive Association 2000 survey of individuals with bipolar disorder. J Clin Psychiatry. 2003;64:161-174.

2. Gao K, Kemp DE, Conroy C, et al. Comorbid anxiety and substance use disorders associated with a lower use of mood stabilizers in patients with rapid cycling bipolar disorder: a descriptive analysis of the cross-sectional data of 566 patients. Int J Clin Pract. 2010; 64:336-344.

3. Angst J, Adolfsson R, Bennazzi F, et al. The HCL-32: towards a self assessment tool for hypomanic symptoms in outpatients. J Affect Disord. 2005;88:217-233.

4. Yang HC, Yuan CM, Liu TB, et al. Validity of the 32-item Hypomania Checklist (HCL-32) in a clinical sample with mood disorders in China. BMC Psychiatry. 2011;11:84.

5. Merikangas KR, Akiskal HS, Angst J, et al. Lifetime and 12-month prevalence of bipolar spectrum disorder in the National Comorbidity Survey replication. Arch Gen Psychiatry. 2007;64:543-552.

6. Gao K, Wang Z, Chen J, et al. Should an assessment of axis I comorbidity be included in the initial diagnostic assessment of mood disorders? Role of QIDS-16-SR total score in predicting number of axis I comorbidity. J Affect Disord. 2013;148:256-264.

7. Schaffer A, Isometsa ET, Tondo L, et al. International Society for Bipolar Disorders Task Force on Suicide: meta-analyses and meta-regression of correlates of suicide attempts and suicide deaths in bipolar disorder. Bipolar Disord. 2014;17:1-16.

8. Schaffer A, Isometsa ET, Azorin JM, et al. A review of factors associated with greater likelihood of suicide attempts and suicide deaths in bipolar disorder: part II of a report of the International Society for Bipolar Disorders Task Force on Suicide in Bipolar Disorder. Aust N Z J Psychiatry. 2015;49:1006-1020.