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Expert Q&A: Bipolar Disorder

Expert Q&A: Bipolar Disorder

Terence A. Ketter, MD

6 Key Questions

James Phelps, MD, Bipolar Disorder Section Editor for Psychiatric Times, provided the questions for this interview.

Dr. Ketter is Professor in the Department of Psychiatry and Behavioral Sciences and founder and Chief of the Bipolar Disorder Clinic at the Stanford University School of Medicine, Stanford, CA.


1: Do you think the DSM-5 changes have made detection of bipolar disorder in depressed patients easier, harder, or some of each?

A: DSM-5 changes, which include the addition of mixed depression (major depressive episode with mixed features), have made detection of bipolar disorder in depressed patients more complex—although this better reflects the very substantial challenge of diagnosing bipolar disorder in depressed patients.

2: Dr. David Kupfer, chair of the DSM-5, stated in a 2013 article with Dr. Mary Phillips that unipolar and bipolar depression “might be better represented as an affective disorders continuum, with variable expressions of bipolarity representing dimensions of underlying pathophysiologic processes.”1 Do you agree with that?

A: I agree with the continuum/spectrum approach to mood disorders. This approach permits mixed depression (major depressive episode with mixed features) to occur in both bipolar disorder and unipolar major depressive disorder. It also allows more nuanced diagnostic determinations, and addresses questions such as “What is the probability that this current mood problem with prominent depression will ultimately be determined to be bipolar disorder rather than unipolar major depressive disorder?” rather than “Is this bipolar disorder or unipolar major depressive disorder?”

3: Regeer and colleagues2 from the Netherlands reported that only 22% of patients with bipolar disorder recognized their episodes of hypomania (vs 82% who recognized a depressive episode). Do you think most practitioners are aware of this problem? How are most of them making a diagnosis of bipolar disorder in patients who present with depression?

A: I agree that retrospective detection of at least one prior episode of hypomania in a currently depressed patient is very challenging. The reasons for this are multiple and complex; they likely include that prior hypomania by definition lacks severe adverse consequences (or commonly lacks even any functional impairment) and often is not detected or treated at the time. Another issue is state-dependent memory—the inability of currently depressed individuals to recall prior experiences that occurred when not depressed.

4: On markers of bipolarity that do not appear in the DSM criteria (eg, family history, age of onset, and “problematic outcomes” with antidepressants) that indicate increased probability of bipolar disorder in a patient presenting with depression: do you think we’re ready to expect gathering and reporting of those data from providers who are treating such a patient (ie, is it time to make that “standard of care”)?

A: In my view, there is sufficient evidence regarding non-DSM factors (eg, family history of bipolar disorder; first depression before age 25 years; history of psychosis; hypersomnia, hyperphagia, anergic depression; and worsening with antidepressants) that increase the likelihood of a bipolar outcome to invoke these clinically. Thus, treatment of depressed patients with more than one such factor merits particular caution regarding the possibility of a bipolar spectrum problem.


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