Bipolar II in Primary Care

Study: A screening tool to improve detection of Bipolar II in primary care.

Primary Care Providers are more likely to encounter patients with depressive complaints than in specialty care, and a substantial number of patients who exhibit symptoms of depression in primary care settings may actually have bipolar spectrum disorders.

Studies show:

  • 64% of clinical visits related to depression occur in primary care settings rather than specialty care.1
  • Approximately half of individuals initially diagnosed with major depressive disorder may fall within the bipolar spectrum.2

Most bipolar patients first present in primary care for depression are often given antidepressants as monotherapy, causing detrimental consequences for those undiagnosed with bipolar disorders.3 These include rapid cycling, more severe depressive episodes, a switch to mania and permanent worsening of the illness.

The bipolar II spectrum represents the most common phenotype of bipolarity. Numerous studies indicate that in clinical settings this soft spectrum might be as common–if not more common than–major depressive disorders.4

Bipolar II is especially difficult to recognize as it manifests hypomania rather than mania, which causes more obvious dysfunctional behaviors.

A key challenge lies in the recognition of hypomania. While it can be a significant indicator of Bipolar II, particularly in its early stages, many individuals are either unaware of experiencing these elevated moods or struggle to recall them accurately. This lack of awareness hinders proper diagnosis and increases the likelihood of inappropriate antidepressant treatment.

The most promising screening tools for assessing hypomania are the hypomanic checklists. Among these checklists, the HCL-33 is a self-report tool for patients to complete and is the most recent version.

However, hypomania is difficult for patients to identify in themselves because, by definition, it does not cause any functional impairment. Since patients are unlikely to recognize and report past experiences as hypomania, an interview with a significant other or family member may be more helpful in diagnosis.5

The Hypomanic Checklist 33 External Audit (HCL-33-EA) was developed to gather data from other family members, caregivers, and significant others in lieu of interviews. This external version has shown early success in identifying hypomania from the perspective of friends and relatives of the patient, who may have a reduced recall bias in other countries.

However, there has been no data to gather opinions of primary care providers on the usability of this tool in primary care or the concept of involving others to aid in the detection of hypomania and a bipolar II diagnosis.


References

  1. McIntyre, R. S., Zimmermann, M., Goldberg, J. F., & First, M. B. (2019). Differential diagnosis of major depressive disorder versus bipolar disorder: Current status and best clinical practices. Journal of Clinical Psychiatry, 80(3). https://www.psychiatrist.com/read-pdf/20884/ ↩︎
  2. McIntyre, R. S., Zimmermann, M., Goldberg, J. F., & First, M. B. (2019). Differential diagnosis of major depressive disorder versus bipolar disorder: Current status and best clinical practices. Journal of Clinical Psychiatry, 80(3). https://www.psychiatrist.com/read-pdf/20884/ ↩︎
  3. 64% of clinical visits related to depression occur in primary care settings rather than specialty care. ↩︎
  4. Perugi, G., Akiskal, H. (2002) The soft bipolar spectrum redefined: focus on the cyclothymic, anxious-sensitive, impulse-dyscontrol, and binge-eating connection in bipolar II and related conditions, Psychiatric Clinics of North America, Volume 25, Issue 4, https://doi.org/10.1016/S0193-953X(02)00023-0. ↩︎
  5. Regeer, E., Kupka, R., Have, M., Vollebergh, W., & Nolen, W. (2015) Low self-recognition and awareness of past hypomanic and manic episodes in the general population. Journal of bipolar disorders 3(22). DOI 10.1186/s40345-015-0039-8 ↩︎
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