Academic Writing

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A Collated Research Critique and Research Proposal can be viewed below;

 

Collated Research Critique

Review Abstract

Research has highlighted the frequent misdiagnosis of bipolar disorder as a depressive disorder in patients presenting with symptoms associated with depression (Correa et al, 2010). The prevalence of misdiagnosis leads to ineffective and potentially damaging treatment options prescribed to bipolar sufferers (Awad, Rajagopalan, Bolge & McDonnell, 2007; Dunner, 2003). Research further highlights that in patients where a correct diagnosis of bipolar disorder has been established through pertinent screening measures, treatments have good outcomes (Angst et al, 2005; Bschor et al, 2012). The research has been inconclusive however, as to the benefits of routine screening for bipolar disorder by the initial general practitioner to treat the patient for symptoms associated with depression (Hu et al, 2012; Zimmerman et al, 2011). A systematic review was undertaken to explore the benefits of routine screening for bipolar disorder in patients presenting to general practitioners with symptoms associated with depression. The systematic review found evidence to suggest that bipolar disorder screening tools vary on measures of sensitivity and reliability, but are a good measurement of bipolar disorder. Therefore, a tool that tends towards higher sensitivity (e.g. over-diagnosing bipolar disorder) would be beneficial in general practice to detect the possibility of bipolar disorder and put in place early specialist diagnosis and interventions.

Background

Bipolar disorder is frequently misdiagnosed as a depressive disorder in patients presenting with symptoms associated with depression (Correa et al, 2010). The prevalence of misdiagnosis leads to ineffective and potentially damaging treatment options prescribed to bipolar sufferers, however where an early and correct diagnosis of bipolar disorder has been made, there is evidence for good treatment outcomes  (Awad, Rajagopalan, Bolge & McDonnell, 2007; Dunner, 2003). The research has been inconclusive however, as to the benefits of early screening for bipolar disorder using a bipolar screening tool by the initial general practitioner to treat the patient for symptoms associated with depression (Hu et al, 2012; Zimmerman et al, 2011). Therefore a systematic review was conducted to explore the reliability and validity of bipolar disorder screening tools, and their effectiveness in detecting and diagnosing bipolar disorder in a general practice setting in patients presenting with symptoms associated with depression.

Objectives

To identify whether routine screening for bipolar disorder in patients presenting to general practitioners with symptoms associated with depression is beneficial by: (1) reducing the prevalence of misdiagnosis; (2) reducing the length of time between misdiagnosis and correct diagnosis; (3) providing better quality of life to patients; and, (4) lessening the negative impact misdiagnosis has on the health sector.

Search Strategy

Research was identified by searching the EBSCOhost database, PubMed database, SAGE Journals Online database, Federation University online library, the Cochrane Controlled Trial Register and the Campbell Collaboration. Reference lists of published articles were also used for collating articles. Keywords used: bipolar disorder; bipolar II; depression; misdiagnosis; hidden bipolar; under-recognized bipolar; hypomania.

Selection Criteria

English-language, peer reviewed journals published between 2003 – 2014 were used for the systematic review. Quantitative research was used in the form of systematic reviews, studies and pilot studies. One qualitative review article (Dunner, 2003) was also used to gain interpersonal insight into the issue. International studies were included to widen the yield of eligible journal articles.  Included studies were generally conducted on patients in large integrated-health centres with a diagnosis of depression; however some studies included patients from general practice settings and patients without a formal diagnosis of depression. Studies conducted on children were omitted from the systematic review as the focus of the review was on an adult population, and also due to limited research on children.

Data Collection and Analysis

Keyword search results yielded hundreds of articles however after applying the criteria above, 13 articles were considered for systematic review. One article was excluded as its focus was on the categorisation of depression as agitated or non-agitated and thus argued bipolar disorder may simply be a state of depression. A total of 12 articles matching the criteria outlined above were used.

Main Results

Under-recognised, undiagnosed or ‘hidden’ bipolar disorder was found to be prevalent in patients presenting with symptoms associated with depressive disorders (Correa et al, 2010; Stang et al, 2006a). Hidden bipolar disorder causes strain on the health sector, poor quality of life to misdiagnosed patients and limits treatment outcomes for these patients (Awad, Rajagopalan, Bolge & McDonnell, 2007; Dunner, 2003, Stang et al, 2006b). Various screening tools have demonstrated degrees of reliability in diagnosing bipolar disorder (Angst et al, 2005; Bschor et al, 2012). There is insufficient evidence to support the use of screening tools in a clinical setting to diagnose hidden bipolar disorder in patients already diagnosed with depression (Hu et al, 2012; Zimmerman et al, 2011). There is, however, evidence to support the use of a validly sound screening tool with high sensitivity in a general practice setting to assist general practitioners in making an initial diagnosis of bipolar disorder (Angst et al, 2005; Das et al, 2005; Mosolov et al, 2014; Sasdelli et al, 2013).

Conclusion

The findings of the systematic review allow for the conclusion to be made that routine screening for bipolar disorder in patients with symptoms associated with depression attending a general practice setting would be beneficial by; (1) assisting diagnosis of hidden bipolar disorder; (2) assisting general practitioners to implement correct bipolar treatment options; (3) reducing the patient’s contact hours to have correct diagnosis made, and (4) improve the patient’s quality of life by allowing for a faster diagnosis / treatment. Due to the conflicted results regarding the reliability and validity of all bipolar screening tools, a research proposal is recommended to run a pilot study on the use of bipolar screening tools in general practice settings to specifically explore the sensitivity required to adequately assess for bipolar disorder. Furthermore, the evidence suggesting that screening tools would be beneficial in general practice settings is circumstantial and based on the insufficiency of screening tools to perform in clinical settings. Therefore, the second component of the proposed research proposal is to qualitatively assess general practitioners’ and patients’ experiences having been correctly diagnosed by way of a screening tool.

 

References

Angst, J., Adolfsson, R., Benazzi, F., Gamma, A., Hantouche, E., Meyer, T, D., Skeppar, P., Vieta, E., & Scott, J. (2005). The HCL-32: Towards a self-assessment tool for hypomanic symptoms in outpatients. Journal of Affective Disorders, 88, 217-233. doi:10.1016/j.jad.2005.05.011

Awad, A, G., Rajagopalan, K., Bolge, S, C., & McDonnell, D, D. (2007). Quality of life among bipolar disorder patients misdiagnosed with a major depressive disorder. Primary Care Companion, Journal of Clinical Psychiatry, 9(3), 195-202

Bschor, T., Angst, J., Azorin, J, M., Bowden, C, L., Perugi, G., Vieta, E., Young, A, H., & Kruger, S. (2012). Are bipolar disorders underdiagnosed in patients with depressive episodes? Results of the multicentre BRIDGE screening study in Germany. Journal of Affective Disorders, 142, 45-52. doi:http://dx.doi.org/10.1016/j.jad.2012.03.042

Correa, R., Akiskal, H., Gilmer, W., Nierenberg, A. A., Trivedi, M., & Zisook, S. (2010). Is underrecognized bipolar disorder a frequent contributor to apparent treatment resistant depression? Journal of Affective Disorders, 127, 10-18. doi: 10.1016/j.ad.2010.06.036

Das, A. K., Olfson, M., Gameroff, M. J., Pilowsky, D. J., Blanco, C., Feder, A., Gross, R., Neria, Y., Lantigua, R., Shea, S., & Weissman, M. M. (2005). Screening for bipolar disorder in a primary care practice. Journal of American Medical Association, 293(8), 956-963

Dunner, D, L. (2003). Clinical consequences of under-recognized bipolar spectrum disorder. Bipolar Disorders, 5, 456-463.

Hu, C., Xiang, Y., Wang, G., Ungvari, G., Dickerson, F, B., Kilbourne, A, M., Lai, K, Y, C., Si, T., Fang, Y., Lu, Z., Yang, H., Hu, J., Chen, Z., Huang, Y., Sun, J., Wang, X., Li, H., Zhang, J., & Chiu, H, F, K. (2012). Screening for bipolar disorder with Mood Disorders Questionnaire in patients diagnosed as major depressive disorder – the experience in China. Journal of Affective Disorders, 141, 40-46. doi:10.1016/j,jad.2012.02.035

Moslov, S., Ushalova, A., Kostukova, E., Shaferenko, A., Alfimov, P., Kostyukova, A., & Angst, J. (2014). Bipolar II disorder in patients with a current diagnosis of recurrent depression. Bipolar Disorders, 16, 389-399. doi:10.1111/bdi.12192

Sasdelli, A., Lia, L., Luciano, C. C., Nespeca, C., Berardi, C., & Menchetti, M. (2013). Screening for bipolar disorder symptoms in depressed primary care attenders: Comparison between the Mood Disorder Questionnaire and Hypomania Checklist (HCL-32). Psychiatry Journal, 2013, http://dx.doi.org.10.1155/2013/548349

Stang, P., Frank, C., Ulcickas-Yood, M., Wells, K., Burch, S., & Muma, B. (2006a). Bipolar disorder detection, ascertainment, and treatment: Primary care physician knowledge, attitudes, and awareness. Primary Care Companion, Journal of Clinical Psychiatry, 8(3), 147-152.

Stang, P. E., Frank, C., Kasekar, A., Ulcickas-Yood, M., Wells, K., & Burch, S. (2006b). The clinical history and costs associated with delayed diagnosis of bipolar disorder. Medscape General Medicine, 8(2), PMCID: PMC1785223

Zimmerman, M., Galione, J. N., Ruggero, C. J., Chelminski, I., Dalrymple, K., & Young, D. (2011). Are screening scales for bipolar disorder good enough to be used in clinical practice? Comprehensive Psychiatry, 52, 600-606. doi: 10.1016/j.comppsych.2011.01.004

 

Research Proposal

            Bipolar disorder is frequently misdiagnosed as a depressive disorder in patients presenting to general practitioners with symptoms associated with depression (Correa et al., 2010; Mosolov et al., 2014; Stang et al., 2006a). This is partly due to the bipolar disorder symptoms of mania and / or hypomania being difficult to identify, especially in patients presenting during a ‘depressive’ cycle (Bschor et al., 2012; Hu et al., 2012). This causes bipolar disorder to be ‘hidden’ and disguised by the symptoms associated with depression. The prevalence of misdiagnosis leads to ineffective and potentially damaging treatment options prescribed to bipolar sufferers which ultimately affects the patient’s quality of life and long term outcomes (Awad, Rajagopalan, Bolge & McDonnell, 2006; Dunner, 2003). However, in patients where a correct diagnosis has been established through pertinent screening measures, treatments for bipolar disorder have demonstrated good outcomes (Angst et al., 2005; Das et al., 2005; Sasdelli et al., 2013).

Background

Research to date has acknowledged the importance of early detection of hidden bipolar disorder, however has largely been inconclusive as to the benefits of early screening by the initial general practitioner to treat the patient for symptoms associated with depression (Hu et al., 2012; Zimmerman et al., 2011). Previous research has strongly focused on the use of screening tools in clinical settings (such as large integrated-health systems). Due to the conflicted results regarding the reliability and validity of all bipolar screening tools, further research is recommended to explore the use of bipolar screening tools in general practice settings to specifically measure the sensitivity required to adequately assess for bipolar disorder. Furthermore, the evidence suggesting that screening tools would be beneficial in general practice settings are circumstantial and based on the insufficiency of screening tools to perform in clinical settings. Further research is required to qualitatively assess general practitioners’ and patients’ experiences having been correctly diagnosed primarily by a screening tool.

Proposed Research Question

To address the current gaps in the research, the following research question is proposed; what are the benefits of routine screening for bipolar disorder in patients presenting to general practitioners with symptoms associated with depression.

Methodology

The research question involves three main research components: (1) a comparison of bipolar screening tools; (2) an examination of the reliability of screening tools in a general practice setting, and (3) investigation into the benefits of early diagnosis to patients.

Past research has explored the validity, reliability and sensitivity of bipolar screening tools such as the Mood Disorder Questionnaire (MDQ) and Hypomania Checklist (HCL-32) (Angst et al., 2005). The results of previous studies as to the validity of these screening measures are conflicted suggesting a qualitative study is undertaken on component one of the current research question to directly compare the effectiveness of the two screening tools mentioned. To satisfy component two, the screening tools should be tested on a sample of patients attending a general practice setting to identify the prevalence of hidden bipolar disorder. Component three can be explored by collating and synthesising factual data (e.g. the number of visits required to make a diagnosis with / without use of screening tool), and by engaging in semi-structured face-to-face interviews with patients. Therefore, a bimodal study consisting of both quantitative and qualitative research should be conducted to satisfy the components of the research question as described above.

Quantitative analysis should consist of (1) a comparative study as to the reliability, sensitivity and accuracy of the MDQ and HCL-32 in diagnosing hidden bipolar disorder, and (2) a statically focused study into the effectiveness of screening tools used in a general practice setting to identify hidden bipolar disorder. Qualitative analysis should consist of (1) semi-structured interviews with general practitioners regarding their use and views of utilising screening tools, and (2) semi-structured or unstructured interviews with patients to document their experiences following a pilot study of routine screening where bipolar disorder was diagnosed at an initial general practitioner consult. Both quantitative and qualitative samples should consist of patients already diagnosed with a depressive disorder, but not yet diagnosed with bipolar disorder. A random sample would be desirable during the quantitative component, with enough numbers of participant to achieve randomness and generalisation of a population. Purposive sampling on a limited number of patients and general practitioners within a general practice setting would be beneficial to complete the qualitative analysis.

Ethical Issues

Risks associated with the proposed research revolve around the sensitivity of the screening tool to assess for bipolar disorder. A screening tool with low sensitivity may overlook the presence of bipolar disorder (allocating the patient a false-negative status) and thus preclude sufferers from being correctly referred-on or from receiving appropriate treatment. This risk can be alleviated however by using a screening tool that has undergone validity and reliability testing and errs on the side of being over-sensitive. Whilst this might run the risk of creating false-positive readings by labelling patients with bipolar disorder who do not meet the DSM-IV criteria for bipolar disorder, these patients will still benefit from being referred on to specialist services for concrete diagnosis using the DSM-IV criteria.

These risks are offset when considering the beneficence this research will have on the issue of misdiagnosed bipolar disorder. Stang et al., (2006b) conducted in depth analysis as to the costs that impact upon the health sector as a result of misdiagnosed bipolar disorder. Their research implies that early diagnosis and intervention has the potential to ameliorate increasing costs on the health sector. Further, quality of life for sufferers of hidden bipolar disorder significantly improves if a prompt and correct diagnosis is made at an initial presentation to a general practitioner (Awad et al., 2006). These factors suggest the proposed research is necessary to assist in resolving this prevalent issue in health sector.

Conclusion

Research has identified a prevalent issue in the health sector that affects the quality of life of patients and increases economic drain on the sector. Bipolar disorder is frequently misdiagnosed as a depressive disorder in patients presenting with symptoms associated with depression (Correa et al, 2010). The research has been inconclusive as to the benefits of early screening for bipolar disorder using a bipolar screening tool by the initial general practitioner to treat the patient for symptoms associated with depression (Zimmerman et al, 2011). Therefore a quantitative study and qualitative exploration have been recommended to further assess the reliability and validity of bipolar disorder screening tools, and their effectiveness in detecting and diagnosing bipolar disorder in a general practice setting in patients presenting with symptoms associated with depression. The risk associated with falsely diagnosing bipolar disorder through the use of overly sensitive screening tools outweighs the detrimental effects of bipolar sufferers remaining undiagnosed and untreated. Therefore, the implications of the proposed research include increased awareness and acknowledgement of hidden bipolar disorder by general practitioners, earlier detection and treatment of bipolar in patients, and lessening the impactful costs of hidden bipolar disorder on the health sector.
References

Angst, J., Adolfsson, R., Benazzi, F., Gamma, A., Hantouche, E., Meyer, T, D., Skeppar, P., Vieta, E., & Scott, J. (2005). The HCL-32: Towards a self-assessment tool for hypomanic symptoms in outpatients. Journal of Affective Disorders, 88, 217-233. doi:10.1016/j.jad.2005.05.011

Awad, A, G., Rajagopalan, K., Bolge, S, C., & McDonnell, D, D. (2007). Quality of life among bipolar disorder patients misdiagnosed with a major depressive disorder. Primary Care Companion, Journal of Clinical Psychiatry, 9(3), 195-202

Bschor, T., Angst, J., Azorin, J, M., Bowden, C, L., Perugi, G., Vieta, E., Young, A, H., & Kruger, S. (2012). Are bipolar disorders underdiagnosed in patients with depressive episodes? Results of the multicentre BRIDGE screening study in Germany. Journal of Affective Disorders, 142, 45-52. doi:http://dx.doi.org/10.1016/j.jad.2012.03.042

Correa, R., Akiskal, H., Gilmer, W., Nierenberg, A. A., Trivedi, M., & Zisook, S. (2010). Is underrecognized bipolar disorder a frequent contributor to apparent treatment resistant depression? Journal of Affective Disorders, 127, 10-18. doi: 10.1016/j.ad.2010.06.036

Das, A. K., Olfson, M., Gameroff, M. J., Pilowsky, D. J., Blanco, C., Feder, A., Gross, R., Neria, Y., Lantigua, R., Shea, S., & Weissman, M. M. (2005). Screening for bipolar disorder in a primary care practice. Journal of American Medical Association, 293(8), 956-963

Dunner, D, L. (2003). Clinical consequences of under-recognized bipolar spectrum disorder. Bipolar Disorders, 5, 456-463.

Hu, C., Xiang, Y., Wang, G., Ungvari, G., Dickerson, F, B., Kilbourne, A, M., Lai, K, Y, C., Si, T., Fang, Y., Lu, Z., Yang, H., Hu, J., Chen, Z., Huang, Y., Sun, J., Wang, X., Li, H., Zhang, J., & Chiu, H, F, K. (2012). Screening for bipolar disorder with Mood Disorders Questionnaire in patients diagnosed as major depressive disorder – the experience in China. Journal of Affective Disorders, 141, 40-46. doi:10.1016/j,jad.2012.02.035

Mosolov, S., Ushalova, A., Kostukova, E., Shaferenko, A., Alfimov, P., Kostyukova, A., & Angst, J. (2014). Bipolar II disorder in patients with a current diagnosis of recurrent depression. Bipolar Disorders, 16, 389-399. doi:10.1111/bdi.12192

Sasdelli, A., Lia, L., Luciano, C. C., Nespeca, C., Berardi, C., & Menchetti, M. (2013). Screening for bipolar disorder symptoms in depressed primary care attenders: Comparison between the Mood Disorder Questionnaire and Hypomania Checklist (HCL-32). Psychiatry Journal, 2013, http://dx.doi.org.10.1155/2013/548349

Stang, P., Frank, C., Ulcickas-Yood, M., Wells, K., Burch, S., & Muma, B. (2006a). Bipolar disorder detection, ascertainment, and treatment: Primary care physician knowledge, attitudes, and awareness. Primary Care Companion, Journal of Clinical Psychiatry, 8(3), 147-152.

Stang, P. E., Frank, C., Kasekar, A., Ulcickas-Yood, M., Wells, K., & Burch, S. (2006b). The clinical history and costs associated with delayed diagnosis of bipolar disorder. Medscape General Medicine, 8(2), PMCID: PMC1785223

Zimmerman, M., Galione, J. N., Ruggero, C. J., Chelminski, I., Dalrymple, K., & Young, D. (2011). Are screening scales for bipolar disorder good enough to be used in clinical practice? Comprehensive Psychiatry, 52, 600-606. doi: 10.1016/j.comppsych.2011.01.004