The impact of marketing efforts by pharmaceutical companies and publicity probably plays a role in the emerging tendency to over-diagnose bipolar disorder. Direct-to-consumer advertisements that refer individuals to screening questionnaires can result in patients suggesting to their doctors that they have bipolar disorder. We have seen evidence of this in our practice. This does not necessarily reflect a problem with the performance of a screening questionnaire, but rather how these scales are used. Screening questionnaires maximize sensitivity, at a cost of false positives, because it is presumed that they are followed by expert clinical evaluation. But insufficient diagnostic rigor can result in overdiagnosis.
Clinicians are inclined to diagnose disorders that they feel more comfortable treating. We believe that the increased availability of medications that have been approved for the treatment of bipolar disorder might be influencing clinicians who are unsure whether or not a patient has bipolar disorder or borderline personality disorder to err on the side of diagnosing the disorder that is responsive to medication.
This bias is reinforced by the marketing of pharmaceutical companies to physicians, which has emphasized research on delayed diagnosis and under-recognition of bipolar disorder, possibly sensitizing clinicians accordingly. The campaign against under-recognition has probably resulted in some anxious, agitated and/or irritable depressed patients who complain of insomnia and “racing thoughts” being misdiagnosed with bipolar disorder.
The results of our study are consistent with prior studies suggesting possible problems with the diagnosis of bipolar disorder. With the greater number of medications approved for the treatment of bipolar disorder, along with multiple reports cautioning clinicians against underdiagnosis, it appears that overdiagnosis has become a greater problem than underdiagnosis. Both can have negative consequences.
Mark Zimmerman is associate professor of psychiatry and human behavior at Brown Medical School.
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