Optimizing the Detection of Bipolar II Disorder in Outpatient Private Practice: Toward a Systematization of Clinical Diagnostic Wisdom
J Clin Psychiatry 2005;66(7):914-921
© Copyright 2014 Physicians Postgraduate Press, Inc.
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Background: We review a clinical
diagnostic approach to validate a redefinition of bipolar II
disorder (BPII), which bypasses several conservative steps in the
DSM-IV Mood Module of the Structured Clinical Interview for
DSM-IV Axis I Disorders, Clinician Version (SCID-CV) to make
detection of BPII more "clinician-friendly."
Method: 563 consecutive private
outpatients presenting with a DSM-IV-diagnosed major depressive
episode (MDE) were included in the analyses. We used a modified
SCID-CV in a semistructured way, used a duration of hypomania
> = 2 days (rather than the 4-day floor cutoff recommended), did
not follow the SCID-CV's stem (mood) skip-out instruction,
focused more on past history of overactive behavior rather
than mood change, and assessed hypomanic features both outside
and during index MDE. Validation of BPII so-defined against major
depressive disorder (MDD) was undertaken in the Washington
University tradition. The study was conducted from June 1999 to
Results: BPII occurred in 56.8% of
patients. Compared with MDD, BPII had a significantly earlier
index age and age at onset of first MDE and higher rates of
atypical features, depressive recurrences, hypomanic symptoms
during MDE, trait mood lability, and bipolar family
history (p = .0000 for all variables).
Conclusions: Our experience suggests that when
probing history for past hypomanic episodes, behavioral
activation should be inquired first, thereby facilitating the
patient's subsequent recall of euphoria and/or irritability
during such activated periods. Information from significant
others or past records is also crucial. In light of these
clinical procedures, BPII emerged as more prevalent than MDD. We
submit that clinicians have the distinct advantage of intimate
knowledge of their patients, which, coupled with the procedures
outlined herein, can maximize the yield of BPII diagnoses.