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Running Head: THE DIAGNOSIS OF BIPOLAR DISORDER 1

The delay in the diagnosis of bipolar disorder

Chamberlain College of Nursing

NR 326: Mental Health

00/ 2018

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BIPOLAR DISORDER 2

Introduction

Bipolar disorder has a significant cause to morbidity and mortality rate. Although we

have an active treatment, there is an extensive wait before diagnosis and treatment are initiated.

This research was done to examine factors associated with the delay of bipolar disorder before

the diagnosis and the onset of treatment. Bipolar disorder is also called manic depression. This

disorder is characterized with the events of mood swings ranging from depressive lows to manic

highs. The history of bipolar disorder presents with depression, so initial episodes look very

similar to a major depressive disorder. Therefore, there is often a prolonged delay in the exact

diagnosis of bipolar disorder, and any significant wait influence the initiation of appropriate

treatment. This paper investigates whether the delay in the diagnosis of bipolar disorder is

inescapable. This means is the delay in diagnosing bipolar disorder unavoidable or unpreventable

(Fritz et al, 2017).

Article summary

Bipolar disorder frequently beings with an early diagnosis of depression. This creates a

delay in the exact judgement and treatment of bipolar disorder. Although research has focused on

predictors in the analytic change from the depression stage to bipolar disorder. The research on

this prolonged diagnosis is scant. These researchers examine the time it took to diagnose one

with bipolar disorder after an early diagnosis of major depressive disorder to understand the

patient features and psychological factors that may explain the delay. However, when manic

signs are evident, the diagnosis changes to be bipolar disorder. Research shows that the time

from diagnosing a major depressive disorder to the time of diagnosing bipolar disorder is about

10 years. This means before the optimal treatment for bipolar disorder can be made, there might

be a delay in treatment for almost a decade. This is one of many reasons why it is important to

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BIPOLAR DISORDER 3

investigate the cause, and the delay from the diagnosis of major depressive disorder to time of

bipolar disorder (Fritz et al., 2017).

One of the most common predictors of exploratory conversion from major depressive

disorder to bipolar disorder is with antidepressant treatment resistance. There is a rise in the rate

of diagnostic conversion to bipolar disorder after a failure to respond to two treatments with the

use of antidepressant. Another factor that is associated with the diagnostics change from major

depressive disorder to bipolar disorder is with the initial onset of depression. Studies show that

patients who were formerly diagnosed with major depressive disorder are likely to be diagnosed

with bipolar disorder if they had an early onset of depression and were unresponsive to

antidepressant treatment. Also, the conversion to bipolar disorder has been found related to the

patient family history, but the findings are not truly reliable (Fritz et al., 2017).

The information from the article could be used in nursing practice because it educates the

nurse on the factors that might affect the early diagnosis of bipolar disorder. For example, some

statistical data from this research proves the delay as it was stated in this article. The conversion

time from major depressive disorder to bipolar disorder was about 42.8% lesser in female than it

was in male. Also, for every 1-year increase in the initial diagnosis of major depressive disorder,

the time for bipolar disorder conversion decrease by 2.8%. This data was made after a clinical

evaluation of 382 patients by a psychiatrist and with the of use series of questionnaires. When

there is an increase in the diagnosis of major disorder there is a decrease in the diagnosis of

bipolar and verse versa. Another example is to understand those factors associated with the delay

in bipolar disorder which will help the nurse better understand why some patients are diagnosed

with bipolar and other patients showing the same behavior have not been diagnosed. This article

will help the nurse better understand the diagnosis and the delayed process of bipolar disorder

(Fritz et al, 2017).

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BIPOLAR DISORDER 4

Article critique

Based on the study done, the delay is due to the disease process and other factors that

prolong the diagnosis. This article is informative about the process it takes to diagnose bipolar

disorder. The researchers put together resources from various aspect from their research to

provide why the delay is present. For example, Fritz et al. (2017) found an undesirable

correlation between the age at which the disease is initialed to the time of diagnostic conversion.

This means the younger the age of the patient, the longer the delay in diagnosing the patient.

Therefore, understanding the patient’s features and psychological behavior are also reasons that

may delay bipolar disorder from being diagnosed after an early diagnosis of a major depressive

disorder (Fritz et al, 2017).

Weakness

I feel that although the article did tell us about the factors that are associated with the

delay to diagnose bipolar disorder, the researchers did not show how those factors can be

evitable. Within the article there should have been a clear picture or graph explaining ways to

reduce the long process to diagnosing one with bipolar disorder. The weakness I believe in this

article is not especially from the article presentation, but it is from the disease process. The

weakness in this article is seen in the length of time it takes to diagnose one with bipolar.

Recommendations

I will recommend this article to a colleague because it gave a detailed explanation of the

aim of this research. This article is a good starting point to know why there is a prolonged wait in

the diagnosis of bipolar disorder. As a nursing student, this article makes me understand why

most people who exhibit similar behavior with people diagnosed with bipolar disorder have not

been medically diagnosed. As it was explained in the article, age makes a big difference to

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BIPOLAR DISORDER 5

diagnose a person with bipolar disorder because of patient characteristics and psychological

factors. Younger patients are not mentally developed as an adult patient would be.

Conclusion

In conclusion, this study shows that certain individuals experience a significant delay in

diagnosis and treatment of bipolar disorder which varies depending on different factors. I believe

when there is a better understanding of the factors associated with the delay to diagnose bipolar

disorder, then there will be developmental strategies to reduce them. These findings indicate the

need for an early recognition and initiation of active treatment of bipolar disorder which will

most likely diminish disability and improve outcomes.

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BIPOLAR DISORDER 6

References

Fritz, K., Russell, A., Allwang, C., Kuiper, S., Lampe, L., Malhi, G., (2017). Bipolar disorder: Is

a delay in the diagnosis of bipolar disorder inevitable? 19, 396–400. doi:10.1111/bdi.12499.

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NR326 Mental Health Nursing

RUA: Scholarly Article Review Guidelines

NR326 RUA Scholarly Article Review Guideline 1

Purpose The student will review, summarize, and critique a scholarly article related to a mental health topic.

Course outcomes: This assignment enables the student to meet the following course outcomes. (CO 4) Utilize critical thinking skills in clinical decision-making and implementation of the nursing process for

psychiatric/mental health clients. (PO 4) (CO 5) Utilize available resources to meet self-identified goals for personal, professional, and educational

development appropriate to the mental health setting. (PO 5) (CO 7) Examine moral, ethical, legal, and professional standards and principles as a basis for clinical decision-making.

(PO 6) (CO 9) Utilize research findings as a basis for the development of a group leadership experience. (PO 8)

Due date: Your faculty member will inform you when this assignment is due. The Late Assignment Policy applies to this assignment.

Total points possible: 100 points

Preparing the assignment 1) Follow these guidelines when completing this assignment. Speak with your faculty member if you have questions.

a. Select a scholarly nursing or research article, published within the last five years, related to mental health nursing. The content of the article must relate to evidence-based practice. • You may need to evaluate several articles to find one that is appropriate.

b. Ensure that no other member of your clinical group chooses the same article, then submit your choice for faculty approval.

c. The submitted assignment should be 2-3 pages in length, excluding the title and reference pages. 2) Include the following sections (detailed criteria listed below and in the Grading Rubric must match exactly).

a. Introduction (10 points/10%) • Establishes purpose of the paper • Captures attention of the reader

b. Article Summary (30 points/30%) • Statistics to support significance of the topic to mental health care • Key points of the article • Key evidence presented • Examples of how the evidence can be incorporated into your nursing practice

c. Article Critique (30 points/30%) • Present strengths of the article • Present weaknesses of the article • Discuss if you would/would not recommend this article to a colleague

d. Conclusion (15 points/15%) • Provides analysis or synthesis of information within the body of the text • Supported by ides presented in the body of the paper • Is clearly written

e. Article Selection and Approval (5 points/5%) • Current (published in last 5 years) • Relevant to mental health care • Not used by another student within the clinical group • Submitted and approved as directed by instructor

f. APA format and Writing Mechanics (10 points/10%)

2

NR326 Mental Health Nursing RUA: Scholarly Article Review Guidelines

NR326 RUA Scholarly Article Review Guideline 2

• Correct use of standard English grammar and sentence structure • No spelling or typographical errors • Document includes title and reference pages • Citations in the text and reference page

For writing assistance (APA, formatting, or grammar) visit the APA Citation and Writing page in the online library. Please note that your instructor may provide you with additional assessments in any form to determine that you fully understand the concepts learned in the review module.

NR326 Mental Health Nursing RUA: Scholarly Article Review Guidelines

NR326 RUA Scholarly Article Review Guideline 4 3

Grading Rubric Criteria are met when the student’s application of knowledge demonstrates achievement of the outcomes for this assignment.

Assignment Section and Required Criteria

(Points possible/% of total points available)

Highest Level of Performance

High Level of Performance

Satisfactory Level of Performance

Unsatisfactory Level of

Performance

Section not present in paper

Introduction (10 points/10%)

10 points 8 points 0 points

Required criteria 1. Establishes purpose of the paper 2. Captures attention of the reader

Includes 2 requirements for section. Includes 1 requirement for section.

No requirements for this section presented.

Article Summary (30 points/30%)

30 points 25 points 24 points 11 points 0 points

Required criteria 1. Statistics to support significance of the topic to

mental health care 2. Key points of the article 3. Key evidence presented 4. Examples of how the evidence can be incorporated

into your nursing practice

Includes 4 requirements for section.

Includes 3 requirements for section.

Includes 2 requirements for section.

Includes 1 requirement for section.

No requirements for this section presented.

Article Critique (30 points/30%)

30 points 25 points 11 points 0 points

Required criteria 1. Present strengths of the article 2. Present weaknesses of the article 3. Discuss if you would/would not recommend this

article to a colleague

Includes 3 requirements for section. Includes 2 requirements for section.

Includes 1 requirement for section.

No requirements for this section presented.

Conclusion (15 points/15%)

15 points 11 points 6 points 0 points

1. Provides analysis or synthesis of information within the body of the text

2. Supported by ides presented in the body of the paper 3. Is clearly written

Includes 3 requirements for section. Includes 2 requirements for section.

Includes 1 requirement for section.

No requirements for this section presented.

Article Selection and Approval (5 points/5%)

5 points 4 points 3 points 2 points 0 points

1. Current (published in last 5 years) Includes 4 Includes 3 Includes 2 Includes 1 No requirements for

NR326 Mental Health Nursing RUA: Scholarly Article Review Guidelines

NR326 RUA Scholarly Article Review Guideline 4 4

2. Relevant to mental health care 3. Not used by another student within the clinical group 4. Submitted and approved as directed by instructor

requirements for section.

requirements for section.

requirements for section.

requirement for section.

this section presented.

APA Format and Writing Mechanics (10 points/10%)

10 points 8 points 7 points 4 points 0 points

1. Correct use of standard English grammar and sentence structure

2. No spelling or typographical errors 3. Document includes title and reference pages 4. Citations in the text and reference page

Includes 4 requirements for section.

Includes 3 requirements for section.

Includes 2 requirements for section.

Includes 1 requirement for section.

No requirements for this section presented.

Total Points Possible = 100 points

https://doi.org/10.1177/2045125318769235 https://doi.org/10.1177/2045125318769235

Ther Adv Psychopharmacol

2018, Vol. 8(9) 251 –269

DOI: 10.1177/ 2045125318769235

© The Author(s), 2018. Reprints and permissions: http://www.sagepub.co.uk/ journalsPermissions.nav

Therapeutic Advances in Psychopharmacology

journals.sagepub.com/home/tpp 251

Introduction Bipolar affective disorder (bipolar) is a multicom- ponent illness involving episodes of severe mood disturbance, neuropsychological deficits, immu- nological and physiological changes, and distur- bances in functioning.1 It is one of the leading causes of disability worldwide2 and is associated with high rates of premature mortality from both suicide and medical comorbidities.3,4

The aetiology of bipolar is not well understood and research into the disorder lags behind disor- ders such as psychosis. However, the last decade has seen an expanding evidence into the genetics of the disorder, underlying developmental path- ways, risks and vulnerability factors, gene–envi- ronment interactions and the putative features of the bipolar prodrome.

This article summarizes the research into demo- graphic, genetic and environmental risk factors for the development of bipolar, with a focus on

recent updates and the role of environmental trig- gers. To identify relevant literature, searches were conducted in PubMed and PsycINFO using the terms ‘Bipolar Disorder’, combined with ‘risk fac- tors’ or ‘epidemiology’. Results were reviewed with a focus on the most recent evidence and sys- tematic reviews or large prospective studies, and further individual searches were then expanded for each risk factor category identified. A sum- mary of the included studies relating to specific risk factors for bipolar are included in Table 1.

Epidemiology of bipolar disorder Epidemiological studies have suggested a lifetime prevalence of around 1% for bipolar type I in the general population.54,55 A large cross-sectional survey of 11 countries found the overall lifetime prevalence of bipolar spectrum disorders was 2.4%, with a prevalence of 0.6% for bipolar type I and 0.4% for bipolar type II.56 Although findings

Epidemiology and risk factors for bipolar disorder Tobias A. Rowland and Steven Marwaha

Abstract: Bipolar disorder is a multifactorial illness with uncertain aetiology. Knowledge of potential risk factors enables clinicians to identify patients who are more likely to develop bipolar disorder, which directs further investigation, follow up and caution when prescribing. Ideally, identifying directly causative factors for bipolar disorder would enable intervention on an individual or population level to prevent the development of the illness, and improve outcomes through earlier treatment. This article reviews the epidemiology of bipolar disorder, along with putative demographic, genetic and environmental risk factors, while assessing the strength of these associations and to what extent they might be said to be ‘causative’. While numerous genetic and environmental risk factors have been identified, the attributable risk of individual factors is often small, and most are not specific to bipolar disorder but are associated with several mental illnesses. Therefore, while some genetic and environmental factors have strong evidence supporting their association with bipolar disorder, fewer have sufficient evidence to establish causality. There is increasing interest in the role of specific gene–environment interactions, as well as the mechanisms by which risk factors interact to lead to bipolar disorder.

Keywords: bipolar disorder, epidemiology, risk factors

Received: 9 November 2017; revised manuscript accepted: 13 March 2018.

Correspondence to: Tobias A. Rowland Unit of Mental Health and Wellbeing, Division of Health Sciences, University of Warwick, Coventry, CV4 7AL, UK [email protected] ac.uk

Steven Marwaha Division of Health Sciences, University of Warwick, Coventry, UK

Coventry and Warwick- shire Partnership Trust, The Caludon Centre, Coventry, UK

769235TPP0010.1177/2045125318769235Therapeutic Advances in PsychopharmacologyT A Rowland and S Marwaha review-article2018

Review

Therapeutic Advances in Psychopharmacology 8(9)

252 journals.sagepub.com/home/tpp

Table 1. Studies investigating specific risk factors for bipolar disorder.

Study Risk factor examined Design n (participants/ studies)

Summary of main findings

Genetics

Craddock and Jones5

Familial genetic risk Review 8 studies Meta-analysis provided an overall estimate of the risk of bipolar in first-degree relatives of bipolar type I probands, OR = 7 (95% CI 5–10)

6 studies Pooled data provided an estimate of probandwise monozygotic concordance for bipolar of 50% (95% CI 40–60%)

Psychiatric GWAS Consortium Bipolar Disorder Working Group6

Multiple SNPs Case-control GWAS data

11,974 bipolar patients 51,792 controls

Genome-wide significant evidence of association for rs4765913 in CACNA1C (p = 1.52 × 10−8, OR = 1.14) and rs12576775 in ODZ4 (p = 4.40 × 10−8, OR = 0.89)

Fan and Sklar7 BDNF Val66Met polymorphism

Meta-analysis 14 studies Meta-analysis shows evidence for the association between Val66Met polymorphism in BDNF and bipolar (OR = 1.13, 95% CI 1.04–1.23, p = 0.004)

Cho et al.8 5-HTTL polymorphic region and intron 2 variable numbers of tandem repeat polymorphisms

Meta-analysis 17 studies The review revealed significant pooled OR = 1.12 (95% CI 1.03–1.21) for the association between bipolar and 5-HTTL polymorphic region and OR = 1.12 (95% CI 1.02–1.22) for the intron 2 variable numbers of tandem repeat polymorphisms

Aas et al.9 Gene–environment interaction of childhood trauma and BDNF Val66Met variants

Cross sectional 141 bipolar patients

There was an additive effect between a history of childhood trauma and BDNF Val66Met, with Met carriers with high levels of childhood trauma having the lowest BDNF mRNA levels.

Oliveira et al.10 Gene–environment interaction of TLR2 polymorphism and early-life stress

Cross sectional 531 bipolar patients

A combined effect of TLR2 rs3804099 TT genotype and reported sexual abuse was observed on determining an earlier age at onset of bipolar (corrected p = 0.02)

Oliveira et al.11 Gene–environment interaction of TLR2 genetic variation and Toxoplasma gondii exposure

Case control 138 bipolar patients 167 healthy controls

There was a trend for an interaction between the TLR2 rs3804099 SNP and T. gondii seropositivity in conferring bipolar risk (p = 0.017, uncorrected)

Hosang et al.12 Gene–environment interaction of COMT Val158 Met polymorphism and stressful life events

Case control 482 bipolar patients 205 healthy controls

The impact of stressful life events was moderated by the COMT genotype for the worst depressive episode using a Val- dominant model (adjusted risk difference 0.09, 95% CI 0.003–0.18, p = 0.04)

De Pradier et al.13

Gene–environment interaction of serotonin transporter gene polymorphism, cannabis and childhood sexual abuse

Case control 137 bipolar patients

The short allele of the 5-HTTLPR polymorphism and cannabis abuse were significantly more frequent among patients with psychotic symptoms than in those without (p = 0.01 and p = 0.004, respectively), while childhood sexual abuse was not

T A Rowland and S Marwaha

journals.sagepub.com/home/tpp 253

Study Risk factor examined Design n (participants/ studies)

Summary of main findings

Prenatal and perinatal factors

Barichello et al.14 Perinatal infections Systematic review

23 studies Studies investigated exposure to several pathogens namely cytomegalovirus, Epstein–Barr virus, herpes simplex virus-1, herpes simplex virus-2, human herpesvirus 6, T. gondii, influenza, and varicella zoster virus; overall, studies provided mixed evidence

Sutterland et al.15

T. gondii Meta-analysis 11 studies Significant association of T. gondii infection with bipolar, OR = 1.52 (95% CI 1.06–2.18, p = 0.02)

De Barros et al.16 T. gondii Meta-analysis 8 studies T. gondii infection is associated with bipolar (OR = 1.26, 95% CI 1.08–1.47)

Scott et al.17 Obstetric complications Meta-analysis 8 studies The pooled OR for the exposure to obstetric complications on subsequent development of bipolar was 1.15 (95% CI 0.62–2.14)

Childhood trauma

Watson et al.18 Childhood trauma Case control 60 bipolar patients 55 controls

Significantly higher rates of childhood trauma were observed in patients with bipolar compared with controls; logistic regression, controlling for age and sex, identified emotional neglect to be the only significant childhood trauma questionnaire subscale associated with bipolar

Etain et al.19 Childhood trauma Case control 260 bipolar patients 94 controls

The Childhood Trauma Questionnaire total score was higher for bipolar than controls; the presence of multiple trauma was significantly more frequent in bipolar than controls (63% versus 33%); multiple logistic regression suggested that only emotional abuse was associated with bipolar with a suggestive dose effect

Garno et al.20 Childhood trauma Cross sectional 100 bipolar patients

Histories of severe childhood abuse were identified in about half of the sample and were associated with early age at illness onset; abuse subcategories were strongly inter-related; multiple forms of abuse showed a graded increase in risk for both suicide attempts and rapid cycling

Palmier-Claus et al.21

Childhood trauma Meta-analysis 19 studies Childhood adversity was 2.63 times (95% CI 2.00–3.47) more likely to have occurred in bipolar compared with nonclinical controls; the effect of emotional abuse was particularly robust (OR = 4.04, 95% CI 3.12–5.22)

Table 1. (Continued)

(Continued)

Therapeutic Advances in Psychopharmacology 8(9)

254 journals.sagepub.com/home/tpp

Study Risk factor examined Design n (participants/ studies)

Summary of main findings

Agnew-Blais and Danese22

Childhood trauma and outcomes in bipolar

Meta-analysis 30 studies Patients with bipolar and history of childhood maltreatment had greater severity of mania, depression and psychosis, higher risk of comorbidity, earlier age of onset, higher risk of rapid cycling, greater number of manic or depressive episodes, and higher risk of suicide attempt compared with those with bipolar without childhood maltreatment

Daruy-Filho et al.23

Childhood trauma and outcomes in bipolar

Systematic review

19 studies Childhood maltreatment predicted worsening clinical course of bipolar; childhood maltreatment can be strongly associated with early onset of disorder, suicidality, and substance abuse disorder in patients with bipolar

Upthegrove et al.24

Childhood trauma and psychosis in bipolar

Cross-sectional 2019 bipolar patients

There was no relationship between childhood events or abuse and psychosis; childhood events were not associated with an increased risk of persecutory or other delusions; significant associations were found between childhood abuse and auditory hallucinations, strongest between sexual abuse and mood-congruent or abusive voices

Psychological stressors

Lex et al.25 Life events prior to relapse

Meta-analysis 42 studies Patients with bipolar reported more life events before relapse compared with euthymic phases; they also experienced more life events relative to healthy individuals and to physically ill patients; no significant difference in the number of life events was found comparing bipolar to unipolar depression and schizophrenia

Kessing et al.26 Life events and first admission for mania

Case-control 1565 bipolar patients 31,300 controls

Suicide of a mother or of a sibling was associated with increased risk of first psychiatric admission with mania/mixed episode; death of a relative by other causes was not associated with increased risk of admission; recent unemployment, divorce, or marriage also showed moderate effects

Koenders et al.27 Life events and mood episodes

Prospective cohort

173 bipolar patients

Negative life events were significantly associated with subsequent severity of mania and depressive symptoms and functional impairment, whereas positive life events only preceded functional impairment due to manic symptoms and mania severity; for the opposite temporal direction, mania symptoms preceded the occurrence of positi

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