The mean duration of untreated bipolar disorder (DUB) is "unacceptably" long, say French researchers who report that an increased duration is associated with more mood episodes, more suicidal behavior, and greater mood instability.
In a study of 501 French patients with the mood disorder, Bruno Etain (Hôpital Albert Chenevier, Créteil) and team found that the mean DUB, defined as the interval between the first major mood episode and first treatment with a mood stabilizer, was 9.8 years.
"Not only is the DUB unacceptably long, the missed opportunities to reduce it include insufficient systematic clinical screening for hypomania, inadequate assessment of indicators of bipolarity in early onset depression and/or failure to consider the diagnosis of bipolar disorder (BD) in those with mood episodes who present with a suicide attempt, and a failure to either assess or consider the possible implications of a positive familial history of BD," say the researchers.
They add: "Lack of awareness, poor training in the assessment of bipolarity and lack of adherence to clinical practice guidelines may also play a part."
The study group comprised individuals (53.8% women) with BDI or BDII from general psychiatry follow-up clinics in Paris, Bordeaux, and Nancy.
The team found that the first full syndromal mood episode meeting DSM-IV criteria occurred at a mean age of 25.3 years, while the mean age at first recorded treatment with a mood stabilizer was 34.9 years.
Dividing the participants into groups according to first-episode polarity revealed that patients with a hypomanic onset had the longest mean DUB, at 11.9 years, followed by those with a depressive onset (10.5 years), and those with a manic onset (6.5 years).
In addition, patients with early-onset BD (≤21 years) had a mean DUB of 12.5 years, which was significantly longer than those with an intermediate onset (>21 to ≤37 years) at 7.4 years, and those with a late onset (>37 years) at 5.6 years. And patients with psychotic symptoms during the first mood episode also had a shorter DUB than those without, at 5.5 versus 10.9 years.
The researchers also found that a longer DUB was significantly associated with a positive lifetime history of suicide attempts, a higher number of major mood episodes, and a trend towards greater mood instability, such as rapid cycling, and history of mixed episodes.
Etain et al conclude in Acta Scandinavica Psychiatrica: "The key message from this paper is that - while many studies have raised concerns about the possible over-diagnosis of BD - the bigger problem still seems to be the persistent inadequate identification and delayed intervention for this very debilitating disorder."
They add: "Targeted medical education and training to reduce the DUB, reorganization of mental health and medical care services to better serve the needs of patients with BD in France and/or the development of new early intervention services for mood disorder could help."
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