case study example bipolar disorder

Patient Case #1: 27-Year-Old Woman With Bipolar Disorder

• Theresa Cerulli, MD
• Tina Matthews-Hayes, DNP, FNP, PMHNP

Custom Around the Practice Video Series

Experts in psychiatry review the case of a 27-year-old woman who presents for evaluation of a complex depressive disorder.

EP: 1 . Patient Case #1: 27-Year-Old Woman With Bipolar Disorder

Ep: 2 . clinical significance of bipolar disorder, ep: 3 . clinical impressions from patient case #1, ep: 4 . diagnosis of bipolar disorder, ep: 5 . treatment options for bipolar disorder, ep: 6 . patient case #2: 47-year-old man with treatment resistant depression (trd), ep: 7 . patient case #2 continued: novel second-generation antipsychotics, ep: 8 . role of telemedicine in bipolar disorder.

Michael E. Thase, MD : Hello and welcome to this Psychiatric Times™ Around the Practice , “Identification and Management of Bipolar Disorder. ”I’m Michael Thase, professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.

Joining me today are: Dr Gustavo Alva, the medical director of ATP Clinical Research in Costa Mesa, California; Dr Theresa Cerulli, the medical director of Cerulli and Associates in North Andover, Massachusetts; and Dr Tina Matthew-Hayes, a dual-certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.

Today we are going to highlight challenges with identifying bipolar disorder, discuss strategies for optimizing treatment, comment on telehealth utilization, and walk through 2 interesting patient cases. We’ll also involve our audience by using several polling questions, and these results will be shared after the program.

Without further ado, welcome and let’s begin. Here’s our first polling question. What percentage of your patients with bipolar disorder have 1 or more co-occurring psychiatric condition? a. 10%, b. 10%-30%, c. 30%-50%, d. 50%-70%, or e. more than 70%.

Now, here’s our second polling question. What percentage of your referred patients with bipolar disorder were initially misdiagnosed? Would you say a. less than 10%, b. 10%-30%, c. 30%-50%, d. more than 50%, up to 70%, or e. greater than 70%.

We’re going to go ahead to patient case No. 1. This is a 27-year-old woman who’s presented for evaluation of a complex depressive syndrome. She has not benefitted from 2 recent trials of antidepressants—sertraline and escitalopram. This is her third lifetime depressive episode. It began back in the fall, and she described the episode as occurring right “out of the blue.” Further discussion revealed, however, that she had talked with several confidantes about her problems and that she realized she had been disappointed and frustrated for being passed over unfairly for a promotion at work. She had also been saddened by the unusually early death of her favorite aunt.

Now, our patient has a past history of ADHD [attention-deficit/hyperactivity disorder], which was recognized when she was in middle school and for which she took methylphenidate for adolescence and much of her young adult life. As she was wrapping up with college, she decided that this medication sometimes disrupted her sleep and gave her an irritable edge, and decided that she might be better off not taking it. Her medical history was unremarkable. She is taking escitalopram at the time of our initial evaluation, and the dose was just reduced by her PCP [primary care physician]from 20 mg to 10 mg because she subjectively thought the medicine might actually be making her worse.

On the day of her first visit, we get a PHQ-9 [9-item Patient Health Questionnaire]. The score is 16, which is in the moderate depression range. She filled out the MDQ [Mood Disorder Questionnaire] and scored a whopping 10, which is not the highest possible score but it is higher than 95% of people who take this inventory.

At the time of our interview, our patient tells us that her No. 1 symptom is her low mood and her ease to tears. In fact, she was tearful during the interview. She also reports that her normal trouble concentrating, attributable to the ADHD, is actually substantially worse. Additionally, in contrast to her usual diet, she has a tendency to overeat and may have gained as much as 5 kg over the last 4 months. She reports an irregular sleep cycle and tends to have periods of hypersomnolence, especially on the weekends, and then days on end where she might sleep only 4 hours a night despite feeling tired.

Upon examination, her mood is positively reactive, and by that I mean she can lift her spirits in conversation, show some preserved sense of humor, and does not appear as severely depressed as she subjectively describes. Furthermore, she would say that in contrast to other times in her life when she’s been depressed, that she’s actually had no loss of libido, and in fact her libido might even be somewhat increased. Over the last month or so, she’s had several uncharacteristic casual hook-ups.

So the differential diagnosis for this patient included major depressive disorder, recurrent unipolar with mixed features, versus bipolar II disorder, with an antecedent history of ADHD. I think the high MDQ score and recurrent threshold level of mixed symptoms within a diagnosable depressive episode certainly increase the chances that this patient’s illness should be thought of on the bipolar spectrum. Of course, this formulation is strengthened by the fact that she has an early age of onset of recurrent depression, that her current episode, despite having mixed features, has reverse vegetative features as well. We also have the observation that antidepressant therapy has seemed to make her condition worse, not better.

Transcript Edited for Clarity

Dr. Thase is a professor of psychiatry at the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, Pennsylvania.

Dr. Alva is the medical director of ATP Clinical Research in Costa Mesa, California.

Dr. Cerulli is the medical director of Cerulli and Associates in Andover, Massachusetts.

Dr. Tina Matthew-Hayes is a dual certified nurse practitioner at Western PA Behavioral Health Resources in West Mifflin, Pennsylvania.

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Real Life Bipolar Disorder: A Case Study of Susan

Bipolar disorder is a complex and often misunderstood mental health condition that affects millions of individuals worldwide. For those living with bipolar disorder, the highs and lows of life can be dizzying, as they navigate through periods of intense mania and debilitating depression. To truly grasp the impact of this disorder, it’s crucial to explore real-life experiences and the stories of those who have dealt firsthand with its challenges.

In this article, we delve into the fascinating case study of Susan, a woman whose life has been profoundly shaped by her bipolar disorder diagnosis. By examining Susan’s journey, we aim to shed light on the realities of living with this condition and the strategies employed to manage and treat it effectively.

But before we plunge deeper into Susan’s story, let’s first gain a comprehensive understanding of bipolar disorder itself. We’ll explore the formal definition, the prevalence of the condition, and its impact on both individuals and society as a whole. This groundwork will set the stage for a more insightful exploration of Susan’s experience and provide valuable context for the subsequent sections of this article.

Bipolar disorder is more than just mood swings; it is a condition that can significantly disrupt an individual’s life, relationships, and overall well-being. By studying a real-life case like Susan’s, we can gain a personal insight into the multifaceted challenges faced by those with bipolar disorder and the importance of effective treatment and support systems. In doing so, we hope to foster empathy, inspire early diagnosis, and contribute to the advancement of knowledge about bipolar disorder’s complexities.

The Case of Susan: A Real Life Experience with Bipolar Disorder

Susan’s story provides a compelling illustration of the impact that bipolar disorder can have on an individual’s life. Understanding her background, symptoms, and the effects of the disorder on her daily life can provide valuable insights into the challenges faced by those with bipolar disorder.

Background Information on Susan

Susan, a thirty-eight-year-old woman, was diagnosed with bipolar disorder at the age of twenty-five. Her early experiences with the disorder were characterized by periods of extreme highs and lows, often resulting in strained relationships and an inability to maintain steady employment. Susan’s episodes of mania frequently led to impulsive decision-making, excessive spending sprees, and risky behaviors. On the other hand, her depressive episodes left her feeling hopeless, fatigued, and unmotivated.

Symptoms and Diagnosis of Bipolar Disorder in Susan

To receive an accurate diagnosis, Susan underwent a thorough examination by mental health professionals. The criteria for diagnosing bipolar disorder include significant and persistent mood swings, alternating between periods of mania and depression. Susan exhibited classic symptoms of bipolar disorder, such as elevated mood, increased energy, racing thoughts, decreased need for sleep, and reckless behavior during her manic episodes. These episodes were interspersed with periods of deep sadness, loss of interest in activities, and changes in appetite and sleep patterns during depressive phases.

Effects of Bipolar Disorder on Susan’s Daily Life

Living with bipolar disorder presents unique challenges for Susan. The unpredictable shifts in her mood and energy levels significantly impact her ability to function in both personal and professional spheres. During manic phases, Susan experiences heightened productivity, creativity, and confidence, often leading her to take on excessive responsibilities and projects. However, these periods are eventually followed by crashes into depressive episodes, leaving her unable to complete tasks, maintain relationships, or even perform routine self-care. The constant fluctuations in her emotional state make it difficult for Susan to establish a sense of stability and predictability in her life.

Susan’s struggle with bipolar disorder is not uncommon. Many individuals with this condition face similar obstacles in their daily lives, attempting to manage the debilitating highs and lows while striving for a sense of normalcy. By understanding the real-life implications of bipolar disorder, we can more effectively tailor our support systems and treatment options to address the needs of individuals like Susan. In the next section, we will explore the various approaches to treating and managing bipolar disorder, providing potential strategies for improving the quality of life for those living with this condition.

Treatment and Management of Bipolar Disorder in Susan

Managing bipolar disorder requires a multifaceted approach that combines psychopharmacological interventions, psychotherapy, counseling, and lifestyle modifications. Susan’s journey towards finding effective treatment and management strategies highlights the importance of a comprehensive and tailored approach.

Psychopharmacological Interventions

Pharmacological interventions play a crucial role in stabilizing mood and managing symptoms associated with bipolar disorder. Susan’s treatment plan involved medications such as mood stabilizers, antipsychotics, and antidepressants. These medications aim to regulate the neurotransmitters in the brain associated with mood regulation. Susan and her healthcare provider closely monitored her medication regimen and made adjustments as needed to achieve symptom control.

Psychotherapy and Counseling

Psychotherapy and counseling provide individuals with bipolar disorder a safe space to explore their thoughts, emotions, and behaviors. Susan engaged in cognitive-behavioral therapy (CBT), which helped her identify and challenge negative thought patterns and develop healthy coping mechanisms. Additionally, psychoeducation in the form of group therapy or support groups allowed Susan to connect with others facing similar challenges, fostering a sense of community and reducing feelings of isolation.

Lifestyle Modifications and Self-Care Strategies

In addition to medical interventions and therapy, lifestyle modifications and self-care strategies play a vital role in managing bipolar disorder. Susan found that maintaining a stable routine, including regular sleep patterns, exercise, and a balanced diet, helped regulate her mood. Avoiding excessive stressors and implementing stress management techniques, such as mindfulness meditation or relaxation exercises, also supported her overall well-being. Engaging in activities she enjoyed, nurturing her social connections, and setting realistic goals further enhanced her quality of life.

Striving for stability and managing bipolar disorder is an ongoing process. What works for one individual may not be effective for another. It is crucial for individuals with bipolar disorder to work closely with their healthcare providers and engage in open communication about treatment options and progress. Fine-tuning the combination of psychopharmacological interventions, therapy, and self-care strategies is essential to optimize symptom control and maintain stability.

Understanding the complexity of treatment and management helps foster empathy for individuals like Susan, who face the daily challenges associated with bipolar disorder. It underscores the importance of early diagnosis, accessible mental health care, and ongoing support systems to enhance the lives of individuals living with this condition. In the following section, we will explore the various support systems available to individuals with bipolar disorder, including family support, peer support groups, and the professional resources that contribute to their well-being.

Support Systems for Individuals with Bipolar Disorder

Navigating the challenges of bipolar disorder requires a strong support system that encompasses various sources of assistance. From family support to peer support groups and professional resources, these networks play a significant role in helping individuals manage their condition effectively.

Family Support

Family support is vital for individuals with bipolar disorder. Understanding and empathetic family members can provide emotional support, monitor medication adherence, and help identify potential triggers or warning signs of relapse. In Susan’s case, her family played a crucial role in her recovery journey, providing a stable and nurturing environment. Education about bipolar disorder within the family helps foster empathy, reduces stigma, and promotes open communication.

Peer Support Groups

Peer support groups provide individuals with bipolar disorder an opportunity to connect with others who share similar experiences. Sharing personal stories, strategies for coping, and offering mutual support can be empowering and validating. In these groups, individuals like Susan can find solace in knowing that they are not alone in their struggles. Peer support groups may meet in-person or virtually, allowing for easier access to support regardless of physical proximity.

Professional Support and Resources

Professional support is crucial in the management of bipolar disorder. Mental health professionals, such as psychiatrists, psychologists, and therapists, provide expertise and guidance in developing comprehensive treatment plans. Regular therapy sessions allow individuals like Susan to explore emotional challenges and develop healthy coping mechanisms. Psychiatrists closely monitor medication effectiveness and make necessary adjustments. Additionally, case managers or social workers can assist with navigating the healthcare system, accessing resources, and connect individuals with other community services.

Beyond direct professional support, there are resources and organizations dedicated to bipolar disorder education, advocacy, and support. Online forums, websites, and helplines provide information, guidance, and a sense of community. These platforms allow individuals to access information at any time and connect with others who understand their unique experiences.

Support systems for bipolar disorder are crucial in empowering individuals and enabling them to lead fulfilling lives. They contribute to reducing stigma, providing emotional support, and ensuring access to resources and education. Through these support systems, individuals with bipolar disorder can gain self-confidence, develop effective coping strategies, and improve their overall well-being.

In the next section, we explore the significance of case studies in understanding bipolar disorder and how they contribute to advancing research and knowledge in the field. Specifically, we will examine how Susan’s case study serves as a valuable contribution to furthering our understanding of this complex disorder.

The Importance of Case Studies in Understanding Bipolar Disorder

Case studies play a vital role in advancing our understanding of bipolar disorder and its complexities. They offer valuable insights into individual experiences, treatment outcomes, and the overall impact of the condition on individuals and society. Susan’s case study, in particular, provides a unique perspective that contributes to broader research and knowledge in the field.

How Case Studies Contribute to Research

Case studies provide an in-depth examination of specific individuals and their experiences with bipolar disorder. They allow researchers and healthcare professionals to observe patterns, identify commonalities, and gain valuable insights into the factors that influence symptom presentation, treatment response, and prognosis. By analyzing various case studies, researchers can generate hypotheses and refine treatment approaches to optimize outcomes for individuals with bipolar disorder.

Case studies are particularly helpful in documenting rare or atypical presentations of bipolar disorder. They shed light on lesser-known subtypes, such as rapid-cycling bipolar disorder or mixed episodes, contributing to a more comprehensive understanding of the condition. Case studies also provide opportunities for clinicians and researchers to discuss unique challenges and discover innovative interventions to improve treatment outcomes.

Susan’s Case Study in the Context of ATI Bipolar Disorder

Susan’s case study is an example of how individual experiences can inform the development of Assessment Technologies Institute (ATI) for bipolar disorder. By examining her journey, researchers can analyze treatment approaches, evaluate the effectiveness of various interventions, and develop evidence-based guidelines for managing bipolar disorder.

Susan’s case study provides rich information about the impact of medication, psychotherapy, and lifestyle modifications on symptom control and overall well-being. It offers valuable insights into the benefits and limitations of specific interventions, highlighting the importance of personalized treatment plans tailored to individual needs. Additionally, Susan’s case study can contribute to ongoing discussions about the role of support systems and the integration of peer support groups in managing and enhancing the lives of individuals with bipolar disorder.

The detailed documentation of Susan’s experiences serves as a powerful tool for healthcare providers, researchers, and individuals living with bipolar disorder. It highlights the complexities and challenges associated with the condition while fostering empathy and understanding among various stakeholders.

Case studies, such as Susan’s, play a crucial role in enhancing our understanding of bipolar disorder. They provide insights into individual experiences, treatment approaches, and the impact of the condition on individuals and society. Through these case studies, we can cultivate empathy for individuals with bipolar disorder, advocate for early diagnosis and effective treatment, and contribute to advancements in research and knowledge.

By illuminating the realities of living with bipolar disorder, we acknowledge the need for accessible mental health care, support systems, and evidence-based interventions. Susan’s case study exemplifies the importance of a comprehensive approach to managing bipolar disorder, integrating psychopharmacological interventions, psychotherapy, counseling, and lifestyle modifications.

Moving forward, it is essential to continue studying cases like Susan’s and explore the diverse experiences within the bipolar disorder population. By doing so, we can foster empathy, encourage early intervention and personalized treatment, and contribute to advancements in understanding bipolar disorder, ultimately improving the lives of individuals affected by this complex condition.

Empathy and Understanding for Individuals with Bipolar Disorder

Developing empathy and understanding for individuals with bipolar disorder is crucial in fostering a supportive and inclusive society. By recognizing the unique challenges they face and the complexity of their experiences, we can better advocate for their needs and provide the necessary resources and support.

It is important to understand that bipolar disorder is not simply a matter of mood swings or being “moody.” It is a chronic and often debilitating mental health condition that affects individuals in profound ways. The extreme highs of mania and the lows of depression can disrupt relationships, employment, and overall quality of life. Developing empathy means acknowledging that these struggles are real and offering support and understanding to those navigating them.

Encouraging Early Diagnosis and Effective Treatment

Early diagnosis and effective treatment are key factors in managing bipolar disorder and reducing the impact of its symptoms. Encouraging individuals to seek help and reducing the stigma associated with mental illness are crucial steps toward achieving early diagnosis. Increased awareness campaigns and education can empower individuals to recognize the signs and symptoms of bipolar disorder in themselves or their loved ones, facilitating timely intervention.

Once diagnosed, providing access to quality mental health care and ensuring individuals receive appropriate treatment is essential. Bipolar disorder often requires a combination of pharmacological interventions, psychotherapy, and lifestyle modifications. By advocating for comprehensive treatment plans and promoting ongoing care, we can help individuals with bipolar disorder achieve symptom control and improve their overall well-being.

The Role of Case Studies in Advancing Knowledge about Bipolar Disorder

Case studies, like Susan’s, play a significant role in advancing knowledge about bipolar disorder. They provide unique insights into individual experiences, treatment outcomes, and the wider impact of the condition. Researchers and healthcare providers can learn from these individual cases, developing evidence-based guidelines and refining treatment approaches.

Additionally, case studies contribute to reducing stigma by providing personal narratives that humanize the disorder. They showcase the challenges faced by individuals with bipolar disorder and highlight the importance of support systems, empathy, and understanding. By sharing these stories, we can help dispel misconceptions and promote a more compassionate approach toward mental health as a whole.

In conclusion, developing empathy and understanding for individuals with bipolar disorder is essential. By recognizing the complexity of their experiences, advocating for early diagnosis and effective treatment, and valuing the insights provided by case studies, we can create a society that supports and uplifts those with bipolar disorder. It is through empathy and education that we can reduce stigma, promote accessible mental health care, and improve the lives of those affected by this condition.In conclusion, gaining a comprehensive understanding of bipolar disorder is crucial in order to support individuals affected by this complex mental health condition. Through the real-life case study of Susan, we have explored the numerous facets of bipolar disorder, including its background, symptoms, and effects on daily life. Susan’s journey serves as a powerful reminder of the challenges individuals face in managing the highs and lows of bipolar disorder and emphasizes the importance of effective treatment and support systems.

We have examined the various approaches to treating and managing bipolar disorder, including psychopharmacological interventions, psychotherapy, and lifestyle modifications. Understanding the role of these treatments and the need for personalized care can significantly improve the quality of life for individuals like Susan.

Support systems also play a crucial role in helping those with bipolar disorder navigate the complexities of the condition. From family support to peer support groups and access to professional resources, fostering a strong network of assistance can provide the necessary emotional support, education, and guidance needed for individuals to effectively manage their symptoms.

Furthermore, case studies, such as Susan’s, contribute to advancing our knowledge about bipolar disorder. By delving into individual experiences, researchers gain valuable insights into treatment outcomes, prognosis, and the impact of the condition on individuals and society as a whole. These case studies foster empathy, reduce stigma, and contribute to the development of evidence-based guidelines and interventions that can improve the lives of individuals with bipolar disorder.

In fostering empathy and promoting early diagnosis, effective treatment, and ongoing support, we create a society that actively embraces and supports individuals with bipolar disorder. By encouraging understanding, reducing stigma, and prioritizing mental health care, we can ensure that those affected by bipolar disorder receive the support and resources necessary to lead fulfilling and meaningful lives. Through empathy, education, and continued research, we can work towards a future where individuals with bipolar disorder are understood, valued, and empowered to thrive.

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• Winter 2024 | VOL. 22, NO. 1 Reproductive Psychiatry: Postpartum Depression is Only the Tip of the Iceberg CURRENT ISSUE pp.1-142

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Ethics Commentary: Ethical Issues in Bipolar Disorder: Three Case Studies

• Laura Weiss Roberts , M.D., M.A.

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Sound ethical decision making is essential to astute and compassionate clinical care. Wise practitioners readily identify and reflect on the ethical aspects of their work. They engage, often intuitively and without much fuss, in careful habits—in maintaining therapeutic boundaries, in seeking consultation from experts when caring for difficult or especially complex patients, in safeguarding against danger in high-risk situations, and in endeavoring to understand more about mental illnesses and their expression in the lives of patients of all ages, in all places, and from all walks of life. These habits of thought and behavior are signs of professionalism and help ensure ethical rigor in clinical practice.

Psychiatry is a specialty of medicine that, by its nature, touches on big moral questions. The conditions we treat often threaten the qualities that define human beings as individual, as autonomous, as responsible, as developing, and as fulfilled. The conditions we treat often are characterized by great suffering, disability, and stigma, and yet individuals with these conditions demonstrate such tremendous adaptation and strength as well. If all work by physicians is ethically important, then our work is especially so.

As a service to FOCUS readers, in this column we endeavor to provide ethics commentary on topics in clinical psychiatry. We also proffer clinical ethics questions and expert answers in order to sharpen readers’ decision-making skills and advance astute and compassionate clinical care in our field.

Ms. Genera is a 36-year-old woman with bipolar II disorder, first diagnosed in college, who is brought to the psychiatric emergency room by her boyfriend of 5 years. He is hoping that she will be admitted to the hospital “before she goes all-the-way manic.” He reports that she “almost lost her job last time!”

Over the past 6 weeks, he reports that Ms. Genera has needed “less and less” sleep, has been cleaning the house “around the clock,” and has “wanted a lot of sex even though she is really pissed off all of the time.” The patient states that she is “fine, more than fine, in fact.” She says that she has not been able to sleep “because of the neighbors.” She says that they talk loudly at night and that she and the baby will “fix that” because babies are “noisy at night too!” Her boyfriend is confused by this comment, saying that they have no children—“I don’t know why she says stuff like that. I know it’s the manic-depressive, but it is pretty crazy.” Ms. Genera states that her thoughts are like “O’Hare airport!” and that she has “no problem keeping up” with the different “planes coming and going.” The patient says that she stopped taking all of her medications about 3 months ago—“That lithium is really hard on me. I don’t like to take it unless I have to.” She has no history of alcohol or other substance use, no history of suicide attempts, and no history of dangerousness toward others.

On mental status exam, Ms. Genera is a neatly dressed, mildly overweight woman who appears slightly older than her stated age. She is cooperative with the clinical interview and asks that her boyfriend step out of the room when she is talking with the doctor. She is speaking quickly and loudly, with appropriate affect. Her thought form is linear. She denies hallucinations and reports no thoughts of self-harm.

Ms. Genera says that she has “Bipolar II, not Bipolar I—I don’t have it that bad. Never have. Yessirree, I am really good right now.” She does not want to be admitted to the hospital, despite her boyfriend’s request, but volunteers that she will go to an ambulatory care appointment with her psychiatrist on the next day.

——1.3 The psychiatrist arranges to speak with Ms. Genera alone during the clinical interview.

——1.4 The psychiatrist respects the patient’s preference not to be admitted to the hospital.

——1.5 The psychiatrist recommends diagnostic tests to occur at the time of the emergency evaluation.

——1.6 The psychiatrist sits with the patient’s boyfriend to offer emotional support and “a listening ear” after the clinical interview with the patient is completed.

——1.7 The psychiatrist documents accurately in the electronic medical record the full set of concerns raised by the patient and her boyfriend.

A resident in internal medicine with a well-established diagnosis of bipolar I disorder volunteers for a clinical trial that will test a new combination of medications and also involve two neuroimaging studies. The resident discusses the trial with his psychiatrist, who discourages the idea, stating that he has been concerned about the resident-patient, given the stresses of training and the severity of his illness. The resident responds, “Hey, Doc—get real! How often can you get $500—plus a brain scan, let alone TWO—free of charge?!” He decides to undergo screening for the clinical trial because he thinks he might benefit medically from an imaging test.

The resident knows that the trial will involve a washout period, so he decides to taper his medications in advance of the “official” enrollment date, 3 weeks away, which coincides with a planned vacation. Without medication, the resident becomes increasingly symptomatic. He has difficulty concentrating, becomes easily upset with team members, and develops progressively more erratic sleep. He was seen standing on the roof of the academic hospital and confided in a roommate that he was “tired of it all.”

Although he originally met criteria for the project, by the time of enrollment he had become too ill to enter the study. The psychiatrist-investigator permitted him to have the baseline neuroimaging study but did not allow the resident to progress to the full clinical trial. The resident returned to his apartment for his weeklong vacation. On the day he was scheduled to return to his training program, he did not turn up.

An 18-year-old male previously diagnosed with bipolar disorder is brought by his best friend to the emergency department of a rural hospital located near a ski area. The best friend reports that the patient “is completely wild—he just won’t stop—he’s going to kill himself on the slopes!”

The patient was first diagnosed when he experienced a “flat out manic” episode at age 13 years; he has been stable and doing well on lithium. He has a psychiatrist and therapist “back home,” although he will not provide their names.

The patient confided to his best friend that he “secretly” stopped his lithium recently, and the best friend states that the patient has been using alcohol. (“He says, ‘I like to get high while I’m high.’ ”) The patient is on vacation with his grandparents, two younger siblings, and the best friend.

The patient shows evidence of intoxication and is irritable but cooperative during the initial interview in the emergency department. His vitals are within normal limits and are stable. No abnormalities are found on physical examination.

While waiting to be seen, the patient appears to “sober up.” He is calm, pleasant, and respectful and thanks his friend and the emergency staff for helping him. He appears embarrassed. No abnormalities are found on mental status examination. The patient refuses a drug or urine test, and he refuses to allow the emergency physician to contact his grandparents or parents. The emergency physician calls a psychiatrist for consultation, which the patient declines.

Laura Weiss Roberts, M.D., M.A., Professor, Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, CA

Dr. Roberts reports: Owner, Investigator: Terra Nova Learning Systems

Srivastava S : Ethical considerations in the treatment of bipolar disorder . Focus ( Fall ); 9(4):461–464. Link ,  Google Scholar

Roberts LW, Hoop JG : Professionalism and Ethics: Q & A Self-Study Guide for Mental Health Professionals . Washington, DC, American Psychiatric Publishing, 2008 . Google Scholar

Roberts LW, Dyer A : A Concise Guide to Ethics in Mental Health Care . Washington, DC, American Psychiatric Publishing, 2004 . Google Scholar

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A Closer Look: Case Study on Bipolar Mood Disorder

In the days of Hippocrates, you'd likely attribute the erratic behaviors associated with bipolar mood disorder to an imbalance of bodily humors, but today, you know it's far more complex than that.

As you peruse the pages of this case study, you'll join the intricate journey through the life of a patient with bipolar disorder, whose story might resonate more deeply than you'd expect. You'll witness the oscillation between the highs of mania and the lows of depression, and understand why recognizing the nuances of this condition is pivotal.

The chronicle ahead lays bare the challenges of diagnosis, the trials of treatment, and the reality of living with a mood disorder that's as unpredictable as the weather in April.

Consider for a moment the impact of a single misstep in the delicate dance of managing bipolar disorder—you'll soon see why this case demands your attention, and perhaps, why it might change the way you view mental health care forever.

Key Takeaways

• Bipolar disorder is a complex mental health condition characterized by significant mood swings.
• Family support is critical in managing mental health challenges.
• Understanding the rhythm of mood fluctuations is crucial for managing bipolar disorder.
• Creating a consistent routine and having a strong support system are key to managing daily life with bipolar disorder.

Understanding Bipolar Disorder

Bipolar disorder is a complex mental health condition characterized by significant mood swings that can impact a person's thoughts, feelings, and behaviors. If you're grappling with this, you're not alone; it's a challenge faced by many.

Understanding bipolar mood disorders involves recognizing the pendulum-like shift between manic and depressive episodes. You may wonder if your intense high energy levels or periods of depression are signs of this condition. The diagnosis of bipolar is a critical step and involves a thorough assessment by a healthcare professional. They'll look at your symptoms, how long they last, and how they're affecting your life. It's not just about feeling up and down; it's a pattern that can wreak havoc if not properly managed.

To keep these fluctuations in check, a mood stabilizer is often prescribed. These medications help balance your moods and prevent the extreme highs and lows associated with bipolar disorder. It's essential to adhere to the treatment plan and communicate openly with your healthcare provider about how you're feeling.

Patient Background Profile

Understanding the nuances of bipolar disorder sets the stage for exploring the personal journey of Gary, a 19-year-old whose life was upended by this mental health challenge. Diagnosed with bipolar disorder, Gary's world shifted dramatically during his college years. His manic episode led to a sudden withdrawal from college and an unexpected switch from engineering to philosophy. This was a significant departure from his usual behavior, marked by reduced sleep, engaging in long, intense conversations, and exhibiting grandiose beliefs.

Gary's adolescent years were peppered with warning signs, including periods of withdrawal and depression, which may have hinted at his underlying condition. A family history of mental health issues can often be a precursor to such diagnoses, though Gary's case doesn't explicitly mention this. However, it's known that family support can be critical, and Gary's parents are no exception; they're eager to be involved in his treatment, recognizing early signs of anxiety and depression in his past.

The disruption in Gary's academic performance and personal relationships necessitated a robust treatment plan. Placed on a mood stabilizer and antipsychotic medication, Gary was also recommended adjunctive psychotherapy to help manage his condition and work towards stable behavior and improved functioning.

Episode Chronology

Mapping out the episode chronology in Gary's journey with bipolar disorder reveals the patterns and frequency of his mood swings, providing invaluable insights for managing his care. You'll notice that his major depressive disorder phases often follow intense hypomanic episodes, suggesting a cycle that dictates the rhythm of his life.

Understanding Gary's episode chronology, you'll see that the periods between his mood swings aren't just random; they're clues to what triggers his episodes. Maybe it's stress, lack of sleep, or even changes in the seasons. By keeping track of these patterns, you've got a better shot at predicting and heading off future episodes.

Treatment Approaches

Having explored the rhythm of Gary's mood fluctuations, it's crucial now to focus on how best to manage his bipolar disorder through effective treatment approaches. Treating bipolar can be complex, and it requires a tailored plan that takes into account his unique needs. Here's what you need to keep in mind:

• Medication Management
• Mood stabilizers are often the first line of defense; valproic acid, for instance, can be effective in controlling mood swings.
• Antipsychotics may be added for additional symptom control.
• Regular monitoring for side effects is key to maintaining overall health.
• Psychoeducation
• Understanding bipolar disorder and its management is empowering for you and your family.
• Knowledge about triggers and symptoms aids in early intervention.
• Collaborative Care
• Psychiatrists, therapists, and primary care providers should all be in sync when managing bipolar disorder.
• Communication between healthcare professionals ensures a cohesive and comprehensive approach.

Managing Daily Life

You'll find that creating a consistent routine is key to managing your daily life with bipolar mood disorder.

It's also vital to have a strong support system in place, as the people around you can provide essential help and understanding.

These strategies will help you maintain stability and manage the ups and downs that come with your condition.

Routine Structuring Strategies

Implementing a structured daily routine can significantly ease the management of bipolar disorder symptoms, offering stability and predictability in your life. Here's how you can tailor your daily routine to manage mood dysregulation effectively:

• Set regular times for:
• *Sleep:* Consistent sleep patterns stabilize your mood.
• *Meals:* Regular meals help maintain energy levels.
• *Exercise:* Physical activity is key in managing stress.

Prioritizing these aspects of your routine can lead to better adherence to adequate treatment and improve your overall well-being.

Support System Importance

Leaning on a robust support system, you can navigate the complexities of daily life with bipolar disorder more effectively, ensuring a network of care that promotes stability and well-being. Your support system's importance can't be overstated—it's the foundation that holds you steady amidst the shifting sands of emotions and challenges.

Here's a snapshot of how a strong support network can help you manage essential aspects of your life:

Reflecting on Progress

Reflecting on your progress with bipolar mood disorder, it's essential to evaluate how diagnosis and treatment have influenced your daily life and mental health. You've likely noticed changes in your clinical presentations, and it's crucial to track these shifts. Consider the following:

• Patient Reported Outcomes
• *Symptom Management*: Have you experienced a reduction in the frequency or severity of mood episodes?
• *Quality of Life*: Are you finding more stability and enjoyment in your daily activities?
• *Self-Awareness*: Have you become more attuned to your triggers and early warning signs?

Adherence to your treatment plan plays a pivotal role in your journey. Engaging with your healthcare provider allows for necessary adjustments and ensures that your mental health remains a priority. Comorbid conditions and lifestyle factors also significantly impact your treatment response, necessitating a holistic approach to your well-being.

Regular monitoring is key to managing side effects and maintaining overall stability. By collaborating with your care team and being proactive about your health, you're laying the groundwork for continued progress and a more balanced life.

Frequently Asked Questions What Are Some Interesting Research Topics on Bipolar Disorder?

You might explore the genetic basis of bipolar disorder, the effectiveness of psychotherapy combined with medication, or the impact of lifestyle factors on symptom management in your research.

What Is the Average Age of Death for a Person With Bipolar Disorder?

You've asked about the average age of death for someone with bipolar disorder. It's sadly shorter, typically 9 to 20 years less than the general population, ranging from 47 to 61 years old.

What Is the Leading Cause of Death in Bipolar People?

You should know that the leading cause of death in bipolar people is suicide, a tragic consequence that underscores the importance of vigilant care and support for those managing this condition.

How Does Bipolar Disorder Affect Someone's Everyday Life?

Bipolar disorder is like an unpredictable storm, disrupting your daily life with extreme mood swings that can hinder your work, strain relationships, and make sticking to routines feel nearly impossible.

You've journeyed through the labyrinth of bipolar disorder, navigating its highs and lows alongside our patient. From the chaos of misdiagnosis to the anchor of tailored therapy, you've seen the transformation. Like a time traveler who's witnessed history's pivotal turn, you understand now how crucial timely intervention is.

Let's celebrate the milestones, recognizing that with acceptance and consistent care, managing bipolar disorder isn't just a possibility—it's a reality etched in the annals of personal triumph.

Daniel Logan is a renowned author and mental health expert who specializes in psychology and mental health topics. Daniel holds a degree in psychology from the University of California, Los Angeles (UCLA). With years of experience in the field, he has become a trusted voice in the industry, sharing insights and knowledge on a variety of mental health issues.

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Nursing Case Study for Bipolar Disorder

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Kelli is a 20-year-old patient brought to the ER after being reported by neighbors in her apartment complex for disruptive behavior. Law enforcement and emergency medical services were called, and, as a team, decided she needed a higher level of medical care.

The patient says she is” on a break from art college” but works at a local restaurant as a server and occasionally cleans houses as well. She has also sold her paintings and drawings in the past as well. She denies taking any medication. She also says, “I don’t understand why I am here. I was working on my art projects, and I guess I played my music too loud or something. I said I’d come here so I would not be arrested.”

What are some questions that should be included in the initial assessment?

• Ask about drug and alcohol consumption and previous episodes. Make sure she does not intend to harm herself or others. Check to see why the patient does not understand coming to a medical treatment facility (make sure she is lucid). Ask about trauma or accidents.

What interventions do you anticipate being ordered by the provider?

• Obtain old medical charts (there may be a pattern). Screen for drugs and alcohol. Assess for trauma (especially head injury, so neuro checks). Complete a thorough medical history to rule out medical reasons for behavior. Conduct a medical examination including labs (eg. thyroid-stimulating hormone, complete blood count, chemistries)

Kelli’s drug and alcohol tests are negative. Her roommate is now at the bedside and asks to speak to staff privately. She expresses concern that Kelli can be emotional at times as well as going days without sleep then not being able to get out of bed. The nurse returns to further evaluate the patient.

With this new information, what might the nurse ask Kelli?

• Ask about “periods of unusually intense emotion, changes in sleep patterns and activity levels, and uncharacteristic behavior—often without recognizing their likely harmful or undesirable effects” (from NIH). Dig deeper to find if these “episodes” last for long or short periods. Specifically, ask about extreme highs and lows, change in appetite, racing thoughts vs concentration difficulty, risky behaviors (eg gambling, extreme shopping sprees, sexual promiscuity), anxiety, excessive talking, thoughts of death/dying.

Kelli admits to being able to stay awake for what seems like entire weekends without being tired, but that is when she says her creativity is best. When she was attending college and living in the dorms, she says she had lots of friends but worried about what she calls “all the partying.” This is because she liked to “hook up” with strangers because it was fun, but she worries about possible sexually transmitted infections now that she is older. She says she was extremely popular, and her talent was at its peak. But there are times she could not pay attention in class or even get out of bed, so she dropped out of school. Sometimes, she cannot even touch her art supplies, but says she is probably the “most talented artist around.”

What signs and symptoms indicate Kelli may have bipolar disorder?

• Sleep disturbances, cycling between being creative and not being able to concentrate, sexual promiscuity, feelings of grandiosity, loss of pleasure of usual activities

Are there risk factors for this condition?

• The exact cause of bipolar disorder is not clear. The problem may be related to an imbalance of chemicals in the brain such as norepinephrine, serotonin, or dopamine. These chemicals allow cells to communicate with each other and play an essential role in all brain functions, including movement, sensation, memory, and emotions.
• Approximately one to three percent of people worldwide have bipolar disorder. People with a family history of bipolar disorder are at increased risk of developing the condition. Most people develop the first symptoms of bipolar disorder between age 15 to 30 years.

Kelli’s medical records have arrived, and the provider advises nursing staff she has a history of being brought to the ER for similar episodes. The provider says, “This patient is a schizophrenic. We don’t have time for this.”

What is the best response to the provider’s statement?

• As the patient’s advocate, the nurse should advise the provider this is inappropriate. First, it is a disparaging remark. Second, if he means schizophrenic, that is not accurate and as an ER physician should refer the patient for further psychiatric screening and evaluation.
• It is never wrong to stand up to providers or colleagues, but it should be done respectfully and NOT in front of the patient when at all possible.

What should the nurse screen Kelli for at this point?

• Suicidal ideations include whether she has a plan or has attempted suicide in the past. Suicide screening is an ongoing process and not just a few questions at admission. Per UpToDate, “A review estimated that approximately 10 to 15 percent of bipolar patients die by suicide and many studies indicate that the rate of suicide deaths in patients is greater than the rate in the general population.”

How can the nurse address Kelli’s question about help?

• Something like (from uptodate), “Treatment of mania focuses on managing symptoms and keeping you safe. In the early phase of mania (called the acute phase), you may be psychotic (having false, fixed beliefs or hearing voices or seeing things others cannot see or hear). You may not be able to make good decisions and you may be at risk of hurting yourself or others. You may need to be treated in a hospital temporarily, until your medicine begins to work.”
• Also, “Once the worst symptoms of mania or depression are under control, treatment focuses on preventing a recurrence. People who have suffered a manic episode are often advised to continue taking medicine(s) to control bipolar disorder. Although medicines are the treatment of choice for bipolar disorder, counseling and talk therapy also have an important role in treatment. This is especially true after an acute episode has passed. Psychotherapy may include individual counseling as well as education, marital and family therapy, or treatment of alcohol and/or drug abuse. Therapy can help you to stick with your medicine, which can decrease the risk of relapse and the need for hospitalization.”

Kelli is amenable to being held for the state’s required psychological hold. She says she wants to be able to live her life as “normally” as possible. She asks about medications that may be available to help.

What patient education about medications should the nurse provide at this time?

• While it is beyond the scope of the RN to prescribe medications, generalized education on pharmaceutical options is acceptable. Saying something like, “Treatments with medications is recommended for people with bipolar disorder, and studies show starting it early and maintaining it is best.” Point out there may be multiple medications needed and they may need to be changed and/or adjusted for her individual responses.

The nurse knows which medications may be prescribed for long-term management of this condition?

• Mood stabilizers (examples: lithium, valproic acid, divalproex sodium, carbamazepine,and lamotrigine). Antipsychotics. [examples: olanzapine (Zyprexa), risperidone (Risperdal), quetiapine (Seroquel), aripiprazole (Abilify), ziprasidone (Geodon), lurasidone (Latuda) or asenapine (Saphris)] Antidepressants or antidepressant-antipsychotic combo like Symbyax combines the antidepressant fluoxetine and the antipsychotic olanzapine Anti-anxiety medications (example: benzodiazepines)

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This nursing case study course is designed to help nursing students build critical thinking.  Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process.  To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy  to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs.  If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding.  In the end, that is what nursing case studies are all about – growing in your clinical judgement.

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5 Psychiatric Treatment of Bipolar Disorder: The Case of Janice

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Chapter 5 covers the psychiatric treatment of bipolar disorder, including a case history, key principles, assessment strategy, differential diagnosis, case formulation, treatment planning, nonspecific factors in treatment, potential treatment obstacles, ethical considerations, common mistakes to avoid in treatment, and relapse prevention.

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A Case Study on Bipolar Affective Disorder Current Episode Manic Without Psychotic Symptoms

• International Journal of Clinical Case Reports and Reviews

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Case Report | DOI: https://doi.org/10.31579/2690-4861/290

• Bhadra Sharma E 1
• Sannet Thomas 2*

1 MSc. Psychology Student, Parumala Mar Gregorios College, Valanjavattom, Tiruvalla, Kerala, India.

2 Doctoral Research Scholar, Department of Applied Psychology, Veer Bahadur Singh Purvanchal University, Jaunpur, Uttar Pradesh, India.

*Corresponding Author: Sannet Thomas, Doctoral Research Scholar, Department of Applied Psychology, Veer Bahadur Singh Purvanchal University, Jaunpur, Uttar Pradesh, India.

Citation: Bhadra Sharma E., Thomas S., (2023), A Case Study on Bipolar Affective Disorder Current Episode Manic Without Psychotic Symptoms, International Journal of Clinical Case Reports and Reviews. 13(1); DOI: 10.31579/2690-4861/290

Copyright: © 2023 Sannet Thomas, This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Received: 16 January 2023 | Accepted: 19 January 2023 | Published: 30 January 2023

Keywords: mood disorders; bipolar affective disorder; mania; depression

Mood disorders are the second most common condition and can repeat for a variety of reasons. Bipolar mood disorders can cause severe manic and depressed episodes that, if not adequately treated, can result in substantial social and personal problems. This study used a single case study approach and was qualitative in nature. A patient with bipolar affective disorder without psychotic symptoms participated in the trial. A case history form and a mental state assessment instrument were used to gather the data, which was then analysed using the content analysis approach. A 27-year-old lady who has been diagnosed with bipolar affective disorder and is now experiencing a manic episode without psychotic symptoms served as the study's sample. The patient was a resident of a private mental health facility in Kerala. This study discovered that pharmacotherapy, family therapy, in-patient rehabilitation, out-patient rehabilitation, and cognitive behavioural therapy can all help manage bipolar affective disorder, current episode manic without psychotic symptoms. The outcome of the current study comprises a thorough analysis of the sample's history and present conditions, along with interventions and management techniques.

A mood disorder, formerly known as an affective disorder, is an emotional condition that primarily affects our state of mind. A clinically significant disturbance in how a person feels in connection to their surroundings, which results in unhelpful behavior, characterizes a set of mental illnesses known as mood disorders. (Claudio & Andrea, 2022). The primary issue with these diseases is a shift in mood or affect, typically toward melancholy or elation. (ICD-10). Seasonal affective disorder (SAD), major depressive disorder (MDD), and bipolar disorder (BD) are a few examples of mood disorders. These conditions can also be further classified according to the severity, timing, or suspected cause of the illness. (APA, 2013). Patients with mood disorders have bodily and cognitive abnormalities that impair their ability to function. One such change is the disruption of the sleep–wake cycle, which shows up both physiologically and behaviourally. (Claudio & Andrea, 2022).

Mood disorder patients exhibit two key moods: mania and depression. The extreme sorrow and hopelessness that characterize depression (Hooley et al., 2016). People during depressive episodes will have a persistent depressed mood and may lose interest in previously pleasurable activities along with significant changes in sleep pattern and appetite for at least two weeks. According to the diagnostic criteria of DSM-5, symptoms of a depressive episode include depressed mood, significant changes in sleep patterns and appetite, psychomotor agitation or retardation, diminished ability to think and concentrate, and recurrent thoughts of death. 60percentage to 90percentage of major depressive disorder patients experience sleep difficulties, with insomnia and hypersomnia being the most prevalent disorders. This varies depending on how severe the depression is. (Abad & Guilleminault, 2005).

Mania is the other major mood. The extreme and irrational enthusiasm and exhilaration that characterizes mania. When experiencing a manic episode, a person's mood is noticeably heightened and expansive, perhaps being interrupted by intensely irritable outbursts. (Hooley et al., 2016). For a precise diagnosis, these significant mood swings must last for at least a week. The existence of an abnormally high, expansive, and irritable mood for at least four weeks is the hallmark of the milder variant known as a hypomanic episode. Considering its difficult clinical presentations and long-term view, a patient with mania must be provided with a personalized treatment for functional recovery. Psychoeducational strategies are also used for the maintenance of treatment results (Pacchiarotti et al., 2020).

There are two main classifications of mood disorders. Both unipolar and bipolar mood disorders exist. Unipolar mood disorders are characterized by the recurrent occurrence of full-blown depressive episodes. For a clear diagnosis, the person must show the symptoms of a depressive episode for longer than two weeks. If a person suffers from the occurrence of depressive episodes for about two years, then the person can be diagnosed as having persistent depressive disorder (PDD) or formerly known dysthymia. Here the symptoms are commonly found as half-blown (Hooley et al., 2016).

Bipolar mood disorders are characterized by the presence of both key moods, that is, Depression and mania. A person with bipolar disorder may alternatively experience both depressive and manic episodes (Hooley et al., 2016). Bipolar I disorder and bipolar II disorder are subtypes of bipolar disorders. Among these, the occurrence of mixed episodes—which are characterized by symptoms of both full-blown manic and severe depressive episodes lasting at least one week—signals the existence of bipolar I disorder. When a person has significant depressive periods and hypomanic episodes, bipolar II disorder is identified. When a full-blown manic episode is lacking in a patient with bipolar II disorder, this condition is known as cyclothymia. When someone exhibits half-blown bipolar mood disorder symptoms for at least two years, it is diagnosed. (World Health Organization, 1992).

Suicide and mood problems are related. Compared to the non-clinical population, the clinical group has a much greater prevalence of suicidal conduct. (Shah et al., 2022). Mood disorders can occur with or without psychotic symptoms and they can be seen as associated with somatic symptoms (World Health Organization, 1992). It was shown that kids with social anxiety disorder were more likely to also have a mood problem. It was discovered that those kids had more significant anxiety issues prior to therapy. Recent research says that the treatment of mood disorders was related to anxiety reduction (Baartmans et al., 2022).

Causal factors of mood disorders focus on biological, psychological, and socio-cultural factors. Family studies and twin studies have indicated that the prevalence of mood disorders is around two to three times greater among blood relatives due to biological variables. (Akdemir&Gokler, 2008). This shows the genetic influence in increasing the vulnerability towards the development of unipolar mood disorders. Neurochemical factors and hormonal regulatory and immune system abnormalities can also contribute to mood disorder development. psychological root causes Consider stressful life situations as key causative variables. Numerous studies have demonstrated that extremely stressful life situations might serve as precursors for mood disorders. Numerous studies have shown that this illness has an impact on patients' whole families and may reduce their fortitude and adaptability.

Treatment and management of mood disorders include pharmacotherapy, psychotherapy, and alternative biological treatments. Pharmacological methods cannot be avoided in the treatment of mood disorders. Anti-depressants, anti-psychotics, and mood-stabilizing drugs are found to be commonly used in treating mood disorders. Monoamine oxidase inhibitors (MAOs) and selective serotonin reuptake inhibitors are examples of antidepressants (SSRIs). Patients with mood disorders are treated with lithium as a mood stabilizer. Several forms of psychotherapy are used widely for treating mood disturbances [Datta et al., 2021].

It is common to employ therapies including behavior activation therapy, family and marital therapy, interpersonal therapy, and cognitive behavioral therapy (CBT). In addition to these pharmacological methods and psychotherapies, several biological approaches include electroconvulsive therapy (ECT), bright light therapy, and deep brain stimulation.

When a person has bipolar affective disorder, the present episode is manic without psychotic symptoms (ICD F30.1) and they have previously experienced at least one prior affective episode (hypomanic, manic, depressed, or mixed). (ICD 10) Mania is defined by an elevated mood that is discordant with the patient's condition and lacks psychotic symptoms. It can range from thoughtless merriment to practically uncontrollable excitement. Increased energy that comes with elation causes overactivity, pressure in speaking, and a reduced desire for sleep. There is a lack of continuous attention, and distractions are frequently obvious. Overconfidence and lofty ideals can inflate one's sense of self-worth. Loss of typical social inhibitions can lead to actions that are careless, foolish, or out of character for the situation. (ICD 10).

Relevance Of the Study:

Mood disorders are the second most prevalent type of disorder in psychopathology. Mood disorders are commonly seen with relapses and recurrences. So, a continuation of medication and follow-up sessions are necessary. However, at least half of the people are never receiving adequate treatment. So, this particular study can help in reducing stigma and human rights violations towards the affected people. And, through this particular study, people can have more awareness about mood disorders, Specifically the bipolar affective disorder, current episode manic without psychotic symptoms.

Review Of Literature:

Shah, K., Trivedi, C., Kamrai, D., Srinivas, S., & Mansuri, Z. (2022) conducted a study on suicide in adolescents with mood disorders. The study's goals were to examine the relationship between youth suicide and mood disorders as well as the influence of comorbid conditions in disruptive mood dysregulation disorder on adolescent suicidal thoughts. The National Inpatient Sample dataset was utilized in the study to select individuals with mood disorders, and the Chi-square test was employed to compare groups. According to the study, teenagers with mood disorders who do not have disruptive mood dysregulation disorder had approximately double the chance of having suicidal thoughts or actually attempting suicide.

Baartmans, J. M. D., van Steensel, F. J. A., Klein, A. M., & Bögels, S. M. (2022) conducted a study on The Role of Comorbid Mood Disorders in Cognitive Behavioral Therapy for Childhood Social Anxiety. The study aimed to determine the degree of occurrence of mood disorders as the result of cognitive behavioral therapies in children with social anxiety. The sample of the study consisted of 152 children who were clinically diagnosed as having social anxiety or any other anxiety disorder. The findings imply that children with social anxiety are more likely than those with other anxiety disorders to also have comorbidity with a mood condition.

Rashid, M. H., Ahmed, A. U., & Khan, M. Z. R.  (2019) conducted a study on substance abuse among bipolar mood disorder patients. Determine the prevalence of drug use among patients with bipolar mood disorder was the goal of this descriptive cross-sectional investigation. 115 bipolar patients made up the sample; both males and females, inpatients and outpatients, were taken into account. Data collection was done using a standardized questionnaire. According to the survey, 23.8percentage of the respondents engaged in drug misuse.

Deepika, K. (2019). conducted a study on a case report on bipolar affective disorder: Mania with psychotic symptoms. The study adopted the method of a case study which aims to find the key characteristics and implications of mania with psychotic symptoms.

Akdemir, D., & Gokler, B. (2017) conducted a study on psychopathology in the children of parents with a bipolar mood disorder. The purpose of the study was to determine how frequently offspring of parents with bipolar mood disorder experience mental illnesses. 33 children of 28 control parents and 36 children of 28 parents with bipolar I illness made up the sample. The SADS-L (Schedule for Affective Disorders and Schizophrenia-Lifetime Version) and the SADS-L for School-Aged Children (Present and Lifetime Version) are screening tools (K-SADS-L). According to the study, children of parents with bipolar illness had a greater prevalence of psychopathology than children of the control group.

A case study can be defined as a record of research that consists of information about the development of a particular individual, group, or situation over time. It is a systematic investigation of a single individual or group of individuals which uses several statistical and psychological tools (McCombes, 2022)

The present study adopted the case study method. It is consisted with combined form of exploratory, cumulative and critical instance case studies. As a case study is an in-depth investigation of a person, a group of individuals, or a unit with the intention of generalizing it on several occasions. it allows us to explore the characteristics, meanings, and implications of the particular case. Exploratory case study involves detailed research of the subject aimed at providing an in-depth understanding of the study. Cumulative case study involves generalizing a phenomenon after collecting information from different sources. Critical instance case study aims in determining the cause and consequences of an event.

In this case study, case history and mental status examination have been taken from the client and informants. Information collected was cross-checked and reversed twice, and reliability and adequacy were also assured.

Sample Description:

A 27-year-old female inpatient with the bipolar affective disorder, current episode manic without psychotic symptoms. The patient was a married woman from a middle-class family who has been taking treatment for the past 10 years. The case was taken from one of the private mental health establishments in Kerala to which the patient was admitted. The patient was admitted to the hospital for 20 days, from there the data were collected by the researcher.

The present study uses Mental Status Examination (MSE) and case history. An MSE is an inevitable part of the clinical assessment which helps find the current state of the client, under the domains of general appearance, mood, affect, speech, thought process, perception, cognition, insight, and judgment.

A case history includes an in-depth analysis of a person or group. It mainly has detailed information relating to the patient’s psychological and medical conditions. A case history is used to get a client’s test results, and professional, sociological, occupational, and educational data. The data collected in a case history includes socio-demographic data, presenting complaints and their duration, nature of the illness, history of present illness, negative history, treatment history, family history, personal history, and pre-morbid personality.

Data Analysis:

The Present study uses the tool content analysis for analyzing data. Content analysis is a research tool that helps analyze the presence, meaning, and relationship of certain words or concepts. Content analysis is also helpful in quantifying the collected information.

Ethical Concerns:

Full consent from the participant was obtained. The confidentiality of the data collected from the participant was ensured. The participant is not harmed in any way. The anonymity of individuals and the privacy of the participant is ensured.

Case History:

Socio-demographic data:  The patient named J.O.V., is a 27-year-old female, hailing from a middle-class family who has been educated up to plus two and is presently unemployed. She was a married woman and mother of a 2-year-old child. The informants were the patient, her husband, and her sibling. The collected information was adequate and reliable.

Presenting complaints and their duration: Reported by the patient- The patient has reported that she was suffering from a decreased need for sleep and tended to throw objects when got angry, for the last seven months. For the past four months, she an increased craving for food and a feeling that people are avoiding her complained and also complains that her family is cursing that she is not attending to her child properly. 

Reported by the informant:   The informant has complained of lack of sleep (not sleeping for about 48 hours), not giving proper attention to the child, suicidal tendency, increased talk, getting raised easily, and throwing objects when got raised for the past seven months. They also complained about spending a lot of money on buying mobile phones, ornaments, and gadgets, and, overuse of mobile phones for the past four months.

Nature of illness:  The onset of illness was found to be gradual. The course was episodic and stable progress has been identified. Precipitating factors were not elicited.

History of present illness:  The patient was maintaining normal till seven months back. Then she started getting raised quickly without any reason and experienced a decreased need for sleep. She felt that everyone around her is trying to avoid her. When having such feelings, she preferred to be alone and isolated herself. At times she lost her interest in everything, so she will not do anything and simply sit alone without doing anything. After that, the patient started spending a lot of money buying ornaments, mobile phones, and gadgets. She experienced an increased craving for food. She had the wish to eat all time a day. Before four months her mood suddenly changed to an extraordinary sadness and continued lack of sleep. Then she started to elicit highly irritable behavior with increased talk. Her symptoms caused impairments in her personal and social life, as she became more irritable with decreased sleep and a situation of missing from the house. As she began not to attend even her child properly, her family brought the patient to one of the private hospitals in Kerala for treatment and getting In-patient care.

Negative history:  The patient has no history of head injury, trauma, epilepsy, headache, and vomiting. There is no history of psychoactive substance use. The patient shows no history of seeing or hearing things that others cannot see or hear. There is no history of the patient having repeated ideas, thoughts, or images coming to her mind. The patient has no history of irrational fear towards objects, events, or situations.

Treatment history:  The patient had taken treatment with in-patient care previously from another private hospital in Kerala. Then she took treatment from one of the Government medical colleges, Kerala In-Patient care for 20 days. In 2017, treatment was taken from another private hospital, in Kerala for 20 days. Then she took treatment from another Government medical college, several times.

History:  When the patient was 17 years old, the family identified behavioral changes such as increased talk, decreased need for sleep, and irritability. The patient was complaining that these changes occurred as a result of losing her friendship and love. But the family is not giving assurance for her complaint. Then she was taken to a private mental health centre, in Kerala for treatment and In-Patient care. There found an improvement with the treatment. She got married at the age of 21 years. After marriage, she started to show her symptoms including irritable behavior and increased talk. Due to this, the relationship got divorced 3 months after the marriage. After the divorce, she attempted suicide by jumping into a well. So, she was taken to one among the Government medical college hospital in Kerala, and was admitted for about 20 days (2015). The patient showed improvement with the treatment. Approximately 1 year later her symptoms started to reappear, and she went to another hospital alone for gaining treatment (according to the client). But the family brought her back and took treatment at a private mental health centre as in-patient for 20 days (2017). She showed improvement with the treatment. After that the client showed similar symptoms and has been getting medical care as in-patient several times from Government medical college, Kerala. 4 years later, she got married again. The relationship happily continued and she gave birth to a child. 7 months back she got hit by the current episode. 

Family history:  Consanguinity is absent. The patient belongs to a middle-class family, where her husband and brother are the earning members. The patient’s father is the family decision-maker. The patient maintained a good relationship with the family. General interaction within the family is good. There is a history of the psychiatric problem in her family. There found a history of wandering and missing out(grandfather). In the mother’s family, there is a history of suicide(grandfather) and mental illness(grandmother). The information about the illness is not known adequately. Her mother shows a history of bipolar affective disorder and her elder sister has a history of suicidal attempts and thyroid. There is no history of substance abuse in the family. The family is aware of the patient’s illness. Several members of the patient’s family show mental and behavioral dysfunctions and there are interpersonal conflicts in the family. So, family dynamics are dysfunctional.

Personal history:  The birth and development of the patient were appropriate. There are no complications during delivery. The delivery was full-term and normal at the hospital. There are no significant abnormalities in the pre-natal and post-natal development. The development milestones were age appropriate. The patient was brought up by their mother. There is no maternal deprivation observed. There is no history of neurotic traits such as nail biting, body rocking, night terrors, phobias, and stammering. Education history started education at 5 years. She belongs to an average student. The medium was Malayalam. She had many friends but the relationships were not well maintained. She discontinued her degree (BA Literature) during her first year due to illness. Relationships with teachers were not good. Occupation history:  The patient started an occupational career at the age of 25. She worked as a sales girl in a gold shop for about 2 months and left the job due to the pandemic situation. 

Marital history:  The patient got married at 21. The marriage was an arranged one with the consent of the family but got divorced after a relationship of only 3 months. Her disorder was the primary reason for the divorce. After 4 years, when she was 25 years old, she married again. The marriage was also an arranged one with the consent of the family. The husband is supportive. Currently, the client and her husband are satisfied with the relationship. Sexual history: the mode of gaining sexual knowledge is from friends. No history of sexual abuse is found. Marital sexual life is also satisfied. Menstrual history: menstrual cycle(menarche) begins at the age of 14 years. There are no significant abnormalities in the response to menarche noted. Then after the menstruation is regular till now. There were no mood swings during the menstrual cycle, but the client complained about back pain during menstruation. Substance use history, the patient has no history of any psychoactive substance use.

Pre-morbid personality:  Attitude towards self, she was a confident personality but was not able to make decisions. And she maintains an average level of self-esteem. Attitude towards others: she was an extrovert who quickly feels empathetic towards others. She doesn’t have many intimate friends. She always kept a good relationship with her family. She was not much talkative in the family except with her mother. The predominant mood was happy. Moral standards, she is a religious person who keeps religious rituals always. Stress reaction, she was able to tolerate and deal effectively with stress. Habit, the sleep pattern was normal, and had no habit of doing exercises. Fantasy life, dream with the content of ‘falling into the water. Other personality traits, there is no presence of personality traits such as OCD, ADHD, ODD, emotionally unstable personality, impulsivity, and narcissistic personality

Mental status examination (MSE)

General appearance and behavior:  The patient was alert, attentive, and conscious during the session. The patient’s dressing was appropriate. Eye contact was established and maintained. A good rapport was made. The patient’s attitude toward the examiner was cooperative. Reality contact was present. Tics/mannerisms and catatonic phenomena were absent.

Psychomotor activity: Increased psychomotor activity by walking during the session and drinking a lot of water.

Speech:  The speech was relevant and coherent. Reaction time was normal. Volume and tone were normal and she maintained the prosody of speech. 

Mood and affect:  The mood were sad and her affect was shallow which was inappropriate to the situation and congruent to the thought content.

Thought: The patient doesn’t show any abnormalities in the stream, form, possession, and content of thought. That is., there is no presence of flight of ideas, circumstantiality, tangentiality, obsessions, compulsions, etc.

Perception:  There is no presence of hallucinations and illusions. Other psychotic phenomena such as somatic passivity and made phenomena are absent. Other phenomena like depersonalization and derealization are also found to be absent.

Cognitive functions: Attention and concentration, the digit span test, and serial subtraction were given. In forward, the digit span is 4 and in backward the digit span is 3. In the serial subtraction test, the patient completed the task in 115 seconds. This shows that the patient’s attention was aroused and maintained. Orientation, the client was asked questions of time, place, and person, and found that the patient’s orientations were intact. Memory, the patient’s immediate memory was tested by conducting a recall test. The patient was able to recall what the examiner has said. The recent memory of the patient was tested by asking her questions regarding the past 24 hours and it is found that the patient’s recent memory was intact. Remote memory was tested by asking questions about personal details such as to say her date of birth. From this, it can be concluded that the patient’s memory was intact.

Intelligence:  General information, the patient was asked questions for testing general knowledge. The responses of the patient indicate that general information is adequate. Comprehension, the patient’s comprehension is assessed by asking some situational questions and is found adequate. Arithmetic ability, after comprehension, the arithmetic ability of the patient is assessed by asking some simple arithmetic questions and is found adequate. Abstract ability, the patient’s abstract ability is assessed by giving tests to find similarities and dissimilarities of objects the examiner is saying. Proverbs are given to the patient and asked to explain them. The assessments of general information, comprehension, arithmetic ability, and abstract ability indicate that the patient has an average intellectual capacity.

Judgment:  The patient's personal, social, and test judgment is found to be intact.

Insight:  The patient has a level five insight. Since she is accepting all her minor and major symptoms and is also aware of the need for treatment.

Provisional diagnosis:  F31.1 (ICD-10 CLASSIFICATION) Bipolar affective disorder, current episode manic without psychotic symptoms.

Diagnostic guidelines:  For a definite diagnosis

• The present episode has to meet the requirements for mania without psychotic symptoms. and
• There must have been at least one prior affective episode in the past, whether it was mixed, hypomanic, manic, or depressed.

Diagnostic criteria for mania:  The episode must last at least a week and be severe enough to substantially interfere with daily tasks and social interactions. Energy levels should rise along with a few of the symptoms listed below when the mood changes.

• Decreased need for sleep
• Grandiosity
• Excessive optimism
• Particularly pressure of speech

The patient has had such emotional episodes in the past and has recently had greater energy, decreased sleepiness, and excessive optimism. Given that this fits the aforementioned requirements, we can provisory classify the patient's present manic episode as having bipolar affective disorder.

Interventions And Management Plan:

A medical doctor or trained clinical psychologist determines an intervention and management plan for any mental disturbance. Since Bipolar affective disorder is a long-term condition, continuous and prolonged treatment is needed. Professionals suggest several management strategies for bipolar affective disorder treatment. This often includes:

Hospitalization- Doctors often prefer hospitalization if the patient seems to be more dangerous and has suicidal ideas. Psychiatric hospital care helps stabilize the patient’s mood, and, maintains a safe and calm atmosphere.

Medications - Several medications are used in treating bipolar disorders. Taking medication helps balance your moods in the right way. The types and doses of medicines are determined by the doctor. Commonly prescribed medications in the treatment of bipolar affective disorder include:

• Mood stabilizers- This includes lithium, valproic acid, equator, etc.
• Antipsychotics- Olanzapine, risperidone, aripiprazole. This comprises commonly prescribed antipsychotics. 
• Antidepressants- Antidepressants are given to manage depression. But these are prescribed along with mood stabilizers or antipsychotics since antidepressants trigger mania.
• Anti-anxiety medications- This has benzodiazepine in it. This provides better sleep and also helps with dealing with anxiety.

Psychotherapy- bipolar disorder treatment includes psychotherapy on a regular basis. Numerous therapies may be beneficial. A family, a group, or an individual may get therapy. 

Treatments provided include:

• Cognitive Behaviour Therapy (CBT)- The goal of this treatment is to discover unhealthy ideas and behaviors and replace them with constructive ones.
• Psychoeducation- Learning about bipolar illness can help patients better comprehend their current situation, prevent relapses, and adhere to therapy.
• Family-focused therapy- Family therapy helps make the family of the patient aware of the disorder and warning signs of bipolar episodes.

If the patient doesn't improve with antidepressants, further therapeutic options include electroconvulsive therapy (ECT) and occasionally transcranial magnetic stimulation.

This study discusses a case of bipolar affective disorder, current episode manic without psychotic symptoms. Here the study concentrates on the characteristics, symptoms and features of bipolar affective disorder, current episode manic without psychotic symptoms and also the interventions used for this case.  For those who suffer from bipolar affective disorder, the present episode is manic without psychotic symptoms, and the patient has previously had at least one prior affective episode (hypomanic, manic, depressed, or mixed). (ICD 10) Mania is defined by an elevated mood that is out of proportion to the patient's circumstances and can vary from casual merriment to almost uncontrollable excitement. Mania is characterized by the absence of psychotic symptoms. Overactivity, difficulty speaking, and a diminished need for sleep are all symptoms of the increased energy that comes with joy. Continuous concentration is lacking, and distractions are usually evident. An exaggerated feeling of self-worth can result from overconfidence and ambitious ambitions. Losing one's normal social inhibitions might cause one to act carelessly, foolishly, or inappropriately given the circumstances.                                                     

Limitations:

The study adopted a single case study method, the result cannot be generalized to larger populations.

Declarations:

This article's completion was not supported by any money.

Conflicts of interest/Competing interests

The authors have no financial or non-financial interests to report.

Data Availability Statement

Only datasets produced during and/or analyzed during the current investigation are available upon reasonable request from the corresponding author.

Authors' contributions

the two writers have each made a meaningful contribution and agree that they should both be given authorship credit.

Ethics approval

The Departmental Research Committee granted ethical approval.

Consent to participate

Informed consent was taken from the informant and also from the institution 

Consent for publication

All authors of this research Study consent to the work being used for publication.

Acknowledgments

The article, A case study on bipolar affective disorder, current episode without psychotic symptoms (ICD F 31.1), is a record of original research effort, we therefore declare. We attest to the work's originality and the absence of any instances of plagiarism across the whole manuscript.      

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• Shanghai Arch Psychiatry
• v.30(2); 2018 Apr 25

Language: English | Chinese

Analysis of Misdiagnosis of Bipolar Disorder in An Outpatient Setting

双相情感障碍在门诊的误诊情况分析.

Bipolar disorder is a mental illness with a high misdiagnosis rate and commonly misdiagnosed as other mental disorders including depression, schizophrenia, anxiety disorders, obsessive-compulsive disorders, and personality disorders, resulting in the mistreatment of clinical symptoms and increasing of recurrent episodes.

To understand the reasons for misdiagnosis of bipolar disorder in an outpatient setting in order to help clinicians more clearly identify the disease and avoid diagnostic errors.

Data from an outpatient clinic included two groups: those with a confirmed diagnosis of bipolar disorder (CD group) and those who were misdiagnosed (i.e. those who did in fact have bipolar disorder but received a different diagnoses and those without bipolar disorder who received a bipolar diagnosis [MD group]). Information between these two groups was compared.

There were a total of 177 cases that met the inclusion criteria for this study. Among them, 136 cases (76.8%) were in the MD group and 41 cases (23.2%) were in the CD group. Patents with depression had the most cases of misdiagnosis (70.6%). The first episode of the patients in the MD group was more likely to be a depressive episode (χ 2 =5.206, p =0.023) and these patients had a greater number of depressive episodes during the course of the disease ( Z =-2.268, p =0.023); the time from the onset of the disease to the first treatment was comparatively short ( Z =-2.612, p =0.009) in the group with misdiagnosis; the time from the onset of disease to a confirmed diagnosis was longer ( Z =-3.685, p <0.001); the overall course of disease was longer ( Z =-3.274, p =0.001); there were more inpatients for treatment (χ 2 =4.539, p =0.033); and hospitalization was more frequent ( Z =-2.164, p =0.031). The group with misdiagnosis had more psychotic symptoms (χ 2 =11.74, p = 0.001); particularly when depression occurred (χ 2 =7.63, p = 0.006), and the incidence of comorbidity was higher (χ 2 =5.23, p =0.022). The HCL-32 rating was lower in the misdiagnosis group ( t =-2.564, p =0.011). There were more patients diagnosed with bipolar and other related disorders in the misdiagnosis group than in the confirmed diagnosis group (11.0% v. 4.9%) and there were more patients in the MD group diagnosed with depressive episodes who had a recent episode (78.7% v. 65.9%).

Conclusions

The rate of misdiagnosis of patients with bipolar receiving outpatient treatment was quite high and they often received a misdiagnosis of depression. In the misdiagnosis group the first episode tended to manifest as a depressive episode. In this group there were also a greater number of depressive episodes over the course of illness, accompanied by more psychotic symptoms and a higher incidence of comorbidity. Moreover, these patients apparently lacked insight into their own mania and hypomania symptoms, resulting in difficulties in early diagnosis, longer time needed to confirm the diagnosis, higher rate of hospitalization, and greater number of hospitalizations.

背景

双相情感障碍是一种高误诊率的精神疾病，常被误诊为抑郁症、精神分裂症、焦虑症、强迫症和人格障碍等精神疾病，导致临床症状不能有效控制，病情呈反复发作趋势，故近年来双相情感障碍的误诊问题越来越引起精神科医生的重视。

目的

了解双相情感障碍在门诊的误诊情况，并分析其误诊原因，指导临床医师加强对双相情感障碍的识别，尽量避免或减少其误诊和漏诊。

方法

纳入专家门诊确诊为双相情感障碍的患者，了解其在门诊的就诊及误诊和漏诊情况，通过比较误诊组（包含漏诊者）和确诊组的临床资料进一步分析导致误诊和漏诊的可能原因。

结果

双相情感障碍在专家门诊就诊患者中占 31.5%。符合本研究入组标准的共有177 例，其中误诊组136 例(76.8%)，确诊组41 例(23.2%)，误诊为抑郁症者最多(70.6%)。误诊组患者首次发作更多的表现为抑郁发作( χ2 =5.206, p =0.023)，并且病程中抑郁发作次数更多( Z =-2.268, p =0.023)；误诊组起病至首次治疗的时间较短( Z =-2.612, p =0.009)、而起病至确诊时间更长 ( Z =-3.685, p <0.001)，总病程更长( Z =-3.274, p =0.001)，并且住院治疗的患者更多( χ2 =4.539, p =0.033)，住院次数也更多( Z =-2.164, p =0.031)；误诊组伴有精神病性症状更多( χ2 =11.74, p =0.001)，尤其抑郁发作时( χ2 =7.63, p =0.006)，共病的发生率更高( χ2 =5.23, p =0.022)；误诊组HCL-32 评分更低( t =-2.564, p =0.011)。误诊组诊断为其他特定的双相及相关障碍的患者较确诊组多(11.0% v. 4.9%)，并且误诊组最近发作情况表现为抑郁发作的 患者较多(78.7% v. 65.9%)。

结论

门诊双相情感障碍患者的误诊率高，常被误诊为抑郁症。误诊组患者首次发作更多的表现为抑郁发作，病程中抑郁发作次数更多，伴有精神病性症状更多，共病的发生率更高，并且患者对自身躁狂或轻躁狂发作情况明显认识不足，导致早期难以明确诊断，确诊所需时间更长，住院比率更高，住院次数更多。临床医生应提高对双相情感障碍的识别，避免或减少双相情感障碍的误诊和漏诊。

1. Background

Misdiagnosis is an incorrect diagnosis. The objectives of making a diagnosis are to determine the nature of a disease and to select targeted treatment so that the condition takes a favorable turn. Therefore, the incorrect, incomprehensive, or untimely diagnosis is considered to be a misdiagnosis. In clinical work, bipolar disorder is usually difficult to diagnose in its early stages, especially when it has an early onset. Hirschfeld and colleagues [ 1 ] reported that the misdiagnosis rate for bipolar disorder could reach as high as 69%. Only 20% of patients with bipolar disorder with a current depressive episode were given a confirmed diagnosis within the first year of treatment. A confirmed diagnosis was typically given 5 to 10 years after the first episode of the disease. [ 2 ] Generally, the disorder was misdiagnosed as major depressive disorder, schizophrenia, anxiety disorder, borderline personality disorder, or substance dependence. [ 3 ] It was most commonly misdiagnosed as major depressive disorder. [ 4 ] Because of psychotic symptoms, 31% of patients with bipolar I disorder were mistakenly diagnosed as having other disorders with obvious psychotic symptoms such as schizophrenia or substance use induced psychotic disorders. [ 5 ] The reason for this may be related to clinical practitioners who believe that Schneider’s first rank symptoms are specific symptoms of schizophrenia. [ 6 ] Patients with bipolar II disorder were usually misdiagnosed as having unipolar depression. [ 7 ] The reason might be related to the disease characteristics of bipolar disorder. When the clinical manifestation of the first episode was depression, the patient was often simply diagnosed as having depressive disorder. [ 6 ] Misdiagnosis also occurs when there are other comorbid disorders making affective symptoms, when there is not sufficient attention paid to medical history, or through overly restrictive use of the diagnostic criteria. Some studies showed that bipolar disorder has high comorbidity [ 8 , 9 ] often combined with alcohol and drug dependence, personality disorder, and all sorts of anxiety disorders. The clinical manifestations of comorbidity often masked or were confused with affective symptoms, thereby causing clinical misdiagnosis.

Currently, there is still a lack of systematic research regarding the identification rate and the diagnostic rate of bipolar disorder and clinicians understanding of bipolar disorder. Therefore, we followed up and analyzed data from patients seen in our psychiatric specialist clinic receving treatment for bipolar disorder in order to further understand the reasons for misdiagnosis.

2.1 Participants

The participants in this study were patients with bipolar disorder that had consecutive consultations in the specialist outpatient clinic of our hospital from March 1 st 2016 to August 31 st 2016. There were a total of 181 cases. After selection, 177 cases were enrolled, including 85 males and 92 females. Range of ages was from 18 to 64 years old. The mean(SD) age was 29.1 (11.5) years old. All participants were in line with the following: (a) meeting diagnostic criteria for bipolar disorder according to DSM-V; (b) at least 2 consultation visits after enrollment into this study; (c) aged 18 to 65 years; (d) did not have severe somatic diseases, mental retardation, mental disorders caused by organic diseases, psychoactive substance or alcohol abuse. We excluded pregnant and lactating women, holdouts and people with incomplete clinical data. The enrolled participants were divided into two groups. The participants who were diagnosed with bipolar disorder in the first visit were regarded as the confirmed diagnosis group. The participants who were not diagnosed with bipolar disorder in the first visit and yet received a bipolar diagnosis in the return visit were regarded as the misdiagnosis group (including patients with missed diagnosis: The diagnosis was depression when the participants only showed depressive episode in the first consultation and there was no confirmed mania or hypomania episodes. The diagnosis was bipolar disorder when mania and hypomania were present in the return visit). There were 41 participants (23.2%) in the confirmed diagnosis group and 136 persons (76.8%) in the misdiagnosis group.

2.2 Study methods

Cross-sectional and retrospective study methods were used. Information were collected by professional psychiatrists. The method of information gathering was a combination of checking medical history and interviews with the patient and at least one immediate family member. The relevant clinical data was recorded in detail. Demographic data and clinical data of all patients with bipolar disorder were collected using a self-compiled questionnaire. Clinical data included the age of first onset, the clinical manifestation of the first episode, the time from the onset to the first consultation, the course of disease, the time from the onset to the confirmed diagnosis, diagnosis and classification, the number of manic depressive episodes, whether there were mixed characteristics to these episodes, whether or not patient was hospitalized for treatment, current clinical manifestation and treatment, whether or not there is a family history of mental illness, history of suicide, psychotic symptoms, and whether the bipolar disorder is rapid cycling or comorbid with another illness. All the enrolled patients were assessed with PHQ-9 and HCL-32 self-rating scales. The demographic data and clinical data of the MD group and CD group were compared.

2.3 Statistical methods

All data were processed using SPSS 17.0 Methods used included t-test, Mann-Whitney test, and chi-square test. A p value of less than 0.05 was considered statistically significant and less than 0.01 was considered highly statistically significant.

3.1 Bipolar disorder consultation and misdiagnosis in an outpatient department

In this study, there were 574 cases of outpatients in the specialist clinic. Among these cases, there were 181 patients with bipolar disorder (31.5%). Of these, 177 cases that met the inclusion criteria. Among the cases, 136 cases had had misdiagnosis and the misdiagnosis rate reached 76.8% (see figure 2 ). The most common misdiagnosis was depression (96 cases, 70.6%) followed by schizophrenia (28 cases, 20.6%) and obsessive compulsive disorder (21 cases, 15.4%); also included were anxiety disorder (9 cases, 6.6%) and personality disorder (2 cases, 1.5%) (see figure 3 ). Among them, 16 patients were misdiagnosed with 2 disorders and 2 patients were misdiagnosed with 3 disorders.

Bipolar disorder consultation in the specialist outpatient clinic

Other diagnoses besides Bipolar given (MD group)

3.2 Comparison of the demographic data between the MD group and CD group (see table 1 )

Comparison of the demographic data between the bipolar disorder misdiagnosis group and confirmed diagnosis group

The difference between the demographic data of the two groups was not statistically significant in any category.

3.3 Comparison of the clinical characteristics between the bipolar disorder MD group and CD group

The age at first episode ( t =-0.059, p =0.953), total number of episodes ( Z = -1.019, p = 0.308), number of manic episodes ( Z = -1.373, p = 0.17), and the PHQ-9 score during depressive episode ( t =1.177, p =0.241) had no statistically significant differences. There was also no difference between the two groups in family history of bipolar disorder.

Patients in the MD group more commonly had depression during their first episode ( χ 2 = 5.206, p = 0.023) and the number of depressive episodes was significantly more during the course of illness ( Z = -2.268, p = 0.023). The time from the onset of illness to first treatment was significantly shorter ( Z =-2.612, p =0.009) in the MD group, the time from the onset of illness to the confirmed diagnosis was longer ( Z =-3.685, p <0.001), the overall course of disease was longer ( Z =-3.274, p =0.001), there were more cases receiving inpatient treatment ( χ 2 =4.539, p =0.033), and hospitalization was more frequent ( Z =-2.164, p =0.031). The MD group had more psychotic symptoms ( χ 2 =11.74, p = 0.001), particularly during depressive episodes ( χ 2 =7.63, p = 0.006), and the incidence of comorbidity was higher ( χ 2 =5.23, p =0.022). The HCL-32 rating was lower in the MD group ( t =-2.564, p =0.011). See table 2 .

Comparison of the clinical characteristics between the bipolar disorder misdiagnosis group and confirmed diagnosis group

3.4 Comparison of diagnosis and pharmacological treatment between the MD group and CD group

There was no statistically significant difference between the two groups in diagnostic classification ( χ 2 =1.417, p =504), but there were more patients diagnosed with other specific bipolar and related disorders in the MD group than in the CD group (11.0% v. 4.9%). In terms of recent episodes and clinical medication, the differences between the 2 groups were not statistically significant ( χ 2 =2.816, p =0.093). However, the patients in the misdiagnosis group that in recent mood episodes presented with depression were more (78.7% v. 65.9%). The ratio of rapid cycling episodes in the two groups ( χ 2 =0.012, p =0.914) and having episodes with mixed features ( χ 2 =0.086, p =0.770) were not statistically significant. See table 3

Comparison of the diagnosis and pharmacological treatment between the bipolar disorder misdiagnosis group and confirmed diagnosis group

* p <0.05

** p <0.01

3.5 Comparison of the number of manic and depressive episodes between the MD and CD groups

There were more depressive episodes than manic episodes reported in both groups. This difference in the MD had high statistical significance ( Z = -9.034, p = 0.001). This difference in the CD group also had statistical significance ( Z = -2.508, p = 0.012). See table 4

Comparison of the manic and depressive episodes between the bipolar disorder misdiagnosis group and confirmed diagnosis group

4. Discussion

4.1 main findings.

The results of this study show that the misdiagnosis rate of bipolar disorder was 76.8%. The misdiagnosis rate is slightly higher than the reported results in studies conducted outside of China. [ 1 ] This could be related to the source of our sample. All the patients selected for this study were from the specialist outpatient department, including a larger number of patients with refractory bipolar disorder and atypical symptoms. Of the 177 patients enrolled, 36 had mixed features, 53 had rapid cycling episodes, 51 had comorbidity with other disorders, and 17 were diagnosed with other specific bipolar and related disorders.

This study shows that bipolar disorder patients are most likely to be misdiagnosed with depression. The misdiagnosis rate is as high as 70.6%. The result shares similarity with other studies. [ 2 , 10 ] The reason may be related to the characteristics of the onset of bipolar disorder itself, especially when the episode of onset is depressive with no mania or hypomania. [ 2 , 11 ] In the entire course of bipolar disorder, there were apparently more depressive episodes than manic or hypomanic episodes. [ 12 ] In particular the patients with bipolar II disorder had a depressive presentation throughout most of their illness, [ 13 ] making the clinical diagnosis even more difficult. In the misdiagnosis group of this study, there were more patients having a depressive episode at onset and the frequency of depressive episodes was apparently higher than the manic episode, thereby prolonging the time for clinical diagnosis and increasing the misdiagnosis rate.

Patients with bipolar disorder are often misdiagnosed as having unipolar depression in many circumstances. The reason is related to clinicians or patients lacking knowledge about manic and hypomanic symptoms. Some research shows that the hypomanic state was often mistaken by clinicians or patients as the signs of improvement or remission of depression and they neglected the risk of the disorder further worsening, resulting in misdiagnosis. [ 14 , 15 ] The results of this study showed that the HCL-32 score of the patients in the MD group was lower, which also confirmed the above views.

The results of this study also showed that 20.6% of the patients with bipolar disorder were misdiagnosed as having schizophrenia. In addition, more than half of the 136 patients in the MD group had psychotic symptoms, so it was clear that the presence of psychotic symptoms increased the risk of being misdiagnosed as having schizophrenia especially during the onset of depression. In other studies, 61.5% of patients with bipolar disorder with psychotic symptoms were misdiagnosed as having other mental disorders at the time of first treatment. Moreover, 45% of the patients showed psychotic symptoms such as hallucinations or delusions during depressive episodes. [ 17 ] Some studies [ 18 ] showed that psychotic symptoms are one of the major risk factors for bipolar disorder in patients with depression. They can even be used as a predictor of whether patients with depression have bipolar disorder.

In this study, 15.4% of patients were misdiagnosed with obsessive-compulsive disorder, 6.6% of them were misdiagnosed with anxiety disorder, and 1.5% of them were misdiagnosed as having a personality disorder. The reason for misdiagnosis may be related to the comorbidity of bipolar disorder. Comorbidity was very common in bipolar disorder. This study showed that 1/3 of the patients in the MD group had comorbidity and it was more than in the CD group. It can be seen that the presence of comorbidity may mask emotional symptoms, leading to an increase in misdiagnosis rate. A meta-analysis [ 8 ] indicated that the incidence of comorbid anxiety disorders with bipolar disorder was 42.7% and comorbid obsessive-compulsive disorder was 10.7%. A systematic review of 64 related articles [ 9 ] indicated that the incidence of bipolar disorder comorbid with obsessive-compulsive disorder was between 11% and 21%. Comorbidity results in complex or atypical clinical symptoms, increases the rate of clinical misdiagnosis, and leads to treatment difficulties.

In terms of diagnosis classification, this study showed that there was no significant statistical difference between the two groups. However, the patients of the MD group diagnosed as other specific bipolar disorder and other related disorder were slightly more than the CD group. This could be one of the reasons for misdiagnosis. Many of the symptoms of the patients in this study were hypomanic or manic yet did not fit the time criteria for bipolar. For example hypomanic symptoms only lasted 2 to 3 days, or the time criteria for a hypomanic episode was met but the criteria for other symptoms were not met. These were harder to identify and diagnose at an early stage. However, this study was carried out in a clinic specializing in affective disorders therefore the staff in this setting may have a higher ability to diagnose this type of bipolar disorder.

4.2 Limitations

This study was a cross-sectional and retrospective study. The clinical data were collected mainly from checking past medical records and interviewing patients and at least one family member regarding history of illness. Although each patient had at least two follow-up visits and was asked carefully about the medical history in order to ensure the integrity of the medical history data, it is not guaranteed that the patients and their family members provided a complete medical history. Patients with a long medical history and recurrent episodes were especially unable to recall the timing and manifestation of each episdoe.

The sample for this study originated from a psychiatric clinic specializing in the diagnosis and treatment of affective disorders. The diagnosis and differential diagnosis in this clinic were more standardized; the compliance of the patients was good; the interruption rate of treatment was low; and the drop-out rate from follow-up visits was low. Therefore this sample should be somewhat conducive to follow-up and research development. However, the source of the sample was relatively narrow in this study as it did not include patients with other diagnoses or in other treatment settings. Moreover, the sample size was limited and the diagnosis and treatment situations of bipolar disorder in the general outpatient service were not covered. Therefore, a wider and larger sample study is needed to further explore the current status of bipolar disorder misdiagnosis in psychiatric outpatient clinics in China.

4.3 Implications

When bipolar disorder is misdiagnosed or missed altogether, symptoms cannot be effectively treated, episodes tend to be recurrent, and rapid cycling episodes are more commonly seen. [ 19 ] The risk of suicide increases, [ 20 ] which in turn increases the need for hospitalization and overall burden of the disease. [ 21 ] This can also explain why the patients in the MD group tended to have a higher rate of hospitalization. Therefore, early diagnosis is conducive to appropriate and timely treatment and is beneficial to the maximum recovery of the patients’ function. The earlier the correct diagnosis and treatment, the greater the chance that the patient will recover.

However, any doctor could make mistakes in cross-sectional diagnosis due to the complexity of the presentation of bipolar disorder. This study looked into the causes of bipolar disorder misdiagnosis and missed diagnosis in the outpatient service in hopes of improving guidance for clinical workers. In order to prevent the misdiagnosis of bipolar disorder, clinicians should conduct comprehensive and in-depth clinical examination, pay full attention to emotional symptoms, identify hypomanic symptoms carefully, search for diagnostic clues for bipolar disorder from the clinical symptoms of depression, ask about whether there were past episodes of hypomania or mania especially during medical history collection, and enhance the identification of bipolar disorder so as to avoid or reduce the misdiagnosis and missed diagnosis of bipolar disorder.

Subsequently, clinicians should try harder to identify psychiatric symptoms and affective symptoms and pay close attention to those depressive patients with psychotic symptoms. At the same time, they should consider that comorbidity with other disorders in bipolar is common. Clinicians should improve the identification of comorbidity and avoid or reduce the misdiagnosis and missed diagnosis of bipolar disorder so as to give timely and standardized treatment to patients with bipolar disorder and improve the short-term and long-term treatment effects and quality of life to the greatest extent.

Flowchart of the study

Hui Shen acquired her bachelor’s degree in clinical medicine at Shanghai Second Medical University in 2003. In the same year she began working at the Shanghai Mental Health Center. She has 13 years of clinical work experience in psychiatry. At present, she is the chief rehabilitation doctor at SMHC. Her research interests are the treatment of schizophrenia and bipolar disorder, as well as the cognitive function and rehabilitation therapy of psychiatric patients.

Funding statement

Shanghai Mental Health Center affiliated to the Shanghai Jiao Tong University project (project code: 2016-YJ-12);

Shanghai Mental Health Center affiliated to the Shanghai Jiao Tong University project (project code: 2014 - YL - 04);

National Key Technology Research and Development Program (project code:2012BAI01B04)

Conflicts of interest statement

The authors declare no conflict of interest related to this manuscript.

Informed consent

Written informed consent was provided by all participants.

Ethical approval

This study was approved by the ethics committee of the Shanghai Mental Health Center affiliated to Shanghai Jiao Tong University.

Copyright permission on work’s translation

I have authorized the article to Shanghai Archives of Psychiatry for translation from Chinese to English. I have confirmed all the information included in this article is correct.

Authors’ contributions

Hui Shen: research design, data analysis, and article writing

Li Zhang: medical history collection, scale evaluation

Chuchen Xu: medical history collection, scale evaluation, and literature review

Meijuan Chen: research guidance

Yiru Fang: research guidance

• Open access
• Published: 09 April 2024

Association of major depression, schizophrenia and bipolar disorder with thyroid cancer: a bidirectional two-sample mendelian randomized study

• Rongliang Qiu 1 , 2 ,
• Huihui Lin 3 ,
• Hongzhan Jiang 3 ,
• Jiali Shen 3 ,
• Jiaxi He 4 &
• Jinbo Fu 1 , 2  

BMC Psychiatry volume  24 , Article number:  261 ( 2024 ) Cite this article

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Major depressive disease (MDD), schizophrenia (SCZ), and bipolar disorder (BD) are common psychiatric disorders, and their relationship with thyroid cancer has been of great interest. This study aimed to investigate the potential causal effects of MDD, SCZ, BD, and thyroid cancer.

We used publicly available summary statistics from large-scale genome-wide association studies to select genetic variant loci associated with MDD, SCZ, BD, and thyroid cancer as instrumental variables (IVs), which were quality controlled and clustered. Additionally, we used three Mendelian randomization (MR) methods, inverse variance weighted (IVW), MR–Egger regression and weighted median estimator (WME) methods, to estimate the bidirectional causal relationship between psychiatric disorders and thyroid cancer. In addition, we performed heterogeneity and multivariate tests to verify the validity of the IVs.

We used two-sample bidirectional MR analysis to determine whether there was a positive causal association between MDD and thyroid cancer risk. The results of the IVW analysis (OR = 3.956 95% CI = 1.177–13.299; P  = 0.026) and the WME method (OR = 5.563 95% CI = 0.998–31.008; P  = 0.050) confirmed that MDD may increase the risk of thyroid cancer. Additionally, our study revealed a correlation between genetic susceptibility to SCZ and thyroid cancer (OR = 1.532 95% CI = 1.123–2.088; P  = 0.007). The results of the WME method analysis based on the median estimate (OR = 1.599 95% CI = 1.014–2.521; P  = 0.043) also suggested that SCZ may increase the risk of thyroid cancer. Furthermore, our study did not find a causal relationship between BD and thyroid cancer incidence. In addition, the results of reverse MR analysis showed no significant causal relationships between thyroid cancer and MDD, SCZ, or BD ( P  > 0.05), ruling out the possibility of reverse causality.

Conclusions

This MR method analysis provides new evidence that MDD and SCZ may be positively associated with thyroid cancer risk while also revealing a correlation between BD and thyroid cancer. These results may have important implications for public health policy and clinical practice. Future studies will help elucidate the biological mechanisms of these associations and potential confounders.

Peer Review reports

Cancer is recognized as a disease that poses a serious threat to human health, and it has been reported that in the United States alone, more than 609,360 people are expected to lose their lives to cancer in 2022 [ 1 ]. However, the mechanisms underlying the development of most cancers are still not fully understood, which has led to delays in the diagnosis and treatment of cancers, contributing to the increasing incidence and mortality of cancer worldwide. Thyroid cancer is one of the most common endocrine tumours, and its incidence has been steadily increasing worldwide over the last three decades due to the widespread use of diagnostic imaging techniques and ultrasound-guided fine needle aspiration (US-FNA) [ 2 , 3 ]. Despite the continued increase in the incidence of thyroid cancer, its mortality trend has remained relatively stable. Risk factors for thyroid cancer include metabolic syndrome (including diabetes mellitus, hypertension, obesity, etc.), poor lifestyle habits, and environmental pollution, but these factors do not fully explain the mechanism of thyroid cancer development. Therefore, identifying other potentially modifiable risk factors, such as psychiatric disorders, is important for the prevention and treatment of thyroid cancer.

Major depressive disease (MDD), schizophrenia (SCZ), and bipolar disorder (BD) are all serious psychiatric disorders that overlap genetically and clinically, suggesting that they may share common aetiological mechanisms [ 4 ]. The results of a study suggest that quantitative changes in plasma lipids affect several individual characteristics, including those affected by serious psychiatric disorders (MDD, SCZ and BD) [ 5 ]. Moreover, clinical studies have shown that patients with MDD, SCZ and BD have altered Homer1a levels in specific regions and cell types of the brain. A growing body of research confirms the close connection between these three disorders [ 6 ]. MDD is ranked by the World Health Organization as one of the most burdensome diseases in the world; it seriously damages people’s physical and mental health and is associated with a variety of endocrine disorders, such as hypothyroidism and hyperthyroidism [ 7 , 8 , 9 , 10 , 11 ]. Studies have shown that patients with hyperthyroidism and hypothyroidism differ in the presentation of depressive symptoms and disorders [ 12 , 13 ]. Specifically, hyperthyroidism was associated with more depressive symptoms (e.g., insomnia and weight loss) [ 14 ], whereas hypothyroidism was associated with fewer depressive symptoms (e.g., energy deficit and fatigue) [ 15 ]. In addition, individuals with hyperthyroidism have a higher incidence of MDD [ 13 ]. The relationship between depression and cancer has long been of interest, and some observational studies have suggested that depression may be an important risk factor for cancer [ 16 ]. A cross-sectional study from Korea revealed a 5.6% incidence of depression in thyroid cancer patients [ 17 ]. Another study from Germany showed that cancer patients were five times more likely to be depressed than was the general population, and thyroid cancer patients with a detectable high burden of depressive symptoms were 9.3 times more likely to be depressed than was the general population [ 18 ]. However, despite observational studies revealing a correlation between MDD and thyroid cancer, the relationship between MDD and thyroid cancer has not been systematically explored.

SCZ is a chronic psychiatric disorder accompanied by inconsistent behavioural and cognitive symptoms and has profound effects on both individuals and society. More than 50% of those diagnosed have intermittent and chronic psychiatric problems [ 19 ]. This results in a particularly high risk of disengagement from the labour market, with employment rates ranging from 10 to 30%, unemployment rates as high as 89–95%, and a 15–20 year reduction in life expectancy [ 20 , 21 ]. There is growing evidence that thyroid function may be altered in patients with SCZ, but the results of observational studies have been inconsistent [ 22 , 23 ]. In addition, the role of the thyroid gland in the pathophysiology of SCZ is poorly understood, and the relationship between thyroid disorders and SCZ is unclear.

SCZ and BD are considered part of the psychiatric continuum and share similar clinical features. BD is a chronic, disabling illness and a major contributor to the global burden of disease. BD can cause mood swings ranging from depression to mania. Patients exhibit fluctuations during the course of the illness, with some patients experiencing episodes only every few years, while others experience episodes almost continuously. A large body of evidence confirms the association between abnormal thyroid hormone levels and different psychopathological conditions, triggering neuropsychiatric symptoms [ 24 ]. However, observational studies may find an association between psychiatric disorders and thyroid disorders, but confounding factors and reverse causality cannot be excluded.

To explore the causal association between psychiatric disorders (MDD, SCZ and BD) and thyroid cancer risk, we used a two-sample bidirectional Mendelian randomization (MR) study. MR studies [ 25 ] use genetic variation as an instrumental variable closely related to the exposure of interest to explore the causal effect between the exposure and the outcome, thereby improving the reliability of causal inference. Because of the random segregation of alleles at the meiotic stage and the stochastic nature of germline genetic variation at fertilization, MR analyses can avoid confounding factors and reverse causation. In this study, we utilized a two-sample bidirectional MR approach to explore the associations between MDD, SCZ, BD, and thyroid cancer based on statistically pooled data from a genome-wide association study (GWAS). This study aimed to gain insights into the potential link between psychiatric disorders and thyroid cancer and to provide new perspectives and insights for the prevention and treatment of thyroid cancer.

This study is an analysis of previously collected and published public data, including statistical aggregations related to MDD, SCZ, BD, and thyroid cancer, from large public GWASs. Due to the source and nature of the data, no additional ethical review or informed consent was required for this study. Two-sample bidirectional MR analyses were used to assess the causal relationship between psychiatric disorders (MDD, SCZ, BD) and thyroid cancer. We chose psychiatric disorders (MDD, SCZ, BD) as the exposure factor and thyroid cancer as the outcome indicator. Moreover, we conducted a reverse two-sample MR analysis with thyroid cancer as an exposure factor and psychiatric disorders (MDD, SCZ, BD) as an outcome indicator. A flow chart of the MR research design constructed according to this paper is shown in Fig.  1 .

Flowchart of the design of a Mendelian randomized study of the causal association between psychiatric disorders and thyroid cancer. Blue solid lines represent associations between instrumental variables (SNPs) and exposure and between exposure and outcome. The red solid line represents reverse causality. psychiatric disorders include major depression, schizophrenia, and bipolar disorder

Data sources for patients with major depression, schizophrenia, bipolar disorder, or thyroid cancer

The summary-level dataset used for GWASs for MDD in this study was obtained from a meta-analysis of GWAS data conducted by Howard et al. [ 26 ]. It comprises three large-scale GWASs, the Psychiatric Genomics Consortium (PGC), the UK Biobank, and 23andme. Of the three GWASs, only the UK Biobank and the PGC publish summary statistics on genetic variation. The dataset included 500,199 European subjects, including 170,756 cases and 329,443 controls. In the UK Biobank, Howard et al. used a broad definition of depression and asked participants if they reported neurological, anxiety, tension, or depression symptoms to their general practitioner or psychiatrist. At the PGC, Wray et al. diagnosed depression in participants according to international consensus diagnostic criteria (DSM-IV, ICD-9, or ICD-10). See Table  1 for details.

Statistical summary data for SCZ and BD were obtained from the most recent PGC’s GWAS summary statistics. The data for SCZ [ 27 ] are based on a major meta-analysis of multiple groups, including Europeans, East Asians, African Americans, and Latinos, including 76,755 cases and 243,649 control participants. BD [ 28 ] was based on a summary analysis of European ancestry and included 20,352 cases and 31,358 control participants. See Table  1 for detailed information.

To perform two-sample bidirectional analyses, we used independent genome-wide significant single nucleotide polymorphisms (SNPs) as exposure indicators for MDD (50 SNPs), SCZ (217 SNPs), and BD (16 SNPs). The F-statistics of the above SNPs are all greater than 10, indicating that they are strongly correlated instrumental variables (IVs). The detailed information is specified in the Supplementary Material: Tables  1 , 2 and 3 .

Data on genetic variants associated with thyroid cancer were obtained by Deutsches the Krebsforschungszentrum (DKFZ) through GWAS [ 29 ] and included 1080 European participants, including 649 in the case group and 431 in the control group, as detailed in Table  1 . For the bivariate analyses, we used independent genome-wide significant SNPs as indicators of exposure to thyroid cancer (347 SNPs). All 347 SNPs had F-statistics greater than 10, indicating that they were strongly correlated IVs. Specific SNP information is provided in the Supplementary Material: Table  4 .

Selection of genetic instrumental variables

This study was conducted in strict accordance with the quality control steps. First, we selected exposure-related GWAS data and screened SNP loci with genome-wide significance ( p  < 5 × 10 − 8 ) for pooled aggregation. Second, to avoid linkage disequilibrium (LD) from affecting the results, we performed a clustering process by setting the parameter (r 2 ) threshold (r 2  < 0.001 and region width = 10,000 kb) to assess LD among SNPs to ensure independence. SNPs need to fulfil three basic assumptions to serve as IVs for exposure factors, and the fulfilment of these assumptions will enhance the testing power and estimation accuracy of IVs: (1) the association assumption: genetic variants are associated with exposure; (2) the independence assumption: genetic variants are independent of confounders between exposure and outcome; and (3) the exclusivity assumption: genetic variants affect the outcome only through exposure [ 30 ]. Next, we extracted summary statistics of eligible SNPs from the outcome GWAS; finally, we determined that the SNPs included in the dataset met the instrumental variable requirements. The palindromic sequences were excluded to ensure that the effects of SNPs on exposure and outcome were from the same allele. This series of steps finalized the identification of SNPs that served as genetic IVs for this study.

Statistical analysis

After coordinating the GWAS effect alleles for MDD, SCZ, BD, and thyroid cancer, we selected three MR approaches. The inverse variance weighted (IVW) test, MR–Egger regression, and weighted median estimator (WME) were used to assess the causal relationship between psychiatric disorders and thyroid cancer risk. The main method of analysis was IVW, while WME and MR–Egger regression were used as complementary methods to IVW estimation, as they provide more reliable estimates under more relaxed conditions [ 31 ]. The Cochran’s Q test was used to estimate the heterogeneity of the causal effects of individual gene variants. If horizontal pleiotropy or heterogeneity is detected, fixed-effects IVW analysis should be chosen, and vice versa for random-effects IVW analysis [ 32 , 33 ]. The IVW method does not take into account the presence of an intercept term and uses the variance of the outcome as the fitting weight. In contrast, the MR–Egger regression method, which is an MR method for assessing the causal effect of genetic variation on the relationship between exposure and outcome, takes into account the presence of an intercept term [ 34 ]. This method corrects for polytropic bias and detects directed polytropy but is susceptible to instrumental variable assumptions. When the Egger intercept of a linear regression is close to zero, it indicates the absence of directional pleiotropy, thus satisfying the exclusivity assumption. The weighted median method is a method that combines data from multiple genetic variants into a single causal estimate and requires that more than 50% of the weights come from valid IVs to obtain a reliable estimate of the causal effect [ 31 ]. To ensure the reliability of the MR estimates, we also detected outliers that may affect our MR estimates by looking at forest plots, funnel plots, scatter plots, and leave-one-out methods.

To test the first hypothesis of correlation, we also assessed the strength of the relationship between IVs and phenotype using the F-statistic (F = beta 2 / se 2 , with beta being the allele effect value and SD being the standard deviation), with F > 10 indicating the presence of strongly correlated IVs [ 35 ].

All of the above MR-related statistical analyses were implemented using TwoSampleMR in R 4.1.1 software.

Three sets of genetic instruments were constructed for the forwards MR study after a series of quality control steps. First, we merged the exposure (MDD)- and outcome (thyroid cancer)-related datasets, and after removing 2 palindromic sequences (rs4936276 and rs4730387), we ultimately included 26 SNPs for analysis. The second set of genetic tools was constructed after the same quality control steps, combining the exposure (SCZ) and outcome (thyroid cancer) datasets and deleting six palindromic sequences (rs12363019, rs217310, rs2470951, rs2944821, rs7709645, rs9925915) before finally including 111 SNPs that were analysed. A third set of genetic instruments was constructed following the same quality control steps, combining exposure (BD) and outcome (thyroid cancer), and after deleting 2 palindromes sequences (rs10455979, rs5758065), and finally included 9 SNPs for analysis. The F-statistics of the above SNPs were greater than 10, indicating that they were strongly correlated with each other (Supplementary Material: Tables  1 , 2 and 3 ).

Three sets of genetic instruments were constructed in the reverse MR study after a series of quality control steps. First, we combined exposure (thyroid cancer) and outcome (MDD)-related datasets, resulting in the inclusion of 331 SNPs for analysis. The second set of genetic instruments was constructed following the same quality control steps, combining the exposure (thyroid cancer) and outcome (SCZ) datasets, resulting in the inclusion of 338 SNPs for analysis. A third set of genetic instruments was constructed following the same quality control steps, combining the exposure (thyroid cancer) and outcome (BD) data and ultimately including 338 SNPs for analysis. The F values of the above IVs were all > 10, indicating reliable results without weak bias.

Mendelian randomization analysis

In our study, we explored the causal relationship between psychiatric disorders (MDD, SCZ, and BD) and thyroid cancer using psychiatric disorders as exposure factors. The results of the IVW analysis showed a significant association between MDD and the risk of thyroid cancer (OR = 3.956 95% CI = 1.177–13.299; P  = 0.026), confirming the possibility of an increased risk of thyroid cancer due to MDD. These findings were reinforced by the results obtained by the WME method (OR = 5.563 95% CI = 0.998–31.008; P  = 0.050), which were consistent with those of the IVW method. However, the results of the MR–Egger regression (OR = 76.975 95% CI = 0.008-766576.333; P  = 0.364) showed that the difference in the effect of MDD and thyroid cancer was not statistically significant (Table  2 ), which may be due to the high false-positive rate of false-negative results from this method. Nevertheless, the IVW and WME methods suggest that MDD may increase the risk of thyroid cancer.

In addition, we found that genetic susceptibility to SCZ was correlated with thyroid cancer (OR = 1.532 95% CI = 1.123–2.088; P  = 0.007). The results of the WME method analysis based on the median estimate (OR = 1.599 95% CI = 1.014–2.521; P  = 0.043) also support that SCZ may increase the risk of thyroid cancer (Table  2 ).

However, no causal relationship between BD and thyroid cancer was found in any of the MR analyses. In addition, we performed reverse MR analysis, which showed no evidence of a causal relationship between genetic susceptibility to thyroid cancer and psychiatric disorders (MDD, SCZ, and BD), ruling out the possibility of reverse causation (Supplementary Material: Table  5 ).

Sensitivity analysis

For sensitivity analysis, we first tested for heterogeneity of results using Cochran’s Q for IVW and MR–Egger regression. The results showed that the p values of the analyses were greater than 0.05, which indicated that there was no significant heterogeneity in our study. Similarly, the MR–Egger intercept method results also showed no horizontal pleiotropy (all p values greater than 0.05). We also constructed funnel plots and leave-one-out plots. The funnel plot was roughly symmetrical, indicating a relatively low risk of bias and high reliability of the results. A leave-one-out plot was generated to reject SNPs one by one, and the analysis showed that the causal relationship between psychiatric disorders and thyroid cancer was largely not driven by a single SNP. We also examined scatter plots, in which each point represents an instrumental variable. Each horizontal solid line in the forest plot reflects a single SNP estimated using the Wald ratio method. Leave-one-out, scatter, funnel, and forest plots can be found in the supplementary materials.

In the inverse sensitivity analyses, Cochran’s Q test revealed heterogeneity between the effects of thyroid cancer on MDD, SCZ, and BD. Therefore, IVW analysis under a random effects model was chosen to balance the heterogeneity of the results. However, it is noteworthy that no heterogeneity was found in thyroid cancer patients with MDD or SCZ. p values for the MR–Egger intercept method were all greater than 0.05, suggesting that there was no horizontal pleiotropy in the results. Leave-one-out, scatter, funnel, and forest plots can be found in the supplementary materials.

With the increasing prevalence of psychiatric disorders and thyroid cancer, there is an increasing overlap between them, prompting us to delve deeper into their relationship. This study is the first two-sample bidirectional MR study of psychiatric disorders (MDD, SCZ, BD) and thyroid cancer. Our MR study showed a significant causal association between MDD and SCZ and thyroid cancer, whereas no such association was found between BD and thyroid cancer. Reverse MR analysis ruled out the possibility of reverse causation.

MR studies have the advantage of effectively avoiding confounding bias. Because SNPs are randomly assigned at conception, MR is also able to exclude reverse causality effects relative to observational studies, thus enhancing the credibility of causal inferences. We suggest the following possible mechanisms for the positive causal relationship between MDD and thyroid cancer: First, MDD may lead to abnormal functioning of the hypothalamic–pituitary–thyroid (HPT) axis, which in turn affects thyroid hormone levels and thyroid-stimulating hormone (TSH) secretion. TSH is a key factor in promoting thyroid cell proliferation, and abnormal TSH levels may increase the risk of thyroid nodules and cancer. Patients with early-stage MDD may suffer from thyroid and metabolic dysfunction [ 36 ]. Data from the study showed that 26.2% of depressed patients had abnormal thyroid function, 18.3% of whom had MDD, and 62.4% of the study population was female [ 37 ]. The results of a multicentre study by the European Antidepressant Study Group showed that the prevalence of hypothyroidism and hyperthyroidism in patients with MDD was 13.2% and 1.6%, respectively [ 38 ]. These results imply that MDD may regulate thyroid hormone levels through the HPT axis, thereby affecting thyroid function and structure. Abnormal HPT axis function has been the focus of research on neuroendocrine mechanisms in patients with psychiatric disorders, and our findings provide insight into the relationship between genetic susceptibility to MDD and thyroid cancer. Second, MDD leads to elevated peripheral inflammatory marker levels [ 39 , 40 ], which induce chronic inflammation and gene mutations in the thyroid gland. These peripheral inflammatory markers include interleukins (ILs), tumour necrosis factor (TNF), and C-reactive protein (CRP), which can affect thyroid tissues through blood circulation or neuroendocrine pathways. Chronic inflammation can mediate tumour development, and the two are interconnected through endogenous and exogenous pathways. Chronic inflammation of the thyroid gland may contribute to genetic defects through the secretion of high levels of mutagenic agents (e.g., reactive oxygen species and nitric oxide) [ 41 ]. Finally, MDD may be associated with type C personality, which is characterized by abnormal emotional expression and abnormal emotion regulation that may affect the immune system and endocrine function [ 42 , 43 , 44 ]. Some scholars [ 43 ] regard negative emotions as an independent risk factor for the occurrence of thyroid cancer and believe that the persistence or recurrence of depression and anxiety is a stress factor for the human body and that stress causes changes in the cerebral cortex and hypothalamus, which can directly or indirectly suppress the immune system and interfere with the endocrine function of the body [ 44 ], thus affecting the normal synthesis and release of thyroid hormones and triggering thyroid nodules and increasing the likelihood of thyroid cancer.

There may be different aetiologies regarding the genetic susceptibility of patients with SCZ to an increased risk of thyroid cancer. Beginning in the late 19th century, when hypothyroidism was connected with psychiatric disorders, an increasing number of clinical studies have shown a strong independent association between SCZ and hypothyroidism [ 45 ]. A recent community-based cross-sectional study comparing patients with SCZ ( n  = 1252) and healthy controls matched for age, sex, socioeconomic status and ancestry ( n  = 3756) revealed that the incidence of hypothyroidism in patients with SCZ increased after treatment but not before diagnosis [ 22 ]. Similarly, in observational studies, patients with SCZ are more likely to have abnormal thyroid function after initiating treatment with antipsychotics [ 46 , 47 ]. Thus, the use of antipsychotics may lead to abnormalities in thyroid function, although it is not clear whether the HPT axis can be directly affected. A systematic review and meta-analysis summarizing 19 studies suggested that TSH levels may be reduced at the onset of psychosis and elevated in patients with multiple episodes of psychosis [ 48 ]. Studies have shown that dopamine or dopamine agonists inhibit TSH secretion, and a possible explanation for the elevated TSH levels lies in the fact that antidopaminergic drugs used to treat SCZ inhibit dopamine neurotransmission, which may cause elevated TSH levels [ 49 ]. Thus, there may be a causal relationship between hypothyroidism or elevated TSH levels and the manifestations of SCZ. Thyroid hormones not only play a role in the dopaminergic system but also in the regulation of serotonergic, glutamatergic, and GABAergic networks [ 50 ]. During neurodevelopment, thyroid hormones play a critical role, and their deficiency may severely impair the development of neural tissues, leading to abnormalities and damage in the cerebellar cortex and cerebral cortex [ 51 ]. In the adult brain, thyroid hormone interacts with glial cells to regulate immune responses and neurotransmitter release and to control neuronal metabolism.

However, our study did not find conclusive evidence to support a causal role between genetic susceptibility to BD and thyroid cancer risk. To date, the association between affective disorders and thyroid cancer has not been widely reported. Although previous epidemiologic studies using case–control methods have suggested an association between BD and abnormal thyroid function [ 52 , 53 , 54 ], this topic has yet to be thoroughly investigated. One large meta-analysis reported that thyroid hormones may affect neurodevelopment by modulating the brain’s serotonin system [ 43 ]. The current preferred mood stabilizer for maintenance treatment of BD is lithium, although lithium alters thyroid functional status [ 55 ]. However, little is known about the pathophysiologic role of thyroid hormones in BD, and genetically, our study did not find a direct relationship between BD and thyroid cancer. However, further validation with larger datasets is needed in the future.

Our study has important implications for understanding the potential link between psychiatric disorders and thyroid cancer, as well as providing new ideas and strategies for the prevention and treatment of these common psychiatric disorders. For example, we can reduce the risk of thyroid cancer by screening and treating psychiatric disorders or improve the clinical management of psychiatric disorders by monitoring and regulating thyroid hormone levels. Specifically, we could conduct thyroid function testing and interventions in patients with psychiatric disorders, along with psychological assessment and treatment in patients with thyroid cancer. This integrated approach is expected to mitigate, to some extent, the adverse effects of psychiatric disorders and thyroid cancer on patients’ quality of life and socioeconomic status. In addition, our study provides clues and research directions for in-depth exploration of the potential relationships between MDD and thyroid cancer and between SCZ and thyroid cancer. More experimental and clinical studies are needed in the future to validate our findings and reveal the molecular cellular mechanisms underlying the causal relationship between psychiatric disorders and thyroid cancer.

In conclusion, our study is the first two-sample bidirectional MR study on the causal relationship between psychiatric disorders and thyroid cancer. Although our study provides useful insights for obtaining a deeper understanding of the relationship between psychiatric disorders and thyroid cancer, there are several limitations to consider. First, we used European population-based GWAS data to select IVs and obtain exposure data, which may limit the generalizability and applicability of our results. Second, our IVs were based on the use of a single nucleotide polymorphism-based design, which may not fully capture genetic variability in exposure or outcome. Finally, due to the limitations of the dataset, the number of thyroid cancer patients in the study was relatively small, which may have led to bias.

In summary, our study provides some suggestive evidence that MDD and SCZ are positively associated with thyroid cancer. This finding may have implications for health care policies regarding psychiatric disorders and thyroid cancer. Considering the high prevalence of psychiatric disorders and thyroid cancer in the general population, revealing the causal relationship between psychiatric disorders and thyroid cancer is important for public health policies for early prevention and timely prevention.

Data availability

Major depression：https://gwas.mrcieu.ac.uk/datasets/ieu-b-102/;Schizophrenia;https://gwas.mrcieu.ac.uk/datasets/ieu-b-5099/; Bipolar disorder:https://gwas.mrcieu.ac.uk/datasets/ieu-b-41/; Thyroid caencer:https://gwas.mrcieu.ac.uk/datasets/ieu-a-1082/;

Abbreviations

• Major depressive disease

schizophrenia

bipolar disorder

• Mendelian randomization

instrumental variables

inverse variance weighted

ultrasound-guided Fine Needle Aspiration

genome-wide association study

Psychiatric Genomics Consortium

single nucleotide polymorphisms

Deutsches the Krebsforschungszentrum

linkage disequilibrium

Weighted Median Estimator

hypothalamic–pituitary–thyroid

thyroid-stimulating hormone

interleukins

tumour necrosis factor

C-reactive protein

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Acknowledgements

This analysis benefited from the valuable data sets provided by various researchers and the summary statistics of multiple GWAS shared by the research community. We thank them for their contributions.

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School of Nursing, Fujian University of Traditional Chinese Medicine, Fuzhou, 350122, China

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Conception and design: QRL, FJB. Development of methodology: JHZ, LHH. Analysis and interpretation of data: SJL, HJX. Writing of the manuscript: QRL, LHH. Study supervision: FJB.

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Qiu, R., Lin, H., Jiang, H. et al. Association of major depression, schizophrenia and bipolar disorder with thyroid cancer: a bidirectional two-sample mendelian randomized study. BMC Psychiatry 24 , 261 (2024). https://doi.org/10.1186/s12888-024-05682-7

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DOI : https://doi.org/10.1186/s12888-024-05682-7

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