Letters to the Editor
Re: “Cades Disease” and Beyond
Dear Editor:
Dr Ghaemi and colleagues are convinced that bipolar disorder (BD) is greatly underdiagnosed (1).
Recently, I have seen 2 cases in which patients were diagnosed and treated for BD after being treated for other diagnosed disorders. In each case, their conditions worsened.
Case Report 1
Mrs A is married, in early middle age, and has 2 teenaged children. She was admitted to hospital and diagnosed with unipolar depression, together with some long-standing personality and family problems. She responded poorly to treatment, was discharged with mild improvement, and readmitted soon after. On readmission, her treating psychiatrist undertook a detailed review of her history, rediagnosed her with BD, and treated her with divalproex. She was told the diagnosis. She seemed to improve rapidly, and was discharged home. In follow-up for the next few months, her self-report was very good and she was very pleased with the psychiatrist for taking the time to reassess her and find the “correct” diagnosis. Then, one of her daughters attempted suicide, giving as a reason the fact that her mother had no time for her because she was spending all her time on a BD Internet chat line. After this, the patient was no longer pleased with her psychiatrist and was lost to follow-up.
Case Report 2
When she presented for treatment, Mrs B, also middle-aged, was in a second, quite supportive marriage. She had a history of an abusive first marriage and severe dysfunction during her childhood. She had left that marriage, taken a college course that interested her, obtained a diploma, and obtained appropriate work. She quickly found her work too stressful, largely because it reminded her of things in her past that caused a recurrence of posttraumatic stress disorder (PTSD) symptoms. When she presented for treatment, she was diagnosed with unipolar depression, generalized anxiety disorder, and subsyndromal PTSD symptoms. She did not respond well to treatment and was unable to return to work after a period of many months. She and her husband then decided to seek assessment and treatment from a different psychiatrist, with the original psychiatrist’s agreement. She was diagnosed with BD, started on divalproex, and discharged. A few months later, she presented to her original psychiatrist. She said that on divalproex she had felt “totally flat” and refused to live that way. She had therefore discontinued it, and her former symptoms all promptly recurred. Her psychiatrist told her that he did not agree with the diagnosis of BD but had no new treatment to offer her, other than a trial of different antidepressant medication. She accepted that and also learned to accept that she was not able to work in her chosen field. She subsequently improved moderately.
I suggest that there may be as much danger in overdiagnosing as in underdiagnosing BD.
Reference
1. Ghaemi SN, Ko JY, Goodwin FK. “Cade’s disease” and beyond: misdiagnosis, antidepessant use, and a proposed definition for bipolar spectrum disorder. Can J Psychiatry 2002;47:125–34.
EJ Wiebe, MD, FRCPC
Edmonton, Alberta
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