Kamat Siddhesh A, Rajagopalan Krithika, Pethick Ned, Willey Vincent, Bullano Michael, Hassan Mariam
HealthCore, Wilmington, Delaware 19801, USA.
J Manag Care Pharm. 2008 Sep;14(7):631-42.
Patients with bipolar disorder typically present to physicians in the depressed rather than the manic or hypomanic phase of illness. Because the depressive episodes in bipolar disorder may be indistinguishable from those in major depressive disorder (MDD), misdiagnosis may occur.
To estimate from administrative claims data and a telephone survey the prevalence of potential misdiagnosis of bipolar disorder among patients with MDD and the humanistic (health-related quality of life [HRQOL] and disability) effects associated with misdiagnosis in a managed care setting.
Administrative claims data were used to identify patients with medical claims for MDD from a database of 9 million members of commercial health plans from 3 U.S. regions. The inclusion criteria were as follows: (a) adults aged 18 years or older; (b) at least 2 medical claims, including a primary or secondary diagnosis of MDD: ICD-9-CM codes 296.2x (MDD, single episode), 296.3x (MDD, recurrent episode), or 311 (depressive disorder, not classified elsewhere) during an identification period from January 1, 2000, through March 31, 2004 (study intake period); (c) at least 12 months of pre-index and 12 months of post-index plan eligibility; and (d) active enrollment through March 31, 2005. The index date was defined as the date of the first claim for MDD during the identification period. Patients with ICD-9-CM codes for bipolar disorder at any time throughout the study period (January 1, 2000, through March 31, 2005) were excluded from this cohort. This cohort was targeted for a telephone survey that was conducted from August 1 through October 30, 2006. From the telephone survey sampling frame of 5,777, a total of 1,360 interviews were completed for a response rate of 23.5%. Respondents were screened for potential bipolar disorder using the Mood Disorder Questionnaire (MDQ). The Medical Outcomes 12-Item Short Form Survey (SF-12), Version 2, a widely used and validated instrument that assesses health-related functioning, and the Sheehan Disability Scale (SDS), which measures depression-related disability, were administered to a convenience subsample of 112 survey respondents to collect HRQOL and disability information, respectively.
Of 1,360 adult patients aged 18 years or older with a diagnosis of MDD but without a medical claim for diagnosis of bipolar disorder, 94 (6.9%) screened positive for bipolar disorder on the MDQ. More patients with a positive screen for bipolar disorder reported lifetime histories of obsessive compulsive disorder (24.5% vs. 8.2%, P<0.001), psychotic disorders or hallucinations (9.6% vs. 2.4%, P<0.001), suicidal ideation (61.7% vs. 29.4%, P<0.001), and drug abuse (34.0% vs. 11.1%, P<0.001) than did patients with a negative screen for bipolar disorder. In the subgroup of patients who completed the SF-12 and SDS, patients with a positive screen for bipolar disorder (n=33) had lower scores (i.e., greater impairment) on the social functioning, role emotional, and overall mental component summary scales of the SF-12 than did patients with a negative screen for bipolar disorder (n=79, P<0.001), but did not significantly differ on the physical component summary scale. Patients with a positive screen for bipolar disorder on the MDQ were more likely than patients who screened MDQ-negative to report severe depression-related impairment (scores of 7 and higher on the SDS scale) with work life (54.5% vs. 24.1%, respectively, P=0.002), social life (66.7% vs. 39.2%, P=0.008), and family life (66.7% vs. 34.2%, P=0.002) on the SDS.
In this study of patients carrying medical claims for a diagnosis of MDD in their administrative claims data, approximately 7% screened positive for bipolar disorder on a validated self-report assessment instrument. Patients with MDD who screened positive for bipolar disorder reported poorer HRQOL and disability scores than did patients with MDD who screened MDQ-negative. These findings may encourage interventions for appropriate screening, diagnosis, and management of potentially misdiagnosed bipolar disorder patients.
双相情感障碍患者通常在疾病的抑郁期而非躁狂或轻躁狂期就医。由于双相情感障碍的抑郁发作可能与重度抑郁症（MDD）的发作难以区分，因此可能会出现误诊。
根据管理式医疗环境中的行政索赔数据和电话调查，估计MDD患者中双相情感障碍潜在误诊的患病率，以及与误诊相关的人文因素（健康相关生活质量[HRQOL]和残疾）影响。
利用行政索赔数据从美国3个地区的900万商业健康保险计划成员数据库中识别出有MDD医疗索赔的患者。纳入标准如下：（a）18岁及以上成年人；（b）至少2次医疗索赔，包括MDD的一级或二级诊断：在2000年1月1日至2004年3月31日（研究纳入期）的识别期内的ICD-9-CM编码296.2x（MDD，单次发作）、296.3x（MDD，复发发作）或311（未在其他地方分类的抑郁症）；（c）索引前至少12个月和索引后至少12个月的计划资格；（d）至2005年3月31日的有效参保。索引日期定义为识别期内首次MDD索赔的日期。在整个研究期间（2000年1月1日至2005年3月31日）任何时间有双相情感障碍ICD-9-CM编码的患者被排除在该队列之外。该队列被选定进行电话调查，调查于2006年8月1日至10月30日进行。在5777名电话调查抽样对象中，共完成了1360次访谈，回复率为23.5%。使用心境障碍问卷（MDQ）对受访者进行双相情感障碍潜在筛查。对112名调查受访者的便利子样本分别使用医学结局简明健康调查量表（SF-12）第2版（一种广泛使用且经过验证的评估健康相关功能的工具）和希恩残疾量表（SDS）（用于测量与抑郁相关的残疾）来收集HRQOL和残疾信息。
在1360名18岁及以上诊断为MDD但无双相情感障碍诊断医疗索赔的成年患者中，94名（6.9%）在MDQ上双相情感障碍筛查呈阳性。与MDQ筛查阴性的患者相比，MDQ筛查双相情感障碍阳性的患者报告有强迫症终身病史（24.5%对8.2%，P<0.001）、精神障碍或幻觉（9.6%对2.4%，P<0.001）、自杀意念（61.7%对29.4%，P<0.001）和药物滥用（34.0%对11.1%，P<0.001）的比例更高。在完成SF-12和SDS的患者亚组中，MDQ筛查双相情感障碍阳性的患者（n = 33）在SF-12的社会功能、角色情感和总体精神成分汇总量表上的得分低于MDQ筛查阴性的患者（n = 79，P<0.001），但在身体成分汇总量表上无显著差异。MDQ筛查双相情感障碍阳性的患者比MDQ筛查阴性的患者更有可能报告在工作生活（分别为54.5%对24.1%，P = 0.002）、社交生活（66.7%对39.2%，P = 0.008）和家庭生活（66.7%对34.2%，P = 0.002）方面有严重的与抑郁相关的损害（SDS量表得分7分及以上）。
在这项对行政索赔数据中有MDD诊断医疗索赔的患者的研究中，约7%的患者在经过验证的自我报告评估工具上双相情感障碍筛查呈阳性。MDQ筛查双相情感障碍阳性的MDD患者报告的HRQOL和残疾得分比MDQ筛查阴性的MDD患者更差。这些发现可能会促使对潜在误诊的双相情感障碍患者进行适当的筛查、诊断和管理干预。
