case study bipolar 2

Bipolar II disorder case study

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• 1 174 Baum Bay Drive NE, Milledgeville, GA 31061, United States. Electronic address: [email protected].
• PMID: 30454630
• DOI: 10.1016/j.apnu.2018.06.014

When a patient suffering from bipolar II disorder is misdiagnosed as experiencing unipolar depression, the recommended treatment of the latter may precipitate a hypomanic or manic episode. Unchecked hypomanic symptoms may include risky behaviors, through which a patient could sustain irreparable damage to relationships, careers, and finances. Sometimes, patients are familiar enough with bipolar illness that they may anticipate or interpret inquiry regarding hypomanic symptomology (Goodwin & Jamison, 1990). Applying their own stigmas to bipolar illness, such patients may only admit to depressive symptoms to avoid a bipolar diagnosis (Goodwin & Jamison, 1990). Also, hypomanic symptoms can be nuanced and difficult to detect in patients who may misinterpret the elevated mood state as a return to good mental health rather than the pathologic condition it is. These and other factors, such as poor memory, substance use, physical problems, and co-morbid mental illnesses, contribute to the misdiagnosis and delayed diagnosis of bipolar II disorder for many patients (APA, 2013; Goodwin & Jamison, 1990). The astute clinician, however, can bypass the cascade of events leading up to the poor outcomes associated with unrecognized and mistreated hypomanic symptoms by committing to due diligence when assessing mood symptoms, depressed and elevated.

Keywords: Bipolar II disorder; Hypomanic episode.

Copyright © 2018. Published by Elsevier Inc.

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• Case Reports
• Bipolar Disorder / drug therapy*
• Middle Aged
• Psychiatric Status Rating Scales
• Selective Serotonin Reuptake Inhibitors / therapeutic use*
• Severity of Illness Index*
• Trazodone / therapeutic use*
• Serotonin Uptake Inhibitors

• Open access
• Published: 28 January 2020

The existential crisis of bipolar II disorder

• Michael Gitlin   ORCID: orcid.org/0000-0001-7236-9649 1 &
• Gin S. Malhi   ORCID: orcid.org/0000-0002-4524-9091 2 , 3  

International Journal of Bipolar Disorders volume  8 , Article number:  5 ( 2020 ) Cite this article

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The issue of categorical vs. dimensional classification of bipolar disorder continues to generate controversy as it has for generations. Despite the evidence that no psychiatric disorder has discrete boundaries separating pathological and nonpathological states, and within a disorder, no clear differences separate subtypes-which would suggest a more dimensional approach-there are valid reasons to continue with our current categorical system, which distinguishes bipolar I from bipolar II disorder. Complicating the issue, a number of interested constituencies, including patients and their families, clinicians, scientists/researchers, and governmental agencies and insurance companies have different interests and needs in this controversy. This paper reviews both the advantages and disadvantages of continuing the bipolar I/bipolar II split vs. redefining bipolar disorder as one unified diagnosis. Even with one unified diagnosis, other aspects of psychopathology can be used to further describe and classify the disorder. These include both predominant polarity and categorizing symptoms by ACE-activity, cognition and energy. As a field, we must decide whether changing our current classification before we have a defining biology and genetic profile of bipolar disorder is worth the disruption in our current diagnostic system.

Until 25 years ago, bipolar II disorder was the Pinocchio of psychiatric disorders-long recognized and referred to- but not a “real disorder”. Finally, in 1994, bipolar II disorder was finally given formal recognition in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) (American Psychiatric Association 1994 ). This recognition has continued in all subsequent DSMs with notably little modification of its definition. Thus, as we settled into the new millennium it seemed as if bipolar II disorder had sufficiently matured and achieved full diagnostic status and was now on par with other major mood disorders such as major depression and bipolar I disorder. Indeed, a decade ago it was even deemed worthy of an entire book (Parker 2012 ). At the same time, its prevalence seemed to be increasing with estimates of an expanded definition (i.e., bipolar spectrum) up to 4.5% in one study and, with definitional modification, 10.9% in others (Merikangas et al. 2011 ; Angst et al. 2003 ). Surely, its status was assured.

And yet, in the last few years, a debate has arisen as to the validity and utility of bipolar II as a diagnostic category. Some authors have suggested its elimination (hence, the existential crisis) (Malhi et al. 2019a , b ) while others support its continued inclusion in our diagnostic systems (Ha et al. 2019 ; Nierenberg 2019 ; Ostacher 2017 ; Post 2018 , 2019 ; Schaffer 2018 ; Vieta 2019 ). In a field as imprecise as ours, it is not surprising that these debates occur. As always, there is at least some merit to both sides of the debate. This paper will summarize both sides of this discussion, highlighting the not always congruent needs of clinicians, patients, researchers and others and the role that this distinction plays in the debate.

As reviewed by Shorter ( 2012 ), the classification of mood disorders has a long history with a continued evolution over thousands of years. Although much of the effort prior to the last four decades was to conceptualize and elucidate the relationship between excited states and depressive states, there was frequent acknowledgment about the dimensional nature of mood pathology. More recently, formally defining a subset of manic-depressive illness in which the patient never has marked excited states and at worse they are relatively mild, was first declared by the Research Diagnostic Criteria (Spitzer et al. 1978 ) in which the term bipolar II first appears. Remarkably, it took 16 more years for DSM to agree that the distinction between bipolar I and bipolar II was worthy of official recognition and include it in its 4th revision.

Core conceptual issue

As many observers have noted, the core issue in evaluating the merits of bipolar II as a distinct disorder is the creation of a categorical system (such as the DSM or ICD) for what are clearly dimensional forms of psychopathology. This is a problem for all psychiatric diagnoses to some extent and there is no evidence that any psychiatric disorder has discrete boundaries that demarcate the disorder either from other psychiatric disorders or normal nonpathological variations of mood, cognition, personality features and so on. This concept is implicitly acknowledged in the multicluster (A, B and C) approach in DSMs in which there was more overlap between some personality disorders (within clusters) than others (across clusters). Dimensional thinking in psychopathology has also given rise to the more colloquial description of spectrum disorders-depressive spectrum disorders, obsessive–compulsive spectrum disorders and, of course, bipolar spectrum disorders. The awkward ‘fit’ of dimensional pathology and measurement into boundary-driven categories is also true for many, but not all, nonpsychiatric disorders. As examples, the boundaries of hypertension and “mild” diabetes create categories out of dimensional measurements, with the definition of pathology shifting over time similar to what is seen in the diagnostic systems for psychiatric disorders. More generally, still, the same can be said for obesity and anorexia nervosa—both of which are subject to cultural factors.

For bipolar II disorder, the purely dimensional approach would be to conceptualize bipolar disorder as one diagnostic entity with variation in the expression of the disorder across individuals (Malhi et al. 2016 ). In contrast, the categorical approach, currently expressed in our major diagnostic systems, is predicated on the assumption that although there are sufficient similarities to warrant grouping of the disorders there are also sufficient and important distinctions between bipolar disorders (bipolar I vs. bipolar II) to justify the different names/labels (see below for a more detailed discussion of the merits of each of these approaches). As the most egregious example in psychiatry, providing different diagnostic terms and different diagnostic codes to major depression and dysthymic disorder (as occurs in both the DSM and ICD systems) suggests to clinicians, especially those in training, that these are separate disorders even though the preponderance of the evidence suggests that they are one depressive disorder with differences in course. In this way, our diagnostic systems shape clinicians’ thinking, some times in ways that are clinically simply wrong.

The use of diagnostic categories and systems

A key question that governs the dimensional/categorical distinction in difficult contexts is: for whom are diagnostic categories composed? In other words, who needs or uses them? It would seem that four groups have a stake in this: (1) patients and their families; (2) clinicians; (3) scientists/clinical researchers; and (4) governmental agencies, insurance companies and the legal profession—all have differing needs, make different uses of the diagnoses and require different applications from a diagnostic system.

The first group that has an interest in this issue are patients and their families. As Porter ( 1997 ) reminded us, among the central roles that physicians have been tasked with for millennia is giving semantic shape—a label, a diagnosis—to patients’ suffering due to illness. For this purpose, describing a disorder in dimensional terms simply does not suffice for most patients and their families. A term, a categorical diagnosis: “You have a disorder called X” is what is specifically asked for and needed. Does it help patients and their families to distinguish between bipolar I and II disorders vs. combining them within the term “bipolar disorder”? The recent controversy over the decision for DSM-5 to eliminate Asperger’s syndrome as a separate disorder from autism and subsume it under autism spectrum disorders is another example of that controversy (see below for more discussion on this point).

The second group that is clearly invested in diagnosis is clinicians. They have a different set of needs from a diagnostic system as compared to patients and their families. For clinicians, a useful diagnostic system would conform (at least somewhat) with the clinical realities that they see (face validity), be simple enough to use without extraordinary training, provide them with a reliable and widely accepted language for communication and perhaps most importantly have clear prognostic and/or treatment implications. Given these multiple and specific needs, it is difficult (although not impossible) for clinicians to adapt to changes in the diagnostic system. Familiarity and expertise with a recognized system of classification means that there is inevitably significant inertia to change.

The third group, scientists/researchers, rely on diagnostic systems for different purposes than the other three groups. Scientists/researchers have the goals of: (1) elucidating how psychopathology expresses itself in different categories, i.e. to have an accurate representation of how nature is “carved at the joints”. This would require a set of biological and genetic studies to distinguish between related disorders based on scientific data, not somewhat arbitrary decisions by committees. (2) Accurate diagnostic classification based on biology would then lead to more targeted treatment algorithms that employ science/pathology based diagnoses. Analogies in medicine abound but maybe the best example is the distinction of different types of cancer even within the same general name, e.g., breast cancer, based on underlying biology-estrogen positive tumors are treated differently than are estrogen-negative cancers.

A fourth group-government agencies and insurance companies-comprise an interested group in only some countries, most glaringly, the United States. Here, the purpose of diagnoses may be to define psychopathological entities that justify treatment that will then be paid for by governmental or commercial insurances. In the United States, new medications are approved by the Food and Drug Adminstration (FDA) for the treatment of one or more specific disorders. If a medication is approved for treatment of bipolar I disorder but not bipolar II disorder, insurance payors may refuse to pay for treatment for the second (in this case, bipolar II) disorder. Clearly, having one more broadly defined category of bipolar disorder would obviate this problem.

Lumping vs. splitting: advantages and disadvantages

Each approach-combining bipolar I and II into one disorder vs. keeping them separate solves different problems. Table  1 presents the advantages of each of these two approaches.

The advantages of a unified diagnosis

Conforms to clinical dimensional reality: The most important and core advantage of a unified single diagnosis is that it is more accurate. It is true—i.e. it reflects the dimensional reality of bipolar disorder. In practical terms it also obviates the need for the non-specific and loosely applied 4-day and 7-day time criteria that are used to define hypomania/mania respectively, and furthermore subsumes the ‘fix’ that DSM-5 has concocted and slipped into its conditions for further study section—namely, ‘short-duration hypomania’—inadvertently acknowledging perhaps the inexactness of its extant definitions. The current formulation of short-duration hypomania in DSM-5 alongside hypomania and mania is confusing because it clearly points to the real-world cut-off between normalcy and manic symptoms as being closer to 2 days as opposed to 4.

Empirically, it is clear that the intensity and severity of excited states exists on a continuum. One can colloquially describe patients as having “bipolar 1.5” if their excited states are either on the more severe end of hypomania or the milder end of mania, but would it not be both more accurate and simpler to describe this state using the language of severity as one would for any other disorder in medicine-e.g., a milder or a more severe flareup of an autoimmune disorder, for example, or to simply capture the duration by describing how long the symptoms have lasted?

Combining bipolar I and II disorders (and implicitly, hypomania and mania) also reflects the lack of any biological characteristics that consistently distinguish between these two disorders as currently defined (Vieta and Suppes 2008 ). Genetically, although some studies have shown that the two subtypes of bipolar breed true; i.e., in the families of bipolar I patients, one sees more bipolar I relatives and only some bipolar II patients, whereas in the families of bipolar II patients, there are a greater number of bipolar II patients with a relative paucity of bipolar Is (Rice et al. 1987 and others), we can simply conceptualize this as reflecting the genetic contribution towards illness severity, similar to the genetic contribution towards cycling frequency (Fisfalen et al. 2005 ).

Conceptually, one unified bipolar disorder would also encourage and allow an overarching set of treatment principles. Of course, the nuances of treating bipolar patients with milder manic states may differ from that in treating more severe bipolar patients. Secondary analyses of studies could then examine potential predictors of treatment response based on severity (e.g., such as the potential risk of a treatment emergent affective switch-TEAS) in order to guide clinicians. Here too, this would be analogous to different treatment approaches of more vs. less severe autoimmune flareups.

Having one unified bipolar diagnosis with the inherent understanding of a disorder with dimensional elements would also encourage a more coherent discussion of bipolar spectrum disorders. Currently, with the bipolar I/bipolar II categorical distinction, a mood syndrome characterized by depressive states as well as excited/energized states that do not meet criteria for hypomania are vaguely described as bipolar spectrum disorders. Although a unified bipolar diagnosis would still require some (admittedly arbitrary) boundaries, simply acknowledging the dimensional expressions of bipolar disorder would encourage thinking about spectrum presentations more easily. For example, it would also allow cyclothymia to be included within the bipolar diagnosis, thereby eliminating another rather arbitrary distinction within the current bipolar diagnoses and perhaps limit the likelihood of non-sensical variants such as short-duration cyclothymia (Malhi and Bell 2019 ). Continuity would also mean that manic number of days could be captured, and other patterns such as mixed states could be included alongside the two extremes of mania and depression.

One of the key problems in practice is that although the idea of dimensionality is increasingly being accepted, it is still limited mainly to mood, which has maintained primacy when considering mood disorders—perhaps understandably given their name. But in reality, depressive and bipolar disorders, or in traditional terms manic-depressive illnesses, are often an admixture of symptoms that don’t neatly fall into DSM categories of major depression or mania. The current DSM fix for this—namely, mixed features has been justifiably criticized and instead an alternative conception that draws on Weygandt’s and Kraepelin’s concepts regarding mixed states has been proposed. In this model three domains of symptoms have been posited—activity, cognition and emotion (Malhi et al. 2018 ) with mood subsumed by the latter. Apart from accommodating mixed states as has been described in detail elsewhere (Malhi et al. 2019c ), this allows for an appreciation of why bipolar I and II may sometimes appear to be so different (see Fig.  1 ). Here it is postulated that the pathophysiology that drives mania ( Manic Drive ) differentially affects symptoms within different domains because of their intrinsic properties. Individual symptoms can be regarded as having their own inherent ‘elasticity’ that stems from the nature of the disturbance that causes them, and so when these processes are impacted upon this is reflected in the displacement of the system and creation of various symptoms. The differing properties underpinning each symptom/group of symptoms then leads to the extent to which a symptom is expressed—in other words its severity. In this way a distinction can be seen between Bipolar I in which every system is ‘maxed out’ and stretched to the limit, and bipolar II, in which because some symptoms are more susceptible than others a different pattern of expression is formed and this creates a seemingly different picture—when in fact the constituents are the same (see Fig.  1 ).

ACE Model of mania. This schematic shows how manic drive, perhaps through differential action on different symptomatic domains can create a seemingly separate phenotype when in fact the difference in manifestation is largely because of the inherent properties of different neurocognitive schema and neural systems within the brain. In florid mania, manic drive (shown in yellow) is so extreme that irrespective of the inherent rigidity of various domains, they are all extended (akin to elastic bands) to the same extent. And so, activity, cognition and emotion are all impacted equally and symptoms from each of these domains are evident. However, when manic drive is more modest, those domains that are inherently more pliant are impacted first and hence why there is separation between emotion, cognition and activity. Emotion, by its very nature is more malleable and variable, whereas cognition succumbs more slowly, and activity is the most hard-wired and therefore requires significant manic drive before it is impacted. The figure also shows that lesser degrees of variation and more subtle changes lead to a more mixed presentation in which features of both mania and depression exist alongside each other, by virtue of belonging to independent domains (ACE). This schematic then explains how ‘bipolar II’ and other putative subtypes could perhaps be created and yet have the same underlying mechanisms and therefore, in essence, remain the same illness

The advantages of continuing the bipolar I vs. II split

In contrast, there are a different set of reasons for continuing the separation of bipolar I vs. bipolar II disorders some of which provide a different set of advantages.

First, why should we merge the two subtypes until we have the biological and genetic data justifying the unity of the two disorders? One day, biological and genetic studies may provide a more scientific basis for distinguishing subtypes of bipolar disorder (or not). That day has not yet arrived. As noted above, the two subtypes breed true in family studies. Should that not be enough to continue the split for now?

As noted above, altering diagnostic systems (especially without the biological data not currently available to justify these changes) would burden patients and families. Bipolar II disorder is often seen as a more palatable diagnosis compared to bipolar I disorder. Would bipolar II patients reject the notion of having a bipolar diagnosis because they do not identify with others who have full blown manias?

Additionally, important clinical characteristics distinguish bipolar I and II disorders. First, depression dominates bipolar II disorder far more than it does bipolar I disorder in both the percentage of time spent in depression and the ratio of depressive to manic/hypomanic times (Judd et al. 2002 , 2003 ). Second, switch rates associated with antidepressants are twice as high with bipolar I vs II disorders (Bond et al. 2008 ). Consistent with this, when bipolar I patients switch into excited states, they develop full mania 45% of the time and hypomania 55% of the time whereas bipolar II patients who have a TEAS develop a hypomania 95% of the time (Bond et al. 2008 ). These data suggest that there is a different clinical profile for bipolar II disorder and that it has a different susceptibility to the induction of mania and that as a consequence, optimal treatment algorithms may differ between bipolar I and bipolar II patients. Thus, from a practical perspective keeping the distinction would perhaps help clinicians assess risk/benefit ratios more accurately.

Furthermore, given the inherently and definitionally greater functional impairment in mania vs. hypomania, distinguishing bipolar I from bipolar II disorders would concretize for clinicians the need to think more carefully about excited states in those labelled bipolar I disorder. This would include both the above mentioned risks with antidepressants [overblown as they might be (Gitlin 2018 )], but also the need to more aggressively treat emerging excited/energized states in those with bipolar I disorder, since they are capable of accelerating into a far more destructive state than those with bipolar II disorder.

Alternative options for classifying bipolar disorder

The proper classification of mood disorders in general, and in particular, bipolar disorder has been a longstanding conundrum. As is currently the case, in the absence of the basic scientific data that would allow a more biologically based classification system, interested observers can only suggest improvements on our current, somewhat arbitrary system. With that caveat, there may be other methods of classifying bipolar disorder.

An example of an alternate method of classifying bipolar disorder utilizes predominant polarity as the central factor, initially described by Angst ( 1978 ) and revisited and updated more recently by others (Popovic et al. 2012 ; Carvalho et al. 2014 ). Predominant polarity (PP) reflects the relative number and severity of manic vs. depressive episodes within individual patients, defined by at least twice as many episodes of one pole vs. the other (Colom et al. 2006 ). Patients may be mania predominant, depression predominant or neither, when neither pole dominates the clinical course. Rates of PP differ markedly across different populations but, in general, depressive PP patients outnumber manic PP patients (Pal 2019 ).

As reviewed elsewhere (Malhi et al. 2019a ), other criteria that may also be used to characterize bipolar disorder include duration of episodes and severity of functional impairment. Whether these characteristics can be used to create meaningful diagnostic categories is not clear and perhaps that can be used in the manner that specifiers are currently used in DSM-5. The ACE model mentioned previously allows for a transdiagnostic classification of mood disorders—combining depressive and bipolar disorders, including mixed states and allowing for links to anxiety and even psychosis.

Conceptual and societal consequences of diagnostic categories

Until we have a biological/genetic basis for our mood classification system, our diagnoses will remain tentative at best, based on somewhat arbitrary criteria of severity and/or duration and hence not always clinically useful in terms of prognosticating outcomes or determining optimal therapies. Nonetheless, for now, the question is whether the distinction between bipolar I and bipolar II disorder is clinically useful and should be continued or changed. To address this it is perhaps useful to consider an existing example—the merging of autism and Asperger’s syndrome in DSM-5 into autism spectrum disorder (ASD). This is a critical example of where two disorders have been merged into one broader dimensional category. In that circumstance, the framers of DSM-5 felt that the conceptual unity of autism as a disorder that could be expressed on a continuum outweighed the somewhat arbitrary distinction between Asperger’s as a mild autism spectrum disorder from more classic autism. It is important to note that at times, diagnostic categories become important issues of identity to both patients and their families. This was certainly the case with ASD where there were objections among patients and families about using the term associated with the more severe disorder and patients protesting that “I don’t have autism; I have Asperger’s.” Similarly, perhaps for many patients there is a risk that they would reject the notion of having ‘bipolar disorder’ because their excited so called ‘manic’ states are not as severe as mania and as such they can identify with bipolar II (the milder, and putatively somewhat different form of the illness) but cannot identify with the label ‘bipolar disorder” as it connotes a more severe, more destructive, mania characterized often by psychotic symptoms.

Nonetheless, classification systems do indeed shape as well as reflect clinicians’ and patients’ thinking. Over time, measured in years, not decades, we would all get accustomed to the new diagnostic categories. Reviewing history once again, the emergence of the DSM-III with its new terminology and diagnostic categories is a good example. At first, there were legitimate objections to the somewhat arbitrary nature of the new categories. (e.g., “why would we eliminate anxiety neurosis?” or “What is the relationship of dysthymic disorder to the types of patients we have been seeing in psychoanalytic psychotherapy?”). But gradually the field has accepted these new terms and diagnostic categories have continued to refine the classificatory criteria in subsequent DSMs. Furthermore, the new generation of mental health professionals who grew up with DSM-III and beyond, predictably accepted this system and over time it has become integral to our lexicon and thinking. Thus, perhaps if we merged bipolar I and II into one category with other specifiers (such as predominant polarity), and utilized a model that didn’t assign so much emphasis to mood such as ACE, then after an initial period of adjustment in which there would no doubt be some voicing concerns, objections and even predictions of catastrophic consequences—these would, over time, diminish and give way to gradual acceptance.

It is our opinion that, from a conceptual viewpoint, eliminating bipolar II disorder would be the most intellectually honest. The question is whether it is worth the work of this change now or whether it would be wiser to wait for the anticipated genetic studies over the coming years and decades until we have a more biologically informed classification system.

Availability of data and materials

Not applicable.

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Department of Psychiatry, Geffen School of Medicine at UCLA, Los Angeles, USA

Michael Gitlin

CADE Clinic, Department of Psychiatry, Royal North Shore Hospital, St Leonards, USA

Gin S. Malhi

Discipline of Psychiatry, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia

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Gitlin, M., Malhi, G.S. The existential crisis of bipolar II disorder. Int J Bipolar Disord 8 , 5 (2020). https://doi.org/10.1186/s40345-019-0175-7

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EP: 1 . Patient Case: 30-Year-Old Male With Bipolar Disorder

Ep: 2 . approaching the treatment of bipolar disorder, ep: 3 . treatment selection for bipolar disorder, ep: 4 . takeaways for bipolar disorder management.

Nidal Moukaddam, MD, PhD: Today, we’re going to talk about a new case. A 30-year-old man has taken short-term disability leave from work due to the progression of a depressive episode. He received a diagnosis of bipolar I disorder about 10 years ago. He had his first episode of mania at the age of 20 and 2 subsequent episodes of mania between the ages of 21 and 29. He was treated with lithium, which was highly effective, but he experienced excessive thirst and developed hyperthyroidism. His lithium level at the time was in the therapeutic range of 0.8 mEq/L. He was switched to valproate; however, valproate lacked the efficacy of lithium and caused adverse effects of sedation and weight gain. During his third manic episode, he started on olanzapine but experienced excessive weight gain. He was then cross-titrated to quetiapine, which improved his manic symptoms. However, weight gain again became an adverse effect, and he also complained of sedation. The patient reported sleeplessness and made unnecessary online purchases when unable to sleep, but the quetiapine sleepiness was unacceptable. Despite these adverse effects, he continued taking] quetiapine until he decompensated into his third depressive episode. The quetiapine was then augmented with lamotrigine, which was titrated up to 300 mg per day but demonstrated no efficacy. At the time of presentation, the patient was adhering to the medications. He did not have a substance use disorder, which was confirmed by a negative toxicology screen. His TSH [thyroid-stimulating hormone] level was in the middle of the normal range, and he had no suicidal ideations or psychotic symptoms.

I think the most important thing to do when somebody comes to you, even if they tell you they have a diagnosis, is to confirm the diagnosis. You want to start by making up your own mind, and sometimes the patient is not a good source of information. But in the case of bipolar disorder without psychosis, you expect the patient to be able to give you a solid history. Typically, the part of the history that’s hardest to nail down is mania. When people experience mania, they have excessive energy and excessive activation that creates the need for sleep, and sometimes they like it. They feel that this is the way it should be, so they don’t point it out as pathological. Now, the DSM-5 [ Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition ] criteria tell us that mania that leads to hospitalization or some negative consequence like incarceration is problematic no matter what the duration is. Assuming the patient did not end up in the hospital or in prison, we want to verify the story of mania. In the current case presentation, I can see many of my colleagues saying, “Hey, you’re not giving us enough symptoms of mania. He’s a bit sleepless. He makes frivolous purchases. That’s bipolar disorder but not bipolar I; maybe it’s bipolar II.”

Thus, my first step would be to explain that this patient had at least a week without sleep. During that week, he was spacing, had pressured speech, and was talking fast to the point that others around him commented about it. He became more impulsive, and buying things was the tip of the iceberg. He also became more sexual to the point where it got him in trouble in his relationships, he spent more money than he had planned, etc. These examples of impulsivity often nail down the diagnosis of bipolar disorder. Of course, these symptoms change with the time that we live in. For example, before unlimited plans on cell phones, you would have been taught to ask: “Do you get a very high bill on your phone when you’re manic?” Because patients with mania talk a lot, and the bills would be higher when they call across state lines or internationally. First, I would recommend verifying the diagnosis. My impression of the patient is that this is somebody with a set diagnosis of bipolar I. Three manic episodes is a lot. He has impairment because of it, and it’s affected his job. Thus, my first step is confirming the diagnosis. My second would be a lot of psychoeducation; make sure that the patient understands what he’s up against and why he needs treatment.

Transcript Edited for Clarity

Assessing, Treating, and Managing Spring Mania in Patients With Bipolar Disorder

Blue Light Blockers: A Behavior Therapy for Mania

ADHD Research Roundup: March 1, 2024

Blue Light, Depression, and Bipolar Disorder

The Week in Review: February 19-23

Bipolar Disorder and Risk of Cardiometabolic Disease, Heart Failure, and Mortality

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Case Studies of Fictional Characters

Bipolar ii disorder.

Name: Casey Roberts

Source: Mad Love (Movie, 1995)

Background Information

Casey Roberts is a female high school student in her late teens. Upon arriving at a new high school, she appears to be fairly normal in behavior. However, it is apparent from early on that she has almost no social relationships, or even more, a desire to have any. Aside from a relationship with her parents, who appear supportive and loving, she only has one other relationship which consumes her throughout the movie: her relationship with her boyfriend Matt. This relationship is what drives many of her actions throughout the movie. Her parents say there is no past mental health history in their families. However, they are in denial of her having an actual mental illness and attribute it to her trying to get back at them for controlling her, so the real history may not be reported. No major drug or alcohol use is apparent although casual drinking is seen throughout the movie and nicotine use, especially while in her depressed episode, is also shown. There are no outward health problems visible in Casey. She is a very intelligent girl with a very strong willed personality. However, she does not seem to care too much about asserting that intelligence towards any goals. School is in no way important to her.

Description of the Problem

Although Casey is at some points able of living and functioning normally, she has a past of suicidal behavior. As stated in the Background Information, she has little to no social relationships. However, she does appear to be a fairly friendly person. Probably the largest hindrance on her functioning is her impulsivity. She seems to think that she should do and be able to do whatever she wants when she pleases. Towards the end she also has a tendency towards thoughts that are very sporadic in nature. Casey displays much risk taking behavior without seeing any important consequences that could occur from them. She is also temperamental and very easy to irritate. Delinquent behavior is also presented in her behaviors in the form of truancy and the case of her pulling a fire alarm in the school. She also has very strong thoughts of guilt and states that as punishment for the things she has done to Matt, he should leave her. When the onset of her illness begins to be very apparent, she shows much distractibility and tends to not behave correctly in social situations. Insomnia also is presented along with strange ideas. These ideas could possibly also be symptoms of Schizophrenia such as thinking people are always watching her and out to get her. She believes that she must put cut outs of eyes up around their apartment to protect them.

The diagnosis for Casey is Bipolar II Disorder (296.89). To reach that diagnosis the following must be true:

• Within the movie there is a Major Depressive Episode. Her parents also referred back to the fact that Casey had experienced episodes before as well.
• A Hypomanic Episode was also included in the movie. Evidence on whether or not she had been through more than one episode of this before was not provided.
• Casey’s symptoms were not severe enough to classify as a Manic or Mixed Episode.
• Although Casey had some odd behaviors that seemed almost similar to ones that would be presented in Schizophrenia or a very similar disorder, they would not be classified as actual delusions. The inconsistencies in her behaviors seem to classify more into Bipolar Disorder.
• Casey’s ability to form relationships was greatly affected by her symptoms. Also, distress was definitely seen within social situations. Casey was found in a bathroom with her dress off and hitting the walls and crying.

A diagnosis of a Major Depressive Episode was found by the following:

• Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). NOTE: In children and adolescents, can be irritable mood.
• Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)
• Significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. NOTE: In children, consider failure to make expected weight gains.
• Insomnia or hypersomnia nearly every day
• Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)
• Fatigue or loss of energy nearly every day
• Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)
• Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)
• Casey presented symptoms a, d, g, and i.
• Her symptoms were not presented as both Manic and Depressive on a nearly daily basis.
• Distress and impairment were definitely apparent in social situations. The example of the bathroom scene previously mentioned demonstrated this.
• No drugs were being used besides nicotine and no other stated medical condition was present.
• No loved ones were lost; the symptoms had been reported for over 2 months and she had attempted suicide numerous times.

A diagnosis of a Hypomanic Episode was found according to the following:

• Casey’s mood was elevated while they were traveling and she was in her Hypomanic Episode. The severity of it would not classify as a Manic Episode however.
• inflated self-esteem or grandiosity
• decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
• more talkative than usual or pressure to keep talking
• flight of ideas or subjective experience that thoughts are racing
• distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
• increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation
• Casey presents symptoms b, c, e, and g within her Hypomanic Episode.
• She seemed to function almost normally when the episode was not happening. When she started presenting symptoms, her level of functioning obviously decreased.
• Like previously stated, her changes were observable.
• Her Hypomanic Episode did not strike Matt as “scary” or needing help immediately like her Depressive Episode. No hospitalization was seen as necessary.

Accuracy of Portrayal

Watching the portrayal of Casey would give a person a fairly good look into Bipolar Disorder. Most people label someone as “bipolar” when really they are just having mood swings or maybe suffering from Cyclothymic Disorder. This idea of such rapid switching is not accurate. Although Casey did have her moments of sudden anger or happiness, that can be accounted for by simply an experience she had or something that was said. Simple reactions like this are very common. However, her episodes as portrayed were seen as changing over periods of time, not just in an instant, giving the watchers a pretty good insight on the disorder. In the film, Casey’s mother stated that Casey suffered from depression. This may have influenced watchers to disregard her Hypomanic symptoms. Overall, the audience would get a fairly good look into the actual life of a person with Bipolar Disorder.

When Casey arrived for treatment, a medical work up would occur to make sure the disorder was accurately diagnosed. This would also allow knowledge of the current episode, suicidal thoughts, and hopefully more family history. Casey would probably then be prescribed lithium carbonate. Because of the potency of this drug, her dosage would need to be very closely monitored. Therapy would also be a very useful tool for Casey’s treatment. Cognitive behavioral therapy would be a good start to help her deal with her emotions and stress. Therapy would also help Casey to fully understand Bipolar Disorder and to know in the future when an episode may happen. Likewise, education would be essential for her parents. Helping them understand what exactly is happening with Casey and to recognize her episodes would be very beneficial.

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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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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

Retraction Note: Environmental factors affecting the frequency of road traffic accidents: a case study of sub-urban area of Pakistan

• Retraction Note
• Published: 26 March 2024

Cite this article

• Hafiz Mohkum Hammad 1 ,
• Muhammad Ashraf 1 ,
• Farhat Abbas 2 ,
• Hafiz Faiq Bakhat 1 ,
• Saeed A. Qaisrani 1 ,
• Muhammad Mubeen 1 ,
• Shah Fahad 3 &
• Muhammad Awais 4  

The Original Article was published on 19 March 2019

Avoid common mistakes on your manuscript.

Retraction Note: Environmental Science and Pollution Research (2019) 26:11674-11685

https://doi.org/10.1007/s11356-019-04752-8

The Publisher has retracted this article in agreement with the Editor-in-Chief. An investigation by the publisher found a number of articles, including this one, with a number of concerns, including but not limited to compromised peer review process, inappropriate or irrelevant references, containing nonstandard phrases or not being in scope of the journal. Based on the investigation’s findings the publisher, in consultation with the Editor-in-Chief therefore no longer has confidence in the results and conclusions of this article.

Hafiz Mohkum Hammad, Hafiz Bakhat, and Muhammad Mubeen disagree with the retraction. Muhammad Ashraf, Farhat Abbas, Saeed A. Qaisrani, Shah Fahad, and Muhammad Awais have not replied to correspondence from the publisher.

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Hammad, H.M., Ashraf, M., Abbas, F. et al. Retraction Note: Environmental factors affecting the frequency of road traffic accidents: a case study of sub-urban area of Pakistan. Environ Sci Pollut Res (2024). https://doi.org/10.1007/s11356-024-33079-2

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Household Transmission Dynamics of Asymptomatic SARS-CoV-2–Infected Children: A Multinational, Controlled Case-Ascertained Prospective Study

• Published Mar 27, 2024

Clinical Infectious Diseases

Asymptomatic SARS-CoV-2 infection in children is highly prevalent but its acute and chronic implications have been minimally described.

In this controlled case-ascertained household transmission study, we recruited asymptomatic children <18 years with SARS-CoV-2 nucleic acid testing performed at 12 tertiary care pediatric institutions in Canada and the United States. We attempted to recruit all test-positive children and 1 to 3 test-negative, site-matched controls. After 14 days’ follow-up we assessed the clinical (ie, symptomatic) and combined (ie, test-positive, or symptomatic) secondary attack rates (SARs) among household contacts. Additionally, post–COVID-19 condition (PCC) was assessed in SARS-CoV-2–positive participating children after 90 days’ follow-up.

A total of 111 test-positive and 256 SARS-CoV-2 test-negative asymptomatic children were enrolled between January 2021 and April 2022. After 14 days, excluding households with co-primary cases, the clinical SAR among household contacts of SARS-CoV-2–positive and –negative index children was 10.6% (19/179; 95% CI: 6.5%–16.1%) and 2.0% (13/663; 95% CI: 1.0%–3.3%), respectively (relative risk = 5.4; 95% CI: 2.7–10.7). In households with a SARS-CoV-2–positive index child, age <5 years, being pre-symptomatic (ie, developed symptoms after test), and testing positive during Omicron and Delta circulation periods (vs earlier) were associated with increased clinical and combined SARs among household contacts. Among 77 asymptomatic SARS-CoV-2–infected children with 90-day follow-up, 6 (7.8%; 95% CI: 2.9%–16.2%) reported PCC.

Conclusions

Asymptomatic SARS-CoV-2–infected children, especially those <5 years, are important contributors to household transmission, with 1 in 10 exposed household contacts developing symptomatic illness within 14 days. Asymptomatic SARS-CoV-2–infected children may develop PCC.

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