This material was presented in the 25th European Congress of Psychiatry which was organised by the European Psychiatry Association in Florence, Italy from 1-4th April 2017. I had access to the material as I attended the full Congress. Please note that this material remains the intellectual property of the European Psychiatry Association and its authors and any citation should include a full reference to it. For more information on the EPA and how to become a member, please visit: http://www.europsy.net/

1. Introduction: Early stages of bipolar disorder are sometimes misdiagnosed as depressive disorders. This symptomatology
can lead to misinterpretation and underdiagnosis of bipolar disorders, mainly at the earliest stages. Estimates of the mean
delay between first onset of mood symptoms and receiving a correct bipolar diagnosis are in the region of 10 years.
Hypomania is often viewed as a normal experience by patients and therefore can be underreported. Also, clinicians do not
always ask depressed patients about hypomania. As a result, patients with bipolar disorder are frequently misdiagnosed with
major depressive disorder and may receive inadequate or inappropriate treatment. Based on the literature findings, the rates
of bipolar patients mistakenly diagnosed with major depressive disorder ranges from 10 to 40%, with some authors
suggesting even higher proportions of misdiagnosis. Undiagnosed and therefore inadequately treated hypomanic symptoms
may be a leading cause of drug resistance in depression diagnosed as unipolar.
Objectives: To describe a patient with a new diagnosis of bipolar disorder after 23 years of psychiatric care.
MISDIAGNOSE BIPOLAR DISORDER: ABOUT A CASE REPORT
Novais C1, Marinho M1, Mota Oliveira M1, Bragança M1,2, Côrte-Real A1, Fonseca S1
1 Psychiatry Department, Clínica de Psiquiatria e Saúde Mental do Centro Hospitalar de São João, Porto, Portugal
2Department of Clinical Neurosciences and Mental Health of Faculty of Medicine, University of Porto, Porto, Portugal
Corresponding author: catarinanovais-87@hotmail.com
Case description
Conclusions: Bipolar disorder is commonly misdiagnosed as unipolar major depressive disorder, especially on initial
presentation, and a misdiagnosis can delay the correct diagnosis. As most bipolar patients present for treatment when
depressed rather than when hypomanic, this issue has important clinical implications, as the treatments used for unipolar
depression may exacerbate the course of illness in bipolar disorder, elevating the risks of switch or cycling. A variety of
studies until now showed that subthreshold features of bipolar disorder were relatively common in individuals with unipolar
depression and were associated with a more morbid course of illness and greater psychosocial and quality of life
impairments. Our case elucidates the importance of ruling out bipolar disorder in patients presenting with depressive
symptoms alternating with non-specific maladjusted behavior, which sometimes can be a challenging task.
References: 1.Chaudhry FI, et al (2015). The developmental stages of Bipolar Disorder: a case report. Psychiatria Danubina; Vol. 27: 198–200; 2. Chang H, et al (2015). Distinguishing bipolar II depression
from unipolar major depressive disorder: Differences in heart rate variability. The World Journal of Biological Psychiatry; 3. Smith DJ, et al (2011). Unrecognised bipolar disorder in primary care patients with
depression. The British Journal of Psychiatry ; 199, 49–56; 4. Young AH, et al (2011). Detection of bipolar disorder. The British Journal of Psychiatry.199, 3–4; 5. Xiang Y-T, et al (2013). Sociodemographic and
clinical features of bipolar disorder patients misdiagnosed with major depressive disorder in China. Bipolar Disorders.15: 199–205; 6. Ghouse A, et al (2013). Overdiagnosis of Bipolar Disorder: A Critical
Analysis of the Literature. The Scientific World Journal; 7. Francesca M, et al (2014). Misdiagnosed Hypomanic Symptoms in Patients with Treatment-Resistant Major Depressive Disorder in Italy: Results from
the Improve Study. Clinical Practice & Epidemiology in Mental Health; 10: 42-47.
Identification
66-year-old caucasian
man, married, 4 sons,
living with his wife and 2
sons, retired for the last
7 years (street
sweeper).
Psychiatric background
Presented with a previous
psychiatric diagnosis of
recurrent depressive
disorder for the last 23
years.
Family background
Without regular contact with all of his
close relatives, which live in different
cities.
There were no known family
psychiatric background.
Disease progression
Beginning of psychiatric follow-up at 42 year-old of age after
a first hospitalization in a psychiatric inpatient unit because
of a major depressive episode.
In subsequent years he was regularly followed in psychiatric
consultation with description of recurrent long periods of
depressed mood requiring therapeutic setting, alternating
with brief remarks of not valued slightly maladjusted
behaviour, characterized mainly by an irritable mood,
coprolalic speech and hypersexuality, always resolved in a
short period of time by reducing the doses of
antidepressants.
At 65, he came to the emergency room presenting with
observable expansive and elevated mood, disinhibited
behaviour, grandiose ideas and overspending, leading to his
hospitalization with the diagnosis of a manic episode.
In the inpatient unit care, we performed blood tests, Cranial-
Computed Tomography (CT) and a cognitive assessment.
His medication has also been adjusted.
Results
Cranial-CT showed some subcortical atrophy of
frontotemporal predominance.
Laboratory investigations and neuropsychological evaluation
were unremarkable.
The patient was posteriorly transferred to a residential unit
for stabilization, where he evolved with major depressive
symptoms that needed new therapeutic adjustment. Later he
was discharged with the diagnosis of bipolar disorder,
medicated with valproic acid 1000mg/day, quetiapine
400mg/day, lorazepam 2,5mg/day and sertraline 100mg/day.