Depression Screening in Primary Care: How to Keep Bipolar Disorder on the Differential

Primary care clinicians diagnose and manage the majority of patients with depression, yet bipolar disorder remains frequently underrecognized in frontline settings.¹ Epidemiologic data suggest that up to 20% to 30% of patients presenting with depressive symptoms in primary care may ultimately meet criteria for bipolar spectrum disorders, and misdiagnosis can delay appropriate treatment by several years.^2,3 Inappropriate exposure to antidepressant monotherapy in patients with unrecognized bipolar depression has been associated with mood destabilization, treatment resistance, and increased health care utilization.⁴ In an interview with Patient Care Online, Gus Alva, MD, a psychiatrist and medical director of ATP Clinical Research in Orange, CA, discusses why efficient, structured screening approaches are increasingly important in busy primary care workflows. He highlights the limitations of relying solely on symptom severity scales and underscores the value of brief tools designed to flag bipolar risk earlier in the diagnostic process. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR) emphasizes the need to rule out bipolar disorder before diagnosing major depressive disorder, particularly at initial presentation.⁵ Shorter screeners with improved sensitivity and specificity, such as the Rapid Mood Screener, may help clinicians differentiate unipolar from bipolar depression more reliably, particularly at the point of antidepressant initiation.⁶ For primary care physicians, improving diagnostic accuracy at the first encounter can support safer prescribing, reduce avoidable adverse outcomes, and inform more timely referral when indicated. As depression screening continues to expand across primary care settings, incorporating tools that address diagnostic nuance—not just symptom burden—may play a critical role in improving long-term outcomes for patients with mood disorders, Alva stated.

References:

1. Smith DJ, Griffiths E, Kelly M, et al. Unrecognised bipolar disorder in primary care patients with depression. Br J Psychiatry. 2011;199:49-56. doi:10.1192/bjp.bp.110.083840
2. Angst J, Azorin JM, Bowden CL, et al. Prevalence and characteristics of undiagnosed bipolar disorders in patients with a major depressive episode. Arch Gen Psychiatry. 2011;68:791-798. doi:10.1001/archgenpsychiatry.2011.87
3. Hirschfeld RM, Lewis L, Vornik LA. Perceptions and impact of bipolar disorder: how far have we really come? Results of the national depressive and manic-depressive association 2000 survey of individuals with bipolar disorder. J Clin Psychiatry. 2003;64:161-74.
4. Ghaemi SN, Boiman EE, Goodwin FK. Diagnosing bipolar disorder and the effect of antidepressants: a naturalistic study. J Clin Psychiatry. 2000;61:804-808. doi:10.4088/jcp.v61n1013
5. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed, text rev (DSM-5-TR). Washington, DC: American Psychiatric Association; 2022.
6. McIntyre RS, Patel M, Masand PS, et al. The Rapid Mood Screener (RMS): a novel and pragmatic screener for bipolar I disorder. Curr Med Res Opin. 2021;37:135-144. doi:10.1080/03007995.2020.1860358