A Diagnostics & Imaging Week

Osteoporosis is often viewed as a woman's health issue, but one in 16 men over 65 suffers from the disease, and few men are currently tested or diagnosed. Because of the aging population, a dramatic increase in osteoporosis among men is expected in the near future.

New recommendations from the American College of Physicians (ACP; Philadelphia) call for physicians to screen for osteoporosis in older men, especially those over the age of 65.

Osteoporosis is significantly under-diagnosed and under-treated in men, and studies show that osteoporotic fractures result in substantial disease, death, and health costs in men. Risk factors for osteoporosis in men are older age, low body weight, weight loss, physical inactivity, previous fractures not caused by substantial trauma, ongoing use of certain drugs (such as corticosteroids like prednisone, or drugs that are sometimes used to treat prostate cancer), and low-calcium diets.

The recommendations say that physicians should obtain a dual-energy X-ray absorptiometry (DEXA) scan for men at increased risk for osteoporosis and candidates for drug therapy.

The new guideline is based on a systematic evidence review of previously published studies and is published in the May 6 issue of Annals of Internal Medicine (www.annals.org), a journal of the ACP.

Over-, under-diagnosis of bipolar disorder

A new study by researchers at Rhode Island Hospital and Brown University (both Providence) concludes that fewer than half the patients previously diagnosed with bipolar disorder received that diagnosis based on a comprehensive, psychiatric diagnostic interview the Structured Clinical Interview for DSM-IV (SCID).
The study concludes that while recent reports indicate that there is a problem with under-diagnosis of bipolar disorder, an equal if not greater problem exists with over-diagnosis.

The study was published online by the Journal of Clinical Psychiatry.

Principle investigator Mark Zimmerman, MD, presented the findings at the annual meeting of the American Psychiatric Association (APA; Arlington, Virginia), concluding today in Washington.

The study enrolled 700 psychiatric outpatients, interviewed using the SCID and completed a self-administered questionnaire between May 2001 and March 2005. The questionnaire asked patients whether they had been previously diagnosed with bipolar or manic-depressive disorder by a healthcare professional. Family history of bipolar disorder was used as an index of diagnostic validity.
Of the 700 patients, 145 reported they had been previously diagnosed as having bipolar disorder; however, fewer than half of the 145 patients (43.4%) were diagnosed with bipolar disorder based on the SCID.

Further, the study showed that patients diagnosed with bipolar disorder based on the SCID had a significantly higher morbid risk of bipolar disorder in first-degree relatives.

Unnecessary side effects are a significant concern of over-diagnosis, according to the APA. Because mood stabilizers are the treatment of choice for bipolar disorder, overdiagnosing can unnecessarily expose patients to serious medication side effects, including possible impact to renal, endocrine, hepatic, immunologic and metabolic functions.

Zimmerman, director of outpatient psychiatry at Rhode Island Hospital and associate professor of psychiatry and human behavior at The Warren Alpert Medical School of Brown University, said, "Clinicians are inclined to diagnose disorders that they feel more comfortable treating. We hypothesize that the increased availability of medications that have been approved for the treatment of bipolar disorder might be influencing clinicians who are unsure whether or not a patient has bipolar disorder or borderline personality disorder to err on the side of diagnosing the disorder that is medication responsive.

"This bias is reinforced by the marketing message of pharmaceutical companies to physicians, which has emphasized the literature on the delayed and underrecognition of bipolar disorder, and may be sensitizing clinicians to avoid missing the diagnosis of bipolar disorder."

Zimmerman concluded: "The results of this study suggest that bipolar disorder is being over-diagnosed and we recommend that clinicians use a standardized, validated method in diagnosing bipolar disorder."

The report is from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) Project, which Zimmerman termed as "unique in its integration of research quality diagnostic methods into a community-based outpatient practice affiliated with an academic medical center."