Clinical Briefs

By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is a consultant for GlaxoSmithKline and is on the speaker's bureau of GlaxoSmithKline, 3M, Wyeth-Ayerst, Pfizer, Novartis, Bristol-Myers Squibb, AstraZeneca, Jones Pharma, and Boehringer Ingelheim.

Is Bipolar Disorder Overdiagnosed?

It has been suggested that bipolar disorder (BPD) is underdiagnosed, and is hence sometimes regrettably discovered subsequent to unmasking with treatment instituted for presumed unipolar depression. The MIDAS project of Rhode Island (Methods to Improve Diagnostic Assessment and Services) has to-date examined psychiatric diagnostic accuracy and recognition in 2500 patients attending an outpatient psychiatric practice affiliated with an academic medical center.

MIDAS has corroborated that utilization of semistructured interviewing using DSM-IV diagnostic criteria coupled with self-administered questionnaires identifies more cases of BPD than simple clinician interview. Zimmerman et al in this communication investigated whether persons who carried a clinical diagnosis of BPD might have been overdiagnosed; ie, how many persons with a clinical diagnosis of BPD might fail to have their diagnosis confirmed using a semistructured interview and questionnaire.

Structured interviews of 145 persons carrying a clinical BPD diagnosis corroborated the diagnosis in only 45%. Although it is certainly possible that DSM-IV criteria for diagnosis of BPD are too narrow, this degree of discrepancy suggests that overdiagnosis of BPD is common—indeed, it may be more commonplace than BPD underdiagnosis.

Zimmerman M, et al. Clin Psychiatry. 2008;69(6):935-940.

One out of Three Prescriptions Are Never Filled

Clinicians would like to think that once a treatment is suggested and prescription written, the prescription will be filled. For a variety of reasons, that is too often not the case. It is not always easy to reliably track prescription filling, but data from the metropolitan area of Copenhagen, Denmark simplify that through the Danish National Electronic Pharmacy Register. Public Health Insurance in Denmark covers 50% of expenses $90-$215, 75% of expenses $215-$510, and 85% of any additional expenses. Private insurance is available to cover the difference.

The Danish Medicines Agency electronically registers all prescriptions from all physicians and pharmacies in the entire nation, all of which are accessible by treating physicians. The population studied in this communication includes only dermatology patients who received a new prescription for a treatment never previously used.

Among 322 evaluable patients, 30.7% had not filled one or more prescriptions 4 weeks later. Patients who did fill prescriptions generally did so promptly (3 days median). No particular demographic distinguished adherence/nonadherence, although geriatric patients were most adherent, and persons with chronic disorders requiring chronic treatment, like psoriasis, were least adherent. The authors remind us in their closing statements that "treatment failure" may sometimes simply represent unrecognized "failure to be treated."

Storm A, et al. J Am Acad Dermatol. 2008;59:27-33.

Skin Cancer Screening in the U.S.

In the United States, skin cancer (S-CA) is the most common cancer, and although usually curable, is responsible for over 10,000 deaths annually. Major groups that provide clinical guidelines differ in their recommendations: the ACS (2007) suggested that S-CA examination should occur as part of the cancer-related check-up at the periodic health examination, whereas the USPSTF found insufficient evidence to recommend for or against routine screening for S-CA.

The National Center for Health Statistics conducts an annual, in-person survey of almost 20,000 adults. In 2000 and 2005, subjects were queried about having a head-to-toe skin check for cancer. Over 38,000 adults were interviewed, of whom 69% had seen a healthcare provider in the past year, yet only 8% acknowledged having received a skin examination.

Of the cancer screenings reviewed by national organizations, these data on S-CA are the most bleak. However, they may not be perfectly accurate, as no chart assessment was done to corroborate patient report. A patient who has undergone colonoscopy or colposcopy would be anticipated to accurately recollect whether or not such a screening had taken place. It may well be that clinicians are doing a much more frequent job of screening for S-CA, but simply not "announcing" it. These sobering statistics suggest that either clinicians need to increase their frequency of S-CA screening, be more forthright about pointing out to patients that a S-CA screening is being performed, or both.

LeBlanc WG, et al. J Am Acad Dermatol. 2008;59:55-63.