The state of the art: diagnostic validity The aim of sharper diagnosis remains an important goal for research in bipolar disorder today. Forty years ago, Robins and Guze3 proposed that the diagnostic validity of psychiatric disorders rested on the proposition that clinical phenomenology should have a predictable relationship to genetics, course, and treatment response.

With respect to bipolar disorder, what is the state of the art in each of these areas? While our accumulated knowledge Inhibitors,research,lifescience,medical about manicdepressive illness in these four fields of research is indeed impressive, we face a paradox. Despite all we know, bipolar illness too often remains unrecognized or misdiagnosed, and inappropriately or ineffectively

treated. Robins and Guze’s criteria can serve as springboards to comment on the contemporary understanding of this fascinating and challenging illness. Clinical phenomenology Clinical phenomenology is the framework that supports most other research. Is manic depressive Inhibitors,research,lifescience,medical illness a valid syndrome? Some4,5 doubt that we can distinguish it from schizophrenia. However, in our opinion, the Kraepelinian model appears well supported by methodologically sound research.6-8 To further solidify the current model, future work should focus on schizoaffective disorder Inhibitors,research,lifescience,medical and the validity of presumed subtypes of bipolar disorder, such as pure vs mixed mania. Future diagnostic validity studies should also seek to sharpen the reliability of diagnostic criteria and clarify discrepancies in prevalence estimates. There appears to be a “coarsening of diagnosis”1 in clinical practice and research that may confuse these issues. Particularly with respect to bipolar Inhibitors,research,lifescience,medical disorder, the subtleties of the diagnostic process

are often Inhibitors,research,lifescience,medical ignored in the effort to avoid incorrectly labeling someone with the diagnosis. Tims, bipolar disorder tends to be underdiagnosed, with even episodes of pure mania being completely missed by clinicians (not to mention mixed mania, hypomania, or bipolar depression). In a recent review of diagnostic patterns in the community,9 we and our colleagues found Carnitine dehydrogenase that about 60 % of the hospitalized patients we diagnosed with bipolar disorder had received that diagnosis from previous psychiatrists. While this may not simply be an issue of diagnostic reliability, part of this diagnostic disagreement represents clinician disagreement. Similar diagnostic difficulties exist in the clinical interview of paranoid patients (thus making it difficult to diagnose some types of NU7441 schizophrenia, schizoaffective disorder, psychotic depression, and borderline personality disorder). As Leston Havens has remarked,10 perhaps diagnosis in psychiatry is in a stage similar to medicine before the advent of auscultation.