In the 1980s, Professor Shen Qijie was the first to organise a bipolar disorder course in China. Given that the majority of patients with mental disorders at that time were labelled as "schizophrenic" and the identification of bipolar disorders was seriously mis/under-diagnosed, Professor Shen's work was of great significance and contribution to promoting the clinical identification and correct diagnosis of bipolar disorders in China. In recent years, Professor Shen's work has contributed to the promotion of the clinical identification and correct diagnosis of bipolar disorder in China. With the rapid development of new media technology, electronic mental health services have become one of the main forms of public health education. In 2014, the Shanghai Mental Health Centre launched the mobile phone app "Mood Thermometer", which screens for anxiety and depression, identifies bipolar disorder at an early stage, helps people at high risk of mood disorders or patients to self-monitor mood changes and provides medical guidance and advice, and promotes and popularises It also provides medical advice to help people at risk of mood disorders or patients to self-monitor their mood changes and to promote awareness of mood disorders. It will play a good role in promoting public awareness of mood problems and bipolar disorder and in standardising clinical diagnosis and treatment.
The first edition of the guidelines for the prevention and treatment of bipolar disorder was published in 2007 to promote the standardisation of clinical treatment, thus strengthening the diagnosis and treatment of bipolar disorder, but there is still a gap between the international advanced level and the realistic needs. The diagnostic assessment service for people with bipolar disorders in China (DASP) was launched in 2010, and 1,487 cases diagnosed with bipolar disorder were included in 13 mental health institutions (6 general hospitals and 7 psychiatric hospitals) across China. The results showed that 20.8%, 7.9% and 12.8% of bipolar disorder overall and bipolar disorder type I and II were misdiagnosed as depression, respectively [8]. Another domestic survey of psychosomatic and liaison consultation patients in general hospitals found that the confirmed diagnosis rate of bipolar disorder was only 11.8%, and the number of misdiagnosed or missed patients was extremely high[9]
Despite the increasing number of treatment guidelines published nationally and internationally for bipolar disorder, clinicians often adopt treatment plans that are inconsistent with the guidelines. Overseas surveys have shown that the compliance rate of bipolar disorder treatment options with guidelines ranges from 30% to 80%, and the rate of compliance is related to the clinical phenotype, severity of illness and definition of guideline compliance criteria, especially the compliance rate of bipolar depression treatment options with guidelines is significantly lower than that of bipolar mania, and the compliance rate of guidelines is even lower for those with mild illness[10]. The DASP survey showed that the proportion of patients with bipolar disorder who followed guidelines was very low, with 73.5% of them receiving antidepressant treatment [11]. In 2012, the Chinese Bipolar Disorder Collaborative Group launched the bipolar mania pathway survey (BIPAS) in 15 psychiatric hospitals and 11 psychiatric departments of general hospitals across China. 3,906 patients with bipolar disorder were included, including 2,828 cases of mild mania/hypomania or mixed episodes and 1,078 cases of depressive episodes. The results showed that 11.1% of the patients with mild mania/hypomania or mixed episodes had medication that did not conform to the Canadian Network for the Treatment of Mood and Anxiety Disorders/International Society for Bipolar Disorder (CANMAT/ISBD) guidelines for the treatment of bipolar disorder, while 50.2% of patients with bipolar depression had medication that did not conform [12,13].
Li Tao's team at West China Hospital of Sichuan University showed that the functional connections between the bilateral amygdala and the inferior frontal gyrus, striatum, right lingual gyrus and posterior cerebellar lobe were weakened in both bipolar manic episodes and bipolar depressive episodes, but the right amygdala-hippocampal connection was weakened in bipolar depression and enhanced in bipolar mania
Since most patients with bipolar disorder start with depression, early prediction of bipolar disorder from the first depressive episode is also an important tool to effectively avoid misdiagnosis. In China, scholars conducted a clinical phenomenological investigation of bipolar depression compared with monophasic depression and pointed out risk factors for early recognition of bipolar: including early age of onset (<25 years), atypical depression (increased appetite and weight, increased sleep, etc.), concomitant psychotic symptoms, psychomotor retardation, unstable mood, short duration (<3 months) and frequent depressive episodes, severe cognitive impairment, family history of bipolar disorder, and a family history of bipolar disorder [37,38,39]. The bipolarity index (BPX), which integrates relevant risk factors or characteristics, has also been introduced and used in clinical practice by Chinese researchers. The BPX scale integrates age of onset, genetic load, course, co-morbidity and response to treatment to provide a comprehensive quantitative assessment of the lifelong characteristics of bipolar disorder [40].
To improve the accuracy of bipolar disorder identification and diagnosis, a comprehensive and accurate assessment of the patient is required. Whereas stereotypical clinical interview questionnaires (e.g. SCID-Ⅰ /P, MINI) are difficult to apply universally because the entries are cumbersome and too time-consuming, a number of simple and validated screening and assessment scales for manic or hypomanic symptoms have gained acceptance among clinicians. These include the Bipolar Spectrum Diagnostic Scale (BSDS) [41], the Mood Disorder Questionnaire (MDQ) [42,43], the 15- or 32-Item Hypomania Checklist 15/32-Items, HCL-15/32) [44,45,46], TEMPS-A (Temperament Evaluation of Memphis, Pisa, Paris and San Diego-Autoquestionnaire Version) Temperament scale [47]. In addition, some researchers have actively sought biological markers for the early identification of bipolar disorder. The results of this study showed that the combination of mRNA and protein levels of BDNF was more accurate than considering only mRNA or protein levels in identifying bipolar disorder and monophasic depression, and that BDNF levels may be a potential early predictor of depression. BDNF levels may become a potential biological marker for the early prediction of bipolarity in depression, a finding that makes early intervention in bipolar disorder possible [48].
Compared to clinical phenomenological investigations and pathogenesis investigations, clinical treatment studies for bipolar disorder in China are significantly lacking, especially multicentre randomised controlled clinical trials.
Based on the current situation that the treatment of bipolar disorder in China is yet to be standardized, the Chinese Medical Association Psychiatry Branch has organized experts to prepare and publish the Expert Recommendations for the Pharmacological Treatment of Depressive Episodes in Bipolar Disorder [55], and the Chinese Guidelines for the Prevention and Treatment of Bipolar Disorder (second edition) will be published soon.
We must see the gap between the current status of the discipline of bipolar disorder in China and the international developed countries, such as the following three outstanding problems: firstly, the epidemiological status of bipolar disorder is not accurately grasped, and the available data only come from a few provinces and cities; secondly, there is a lack of multi-centre and large sample clinical studies, and most of the evidence-based basis for bipolar disorder treatment recommendations in China currently comes from abroad, especially in the treatment of bipolar depression; thirdly The research on etiology and pathogenesis is not in-depth and systematic enough, and there is a lack of multidisciplinary association.
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