Patient presentation and emphasis might be most concerned with the current depressive symptomatology and focused on its alleviation, potentially forgetting, ignoring or downplaying previous manic or hypomanic symptoms; this may be even more likely in bipolar II disorder. Retrospective analysis showed that between Inhibitors,research,lifescience,medical 25% and 50% [Angst, 2007; Hirschfeld et al. 2003; Ghaemi et al. 1999] of those with bipolar depression were initially diagnosed with a unipolar illness, and the first presentation of BPAD was more likely to be with a depressive illness [Forty et al. 2008]. Ghaemi

and colleagues showed a mean interval of 7.5 years to correct diagnosis [Ghaemi et al. 1999], whilst analysis of the National Depression and Manic Depression Survey in 1994 and 2000 showed Inhibitors,research,lifescience,medical that patients were typically symptomatic for more than 10 years before the correct diagnosis was made [Hirschfeld et al. 2003; Lish et al. 1994]. Delays in recognizing and diagnosing bipolar depression can prevent appropriate treatment, with Inhibitors,research,lifescience,medical serious potential implications [Berk et al. 2006; Bowden, 2005] including impaired social development, harmful effects from inappropriate treatment [Ghaemi et al. 2004] and possibly a higher risk of suicide [Baldessarini et al. 2006]. Although

bipolar depression is very similar to unipolar depression, factors in the history and presentation might indicate the possibility of bipolar depression. Demographically, those with bipolar depression are more likely to have Inhibitors,research,lifescience,medical an earlier age of onset, a greater number of illness episodes, a positive family history of a bipolar illness and a more treatment-refractory and severe illness history [Smith et al. 2011; Forty et al. 2008; Bowden, 2005; AS-703026 in vitro Sharma Inhibitors,research,lifescience,medical et al. 2005; Geller et al. 2001]. The clinical

presentation may show a more atypical symptom spectrum than that of unipolar depression; although not diagnostic, there is Linifanib (ABT-869) consistent evidence for a greater incidence of hypersomnia, motor retardation, mood lability, weight gain and psychotic symptoms in bipolar depression [Forty et al. 2008; Bowden, 2005; Swann et al. 2005; Mitchell et al. 2001]. A particular concern, given the issue of misdiagnosis, is that more than 80% of patients with ‘depression’ are managed in primary care [Smith et al. 2011; NICE, 2006] but general practitioners will inevitably have less postgraduate training in mental health and there has been less research on bipolar depression in this environment. A recent two-phase screening study in primary care by Smith and colleagues estimated the prevalence of undiagnosed BPAD at between 3.3% and 21.