Predictors of diagnostic transition from major depressive disorder to bipolar disorder: a retrospective observational network study

Transl Psychiatry. 2021 Dec 20;11(1):642. doi: 10.1038/s41398-021-01760-6.


Many patients with bipolar disorder (BD) are initially misdiagnosed with major depressive disorder (MDD) and are treated with antidepressants, whose potential iatrogenic effects are widely discussed. It is unknown whether MDD is a comorbidity of BD or its earlier stage, and no consensus exists on individual conversion predictors, delaying BD's timely recognition and treatment. We aimed to build a predictive model of MDD to BD conversion and to validate it across a multi-national network of patient databases using the standardization afforded by the Observational Medical Outcomes Partnership (OMOP) common data model. Five "training" US databases were retrospectively analyzed: IBM MarketScan CCAE, MDCR, MDCD, Optum EHR, and Optum Claims. Cyclops regularized logistic regression models were developed on one-year MDD-BD conversion with all standard covariates from the HADES PatientLevelPrediction package. Time-to-conversion Kaplan-Meier analysis was performed up to a decade after MDD, stratified by model-estimated risk. External validation of the final prediction model was performed across 9 patient record databases within the Observational Health Data Sciences and Informatics (OHDSI) network internationally. The model's area under the curve (AUC) varied 0.633-0.745 (µ = 0.689) across the five US training databases. Nine variables predicted one-year MDD-BD transition. Factors that increased risk were: younger age, severe depression, psychosis, anxiety, substance misuse, self-harm thoughts/actions, and prior mental disorder. AUCs of the validation datasets ranged 0.570-0.785 (µ = 0.664). An assessment algorithm was built for MDD to BD conversion that allows distinguishing as much as 100-fold risk differences among patients and validates well across multiple international data sources.

Publication types

  • Observational Study
  • Research Support, N.I.H., Extramural

MeSH terms

  • Antidepressive Agents
  • Bipolar Disorder* / complications
  • Bipolar Disorder* / diagnosis
  • Bipolar Disorder* / epidemiology
  • Depressive Disorder, Major* / complications
  • Depressive Disorder, Major* / diagnosis
  • Depressive Disorder, Major* / epidemiology
  • Humans
  • Psychotic Disorders*
  • Retrospective Studies


  • Antidepressive Agents