Who transitions to bipolar disorder? A comparison of major depressive disorder, anxiety, and ADHD

Background: Diagnostic delays in Bipolar Disorder (BD) are common and may contribute to worse outcomes. While most studies focus on depression as a primary precursor, both anxiety and attention deficit disorders are also frequent initial diagnoses. In the current study, we utilized a large, diverse electronic health record (EHR) dataset to quantify the rates and correlates of conversion to BD from these major precursor diagnoses. Methods: Our study analyzed a comprehensive ten-year EHR dataset from Johns Hopkins Medicine, a diverse urban medical center, to assess and compare the rates and correlates of conversion to BD from Major Depressive Disorder (MDD), anxiety disorders, and ADHD. Risk factors for transition were assessed as time-varying variables in proportional hazards models. Results: Of the 21,341 patients initially included, 1232 later transitioned to a diagnosis of BD. Adjusted-one-year conversion rates for patients with MDD, anxiety disorders, and ADHD were 4.2 %, 3.4 %, and 4.0 %, respectively, with ten-year rates at 11.4 %, 9.4 %, and 10.9 %, respectively. Age (19-29 years), treatment setting (emergency and inpatient), and psychotropic medications were associated with conversion to BD across all precursor diagnoses. Severe and psychotic forms of MDD were among the strongest risk factors for transitioning to BD. Although risk factors for convertion were similar, transition rates were lower in children, particularly in indivudals with ADHD, who showed a higher rate of BD conversion in adults. Conclusions: The highest risk of transitioning to BD was observed in patients initially diagnosed with MDD, though significant risk was also noted in those with initial diagnoses of anxiety disorders and adult ADHD.