Cross validation with the mood disorder questionnaire (MDQ) of an instrument for the detection of hypomania in Spanish: the 32 item hypomania symptom check list (HCL-32)

Altered visual cortex excitability in premenstrual dysphoric disorder: Evidence from magnetoencephalographic gamma oscillations and perceptual suppression

Premenstrual dysphoric disorder (PMDD) is a psychiatric condition characterized by extreme mood shifts during the luteal phase of the menstrual cycle (MC) due to abnormal sensitivity to neurosteroids and unbalanced neural excitation/inhibition (E/I) ratio. We hypothesized that in women with PMDD in the luteal phase, these factors would alter the frequency of magnetoencephalographic visual gamma oscillations, affect modulation of their power by excitatory drive, and decrease perceptual spatial suppression. Women with PMDD and control women were examined twice-during the follicular and luteal phases of their MC. We recorded visual gamma response (GR) while modulating the excitatory drive by increasing the drift rate of the high-contrast grating (static, 'slow', 'medium', and 'fast'). Contrary to our expectations, GR frequency was not affected in women with PMDD in either phase of the MC. GR power suppression, which is normally associated with a switch from the 'optimal' for GR slow drift rate to the medium drift rate, was reduced in women with PMDD and was the only GR parameter that distinguished them from control participants specifically in the luteal phase and predicted severity of their premenstrual symptoms. Over and above the atypical luteal GR suppression, in both phases of the MC women with PMDD had abnormally strong GR facilitation caused by a switch from the 'suboptimal' static to the 'optimal' slow drift rate. Perceptual spatial suppression did not differ between the groups but decreased from the follicular to the luteal phase only in PMDD women. The atypical modulation of GR power suggests that neuronal excitability in the visual cortex is constitutively elevated in PMDD and that this E/I imbalance is further exacerbated during the luteal phase. However, the unaltered GR frequency does not support the hypothesis of inhibitory neuron dysfunction in PMDD.

Real-world Implementation of a Smartphone-Based Psychoeducation Program for Bipolar Disorder: Observational Ecological Study

BACKGROUND

SIMPLe is an internet-delivered self-management mobile app for bipolar disorder (BD) designed to combine technology with evidence-based interventions and facilitate access to psychoeducational content. The SIMPLe app was launched to the real world to make it available worldwide within the context of BD treatment.

OBJECTIVE

The main aims of this study are as follows: to describe app use, engagement, and retention rates based on server data; to identify patterns of user retention over the first 6-month follow-up of use; and to explore potential factors contributing to discontinuation of app use.

METHODS

This was an observational ecological study in which we pooled available data from a real-world implementation of the SIMPLe app. Participation was open on the project website, and the data-collection sources were a web-based questionnaire on clinical data and treatment history administered at inclusion and at 6 months, subjective data gathered through continuous app use, and the use patterns captured by the app server. Characteristics and engagement of regular users, occasional users, and no users were compared using 2-tailed t tests or analysis of variance or their nonparametric equivalent. Survival analysis and risk functions were applied to regular users' data to examine and compare use and user retention. In addition, a user evaluation analysis was performed based on satisfaction, perceived usefulness, and reasons to discontinue app use.

RESULTS

We included 503 participants with data collected between 2016 and 2018, of whom 77.5% (n=390) used the app. Among the app users, 44.4% (173/390) completed the follow-up assessment, and data from these participants were used in our analyses. Engagement declined gradually over the first 6 months of use. The probability of retention of the regular users after 1 month of app use was 67.4% (263/390; 95% CI 62.7%-72.4%). Age (P=.002), time passed since illness onset (P<.001), and years since diagnosis of BD (P=.048) correlate with retention duration. In addition, participants who had been diagnosed with BD for longer used the app on more days (mean 97.73, SD 69.15 days; P=.002) than those who had had a more recent onset (mean 66.49, SD 66.18 days; P=.002) or those who had been diagnosed more recently (mean 73.45, SD 66 days; P=.01).

CONCLUSIONS

The user retention rate of the app decreased rapidly after each month until reaching only one-third of the users at 6 months. There exists a strong association between age and app engagement of individuals with BD. Other variables such as years lived with BD, diagnosis of an anxiety disorder, and taking antipsychotics seem relevant as well. Understanding these associations can help in the definition of the most suitable user profiles for predicting trends of engagement, optimization of app prescription, and management.

Comparing Screening Abilities of the 33-Item Hypomania Checklist (HCL-33) and the 33-Item Hypomania Checklist External Assessment (HCL-33-EA) for the Detection of Bipolar Disorder

Background: Bipolar disorder (BD) is a severe psychiatric disorder that is often misdiagnosed and under-diagnosed in clinical settings. The 33-item Hypomania Checklist (HCL-33) is a newly developed self-administered scale for BD detection, while the 33-item Hypomania Checklist-external assessment (HCL-33-EA) is a version of the HCL-33 for external rating used by patient's carer (e.g., family member or friend). We aimed to compare the screening abilities between the HCL-33 and the HCL-33-EA, and evaluate the screening consistency between the two scales. Methods: The data were collected from 269 patients with diagnosed BD (n = 84) or major depressive disorder (MDD) (n = 185). The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the curve (AUC) between the HCL-33 and the HCL-33-EA for BD were compared against clinician diagnosis as the gold standard. Results: Using Youden's index, the optimal cut-off value of the HCL-33 is 20, while the corresponding figure for HCL-33-EA is 11. Using Youden's index, the HCL-33-EA showed a better performance than the HCL-33 (0.51 vs.0.41). The HCL-33-EA was more sensitive in correctly identifying BD patients from MDD patients than the HCL-33 (0.83 vs. 0.59), while the HCL-33 presented better specificity than the HCL-33-EA (0.82 vs. 0.68). There was significant screening consistency between the two scales (p < 0.001). Conclusions: Both scales have acceptable psychometric properties in detection BD from MDD. Use of the two scales should be considered based on the assessment purpose in clinical research or daily practice (i.e., prefer sensitivity or specificity). Noticeably, the current sample size is insufficient and future studies are recommended to further evaluate the scales.

Spanish Adaptation of the Inventory of Depression and Anxiety Symptoms (IDAS-II) and a study of its psychometric properties

BACKGROUND

The Inventory of Depression and Anxiety Symptoms (IDAS-II) is composed of 99 items organized into 18 specific scales that provides dimensional assessment of depression, anxiety and bipolar symptoms. To date, IDAS-II is only available in the English and Turkish population. The main purpose of this study is to adapt the IDAS-II to the Spanish population and to assess the psychometric properties.

METHODS

Participants included community adults (n = 620) and college students (n = 378). All participants completed the Beck Depression Inventory-II, Beck Anxiety Inventory, Hypomania Check List-32, Post-traumatic Stress Disorder Checklist-Civilian Version and Obsessive-Compulsive Inventory-Revised, in addition to the Spanish version of the IDAS-II.

RESULTS

The results indicate good internal consistency and high temporal stability of the Spanish version of the IDAS-II. Confirmatory factor analyses show for the first time that the three-factor structure of the IDAS-II (Distress, Obsessions/Fear, and Positive Mood) loads on a second order factor, labeled "Internalizing" according to the Hierarchical Taxonomy Of Psychopathology (HiTOP).

LIMITATIONS

Study was conducted exclusively on student and community samples and some of the measures used as gold-standard have presented limitations CONCLUSIONS: According to previous studies, the results supported the convergent and discriminant validity of the majority of IDAS-II scales. IDAS-II is useful in assessing the severity of depression, anxiety and bipolar symptoms in research contexts in a Spanish population according to the HiTOP model. However, more evidence is required to prove the adequate functioning of the IDAS-II in clinical samples.

Occurrence of mood disorders among educationally active older adults in Bialystok, Poland: a cross-sectional study

BACKGROUND

Mood disorders in older people are an increasingly serious health and social problem, and their prevalence increases with age. The most common mood disorders are bipolar disorder, which is the occurrence of mania and hypomania, and depressive disorders. The aim of this study was to determine the prevalence of mood disorders in a group of educationally active elderly people living in Bialystok, Poland.

METHODS

The study included a total of 162 people-residents of Bialystok-aged 60 or older; 135 women (83.33%) and 27 men (16.67%). The study used five standardized psychometric scales: The Mood Disorder Questionnaire (MDQ), Hypomania Check List (HCL-32), Geriatric Depression Scale (GDS) and The Zung Self-Rating Depression Scale (Zung SDS).

RESULTS

Nearly 90.00% of the respondents obtained GDS scores indicating the presence of mild depressive symptoms; however, on the Zung SDS, which also evaluates depression symptom levels, the result obtained in almost the same number of respondents showed an absence of these symptoms. A similar percentage of respondents also obtained values on the MDQ that allow to determine a lack of bipolar disorder characteristics in the studied population. Over half of the respondents (58.02%) did not show symptoms of hypomania using the HCL-32. There was a significant correlation between the results of the GDS and Zung SDS, the HCL-32 and MDQ, as well as the HCL-32 and Zung SDS in the total studied group.

CONCLUSIONS

Mood disorders, particularly depression, constitute a significant social and health problem in the group of educationally active older adults living in Bialystok. In light of the obtained research results, it is recommended to conduct and improve already realized health education programs for the elderly on the subject of mood disorder prevention and their impact on quality of life. There is a need for further research on mood disorders in the elderly to determine their prevalence on a national scale.

Short versions of the 32-item Hypomania Checklist: A systematic review

PURPOSE

Bipolar disorder (BD) is frequently misdiagnosed, which can lead to negative outcomes. The 32-item Hypomania Checklist (HCL-32) is one of the most widely used self-reported screening instruments for hypomanic symptoms, which has several short versions. This systematic review examined the psychometric properties of HCL-32 short versions.

DESIGN AND METHODS

Five international databases were systematically and independently searched by two researchers for studies that developed the HCL short versions. Basic demographic and clinical characteristics and the psychometric properties of the HCL short versions were recorded.

FINDINGS

Eighteen studies were identified. The majority of the HCL short versions showed satisfactory to good psychometric properties.

PRACTICE IMPLICATIONS

Validated HCL short versions with satisfactory psychometric properties may be helpful in screening for BD.

Comparison of the screening ability between the 32-item Hypomania Checklist (HCL-32) and the Mood Disorder Questionnaire (MDQ) for bipolar disorder: A meta-analysis and systematic review

The frequent misdiagnosis of bipolar disorder (BD) is associated with detrimental consequences and inappropriate treatments. The 32-item Hypomania Checklist (HCL-32) and the Mood Disorder Questionnaire (MDQ) are widely used self-report screening instruments for BD. This is a systematic review and meta-analysis to compare the psychometric properties of the HCL-32 and the MDQ based on the same patient samples. Two reviewers systematically and independently searched PubMed, PsycINFO, EMBASE, Web of Science, and Cochrane Library databases. Studies using the HCL-32 and MDQ concurrently and reporting their psychometric properties were included. Eleven studies that met the entry criteria were included in the systematic review, and 9 studies with relevant data were included in the meta-analysis. Using study-defined cutoffs, summary sensitivities were 82% (95% CI: 72%-89%) and 80% (95% CI: 71%-86%), while specificities were 57% (95% CI: 48%-66%) and 70% (95% CI: 59%-71%) for the HCL-32 and the MDQ respectively. Both the HCL-32 and the MDQ have acceptable psychometric properties to identify BD and appear to be useful screening tools for BD.

OpenSIMPLe: A real-world implementation feasibility study of a smartphone-based psychoeducation programme for bipolar disorder

BACKGROUND

Few evidence-based mental health apps are widely available to patients and, conversely, many of the available apps have not been appropriately evaluated. Given that the ultimate goal is to scale-up and open internet-based platforms (IBP), it is crucial to appropriately evaluate their real-world feasibility beforehand. We aimed to evaluate the implementation feasibility of a smartphone-based psychoeducational programme for bipolar disorder, exploring its long-term retention, usability, perceived helpfulness and satisfaction, alongside its impact on secondary health outcomes.

METHODS

Participants were recruited via the project website after completing an online screening questionnaire. They were requested to complete web-based questionnaires before using the app and after 6 months of use which included sociodemographic, illness and treatment variables, the world health organisation-five well-being index (WHO-5) and the short form health survey (SF-36). The follow-up questionnaires also contained satisfaction and usefulness questions.

RESULTS

201 participants took part in the study. According to their retention, 66.2% of the participants were classified as noncompleters and 33.8% as completers. The only predictor significantly associated with higher odds of retention was older age (OR = 1.021, p < 0.001). 62% of the users reported they were satisfied with the programme with a higher percentage among completers. Who-5 baseline and follow-up scores showed a significant improvement as well as 6 out of 8 domains of the SF-36.

LIMITATIONS

Screening and outcome measures were administered using exclusively self-reported online methods.

CONCLUSION

The 6-month attrition rate of the programme was high. Positive outcomes regarding satisfaction were found predominantly among completers. The optimal dosage and retention of IBP mental health programmes remain challenging issues that need further research.

Screening for psychiatric disorders with self-administered questionnaires

Given the time demands of clinical practice it is not surprising that diagnoses are sometimes missed. To improve diagnostic recognition, self-administered screening scales have been recommended. A problem with much of the research effort on screening scales is the confusion between diagnostic testing and screening. It is important for a screening test to have high sensitivity because the more time intensive/expensive follow-up diagnostic inquiry will presumably only occur in patients who are positive on the initial screen. Investigators vary in how they analyze their data in determining the recommended cutoff score on a self-administered screening questionnaire. To illustrate this, in the present report we examined how often each of the different approaches towards determining a cutoff score on bipolar disorder screening scales were used. We reviewed 68 reports of the performance of the 3 most commonly researched bipolar disorder screening scales to determine how the recommended cutoff on the scale was derived. Most studies recommended a cutoff point on the screening scale that optimized the level of agreement with the diagnostic gold standard. Only 11 (16.2%) studies recommended a cutoff that prioritized the scale's sensitivity. It is important for clinicians to understand the difference between screening and diagnostic tests. The results of the present study indicate that most studies of the performance of the 3 most commonly studied bipolar disorder screening measures have taken the wrong approach in deriving the cutoff score on the scale for the purpose of screening.

Comparing the screening property of the shortened versions of the Hypomania Checklist-32 (HCL-32): Cross-validation in Korean patients with bipolar disorder and major depressive disorder

BACKGROUND

To date, shortened versions of the Hypomania Checklist-32 (HCL-32) were proposed to overcome the limitation of a lengthy format; however, a cross-validation study is currently needed to identify which shorter version may function optimally in a clinical sample.

METHODS

In a Korean patient sample with bipolar disorder (BD) and major depressive disorder (MDD) (BD-I n = 84, BD = II n = 145, MDD n = 285), we examined the reliability and screening property of three shorter versions of the HCL (HCL-20, -16, -8) in comparison with the full HCL-32. Diagnosis was confirmed by the structured clinical interview (SCID-I).

RESULTS

All three shortened HCLs demonstrated a fair screening ability (Area Under the Curve = .72~.74) to discriminate BD patients from MDD patients, which was comparable to that of the HCL-32. When sensitivity and specificity were considered, the HCL-20 showed relatively superior performance among the shortened versions.

LIMITATIONS

The shorter versions were not administered in a 'stand-alone' manner.

CONCLUSIONS

This is the first cross-validation study in a large clinical sample with an increased statistical power to compare the screening property of the shortened HCLs. Our results suggest that briefer versions of the HCL could be reliably and economically utilized in clinical and research settings to enhance detection of BD.

Hypomania Symptoms Across Psychiatric Disorders: Screening Use of the Hypomania Check-List 32 at Admission to an Outpatient Psychiatry Clinic

Introduction: Hypomania symptoms are best described as a continuum, ranging beyond Bipolar Spectrum Disorders (BSD). Other nosological entities, such as major depressive disorder, schizoaffective disorder, or borderline personality disorder, may also share symptoms with BSD, raising challenges for differential diagnosis. While the Hypomania Checklist-32 is one of the most widely used tools for screening hypomania, there is limited evidence describing its use in a real-world outpatient psychiatric clinical setting. Methods: Here we tested the psychometric properties of a European Portuguese adaptation of the HCL-32, establishing its factor structure, reliability and construct validity. Furthermore, we analyzed differences in hypomanic symptoms among several clinical groups and in a non-clinical sample. Data was obtained retrospectively in an ecological setting from a clinical sample of an outpatient psychiatry and psychology clinic, comprising 463 Portuguese individuals, 326 of whom had a psychiatric diagnosis, namely BSD (n = 66), major depressive disorder (n = 116), or other psychiatric disorders (n = 144). A separate non-clinical sample was also collected among healthy volunteers (n = 62). A battery of self-report measures of affective symptoms was applied, and in a subset of patients, diagnosis was established using a structured diagnostic interview. Results: Psychometric properties of the HCL-32 were adequate, with good internal consistency (Cronbach's α = 0.86) and test-retest stability (ICC = 0.86), and two subscores ("active/elated" and "risk-taking/irritable") defined by Principal Component Analysis. Receiver Operating Characteristic curve analysis demonstrated that the test score discriminated moderately between patients with BSD and other clinical samples as well as healthy volunteers, with a cut-off score of 17 for the total score of the HCL-32 rendering the best combination of sensitivity and specificity. When compared to the HCL-32 total score, the risk-taking/irritable subscore seems to provide additional benefit in discriminating between different clinical groups, namely regarding specificity in the discrimination from patients with a diagnosis of major depressive disorder that was low for the full scale and the alternate subscale. Conclusions: HCL-32 can be used as a screening tool for BSD among adult patients presenting in an outpatient psychiatric clinical setting.

Psychometric Properties of the Hypomania Checklist-32 in Korean Patients with Mood Disorders

Objective

The aim of this study was to examine the validity of the Korean version of the Hypomania Checklist-32, second revision (HCL-32-R2) in mood disorder patients.

Methods

A total of 454 patients who diagnosed as mood disorder according to Structured Clinical Interview for DSM-IV Axis I Disorders, clinician version (SCID-CV) (bipolar disorder [BD] I, n=190; BD-II, n=72; and major depressive disorder [MDD], n=192) completed the Korean module of the HCL-32-R2 (KHCL-32-R2).

Results

The KHCL-32-R2 showed a three-factorial structure (eigenvalue >2) that accounted for 43.26% of the total variance. Factor 1 was labeled “active/elated” and included 16 items; factor 2, “irritable/distractible” and included 9 items; and factor 3 was labeled “risk-taking/indulging” and included 9 items. A score of 16 or more on the KHCL-32-R2 total scale score distinguished between BD and MDD, which yielded a sensitivity of 70% and a specificity of 70%. MDD and BD-II also could be differentiated at a cut-off of 15 with maximized sensitivity (0.67) and specificity (0.66). Cronbach’s alpha of KHCL-32-R2 and its subsets (factors 1, 2, and 3) were 0.91, 0.89, 0.81 and 0.79, respectively. Correlations between KHCL-32-R2 and Montgomery-Asberg Depression Rating Scale, Young Mania Rating Scale and Korean version of Mood Disorder Questionnaire were −0.66 (p=0.41), −0.14 (p=0.9), and 0.61 (p<0.001), respectively.

Conclusion

The KHCL-32-R2 may be a useful tool in distinguishing between bipolar and depressive patients in clinical settings.

Borderline personality and attention-deficit hyperactivity traits in childhood are associated with hypomanic features in early adulthood

BACKGROUND

There is limited understanding of the symptomatic development of bipolar disorder from childhood to early adulthood.

AIMS

We assessed whether borderline personality disorder traits, ADHD, and emotional, behavioural and social difficulties during childhood were associated with hypomania assessed in young adulthood.

METHOD

We used data from the Avon Longitudinal Study of Parents and Children (ALSPAC), to examine associations between measures of childhood psychopathology and lifetime hypomanic features assessed at age 22-23 years using the Hypomania Checklist-32 (HCL-32; n = 3372). We also conducted a factor analysis of the HCL to identify latent constructs underlying hypomania, and the extent to which childhood psychopathology was associated with these.

RESULTS

We identified two factors of the HCL corresponding to energy/mood and risk-taking/irritability. There was evidence of association between childhood borderline personality disorder traits and both hypomania factors, with evidence that the association was stronger with the risk-taking/irritability factor. All individual borderline traits, with the exception of fear of abandonment, were associated with hypomania. There was also evidence of association between most other measures of childhood psychopathology (ADHD, hyperactivity, conduct problems, peer relationship problems and reduced prosocial behaviour) and the risk-taking/irritability factor, but much less consistent evidence of association with the energy/mood factor.

LIMITATIONS

The HCL cannot diagnose bipolar disorder and may be subject to reporting bias.

CONCLUSIONS

A broad range of childhood psychopathologies may represent early markers of risk for hypomania. Further studies are required to understand the mechanisms underlying these associations, and to inform earlier detection of bipolar disorder.

Hypomania Checklist-32 - cross-validation of shorter versions screening for bipolar disorders in an epidemiological study

OBJECTIVE

Self-reports such as Hypomania Checklist (HCL-32) can be used to enhance recognition of bipolar disorders, but they are often too long and only validated in clinical samples. The objectives of this study are therefore to test whether (i) the HCL-32 can be used for screening in the community and (ii) whether two previously suggested shorter versions would do as well.

METHOD

Data stemmed from the CoLaus|PsyColaus, a prospective cohort study which included randomly selected residents aged 35-66 years from an urban area. Participants underwent semistructured interviews to assess DSM-IV disorders and 1712 of them completed the HCL-32.

RESULTS

Forty individuals (2.3%) were diagnosed as having BD. Compared to others, participants with BD scored significantly higher on the HCL-32. The HCL-32 had a sensitivity of 0.78 and specificity of 0.68. Very similar figures were found for two previously proposed shorter versions with 16 and 20 items. The results of confirmatory factor analysis and item response theory (IRT) models supported the postulated two-factor structure for the three HCL versions.

CONCLUSION

Despite the low base rate of BD in this sample, the screening properties of the HCL-32 remained almost as good. Importantly, two previously proposed shorter versions performed as well, suggesting that those could be used without losing essential information.

Comparison of the 32-item Hypomania Checklist, the 33-item Hypomania Checklist, and the Mood Disorders Questionnaire for bipolar disorder

AIM

Bipolar disorder (BD) is frequently misdiagnosed as major depressive disorder (MDD) and hence reliable and culturally appropriate screening tools are needed. This study compared the 32-item Hypomania Checklist (HCL-32), the 33-item Hypomania Checklist (HCL-33), and the Mood Disorders Questionnaire (MDQ) for BD.

METHODS

Altogether, 350 depressed patients were included. The HCL-32, HCL-33, and MDQ were completed by patients to identify manic and/or hypomanic symptoms. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and area under the curve among the HCL-32, HCL-33, and MDQ for BD and MDD were calculated and compared, using cut-offs suggested by respective validation studies.

RESULTS

Of the three scales, the MDQ had the highest sensitivity and NPV (sensitivity = 0.90, 0.81, and 0.90 for BD vs MDD, BD-I vs MDD, and BD-II vs MDD, respectively; NPV = 0.78, 0.86, and 0.86 for BD vs MDD, BD-I vs MDD, and BD-II vs MDD, respectively), while the HCL-33 had the highest specificity and PPV (specificity = 0.74, 0.69, and 0.66 for BD vs MDD, BD-I vs MDD, and BD-II vs MDD, respectively; PPV = 0.74, 0.55, and 0.56 for BD vs MDD, BD-I vs MDD, and BD-II vs MDD, respectively).

CONCLUSION

Compared to both HCL scales, the MDQ had higher sensitivity and lower specificity in screening for BD. These results contradict previous findings in Western populations. As a screening instrument for BD in Chinese clinical settings, the MDQ appears to be appropriate.

Characterization and structure of hypomania in a British nonclinical adolescent sample

BACKGROUND

This study aimed to test the validity of using the Hypomania Checklist-16 [HCL-16] to measure hypomania in a British adolescent community sample. Limited research is available concerning the characterization of hypomania among community adolescent samples, particularly in the UK, despite its potential importance for early intervention policy development.

METHOD

To explore the structure and characterization of hypomania in a British adolescent nonclinical cohort, over 1400 17 year olds (Mean=17.05 years; SD=0.88) completed the HCL-16 along with measures of different psychological and psychopathological dimensions.

RESULTS

Principal components analysis revealed a 2-component solution for the HCL-16, described as active-elated and irritable/risk-taking. Hypomanic symptoms were significantly correlated with many psychopathological dimensions. There were distinct correlation patterns for the two HCL-16 subscales, with the irritability/risk-taking subscale showing significantly stronger associations with psychotic-like experiences, internalizing and externalizing problems, and reduced life satisfaction relative to the active-elated dimension. Adolescents at 'high-risk' for bipolar disorder reported more psychopathology relative to the comparison group.

LIMITATIONS

Absence of the clinical diagnosis of bipolar disorder in the sample means that the classification of the 'high-risk' group cannot be confirmed.

CONCLUSIONS

The structure of the HCL-16 in this UK adolescent sample mirrored that observed in adult and clinical cohorts. The observed links between the HCL-16 and psychopathological dimensions that have been previously associated with both hypomania and bipolar disorder lend support to the HCL-16's validity as a hypomania instrument for adolescents. Better understanding of hypomania prior to adulthood has considerable potential for informing early intervention approaches.

Exposure to tobacco smoke in utero or during early childhood and risk of hypomania: Prospective birth cohort study

OBJECTIVES

Using data from a prospective birth cohort, we aimed to test for an association between exposure to tobacco smoke in utero or during early development and the experience of hypomania assessed in young adulthood.

METHODS

We used data on 2957 participants from a large birth cohort (Avon longitudinal study of parents and children [ALSPAC]). The primary outcome of interest was hypomania, and the secondary outcome was "hypomania plus previous psychotic experiences (PE)". Maternally-reported smoking during pregnancy, paternal smoking and exposure to environmental tobacco smoke (ETS) in childhood were the exposures of interest. Multivariable logistic regression was used and estimates of association were adjusted for socio-economic, lifestyle and obstetric factors.

RESULTS

There was weak evidence of an association between exposure to maternal smoking in utero and lifetime hypomania. However, there was a strong association of maternal smoking during pregnancy within the sub-group of individuals with hypomania who had also experienced psychotic symptoms (OR=3.45; 95% CI: 1.49-7.98; P=0.004). There was no association between paternal smoking, or exposure to ETS during childhood, and hypomania outcomes.

CONCLUSIONS

Exposure to smoking in utero may be a risk factor for more severe forms of psychopathology on the mood-psychosis spectrum, rather than DSM-defined bipolar disorder.

Gestational influenza and risk of hypomania in young adulthood: prospective birth cohort study

BACKGROUND

Previous studies have suggested a possible link between exposure to influenza in utero and bipolar disorder in adulthood. Using data from a prospective birth cohort, we aimed to test for an association between exposure to gestational influenza and the experience of hypomania assessed in early adulthood.

METHODS

We used data on 2957 participants from the Avon Longitudinal Study of Parents and Children (ALSPAC). The two main outcomes of interest were hypomania, assessed using the Hypomania Checklist (HCL-32) at age 22-23, and 'hypomania plus previous psychotic experiences (PE)'. Maternally-reported gestational influenza was the exposure of interest. Multivariable logistic regression was used and estimates of association were adjusted for a range of possible confounding factors, including maternal smoking in pregnancy.

RESULTS

Relative to controls, rates of exposure to gestational influenza were higher for participants with hypomania (24.0%) and for participants with 'hypomania plus PE' (34.2%), but univariate and multivariable analyses of an association between gestational influenza and hypomania (with and without previous PE) were not significant.

LIMITATIONS

The response rate to those who were sent the HCL-32 questionnaire was 36.8%. As a result, some analyses may have been under-powered to detect a true effect. Influenza infection during pregnancy was self-reported by mothers.

CONCLUSIONS

In this prospective population study, gestational influenza was not identified as a clear risk factor for lifetime hypomania or for 'hypomania with PEs' in young adult offspring. It is possible that previous reports of an association between gestational influenza and bipolar disorder in adulthood have been confounded by factors such as maternal smoking during pregnancy.

Investigation of the clinical utility of the hypomania checklist 32 (HCL-32) for the screening of bipolar disorders in the non-clinical adult population

BACKGROUND

The hypomania checklist-32 (HCL-32) is a widely used questionnaire developed for identifying hypomanic components in patients with a depressive episode. Measuring and screening previous hypomanic symptoms in individuals without any definite history of depressive episode would also be needed for early detection of bipolar disorders (BDs). This study aimed at testing the clinical utility of the HCL-32 for screening of BDs in the non-clinical population.

METHODS

Lifetime history of hypomanic symptoms was evaluated by using the HCL-32 in 220 patients with BDs and 313 non-clinical individuals. Sensitivity, specificity, and the area under the curve (AUC) of the Receiver Operating Characteristic (ROC) were evaluated for assessing the discriminatory power of the scale and its two sub-domains in screening BDs.

RESULTS

The mean HCL-32 total score was significantly higher in the Bipolar II disorder group compared to the non-clinical group (P < 0.001). Most of the items (10/12) of the irritable/risk-taking factor showed higher positive responses in patient groups. Items of active/elated factor showed mixed results. The HCL-32 total score and the active/elated factor score were not adequate for both BDs and its subgroups with AUC values of less than 0.7. The irritable/risk-taking factor score showed higher discrimination power, i.e. AUC for BDs, Bipolar I disorder, and Bipolar II disorder was 0.71, 0.67, and 0.75, respectively.

CONCLUSIONS

The HCL-32 could not adequately distinguish BD patients from the non-clinical adult population. However, the current study identified items of irritable/risk-taking factor of the scale that could be useful in screening BDs in the general population.

The 33-item Hypomania Checklist (HCL-33): A new self-completed screening instrument for bipolar disorder

BACKGROUND

Bipolar disorder (BD) is often misdiagnosed as major depressive disorder (MDD). This study tested the psychometric properties and the accuracy of the Chinese version of the 33-item Hypomania Checklist (HCL-33) to identify BD in Chinese clinical settings.

METHODS

A total of 350 depressed patients were consecutively interviewed in a major psychiatric hospital in China. The patients' socio-demographic and clinical characteristics were recorded using standardized protocol and data collection procedures. The HCL-33 was completed by patients to detect symptoms characteristic of mania and hypomania. DSM-IV diagnoses were established using the Mini International Neuropsychiatric Interview (MINI).

RESULTS

The HCL-33 showed high internal consistency with two-factorial dimensions. The optimal cut-off point on the HCL-33 to differentiate BD from MDD was 15, while cut-off points of 14 and 13 differentiated BD-I and BD-II from MDD, respectively. The maximum sensitivity was 0.62, 0.67 and 0.72 for differentiating BD, BD-I and BD-II from MDD, respectively.

CONCLUSIONS

The HCL-33 is a useful tool for screening for BD in Chinese depressed patients. The routine clinical use of the HCL-33 as a screening instrument for BD in Chinese patients is recommended.

The dimensional structure of cycling mood disorders

This study examines whether mood disorders differ fundamentally in terms of phase duration. Most clinically significant mood disorders are recurrent and cyclical. The phase duration of these cycles is part of the diagnostic criteria. Specifically, we determined whether a dimensional or taxonic latent structure better captures cycling mood disorders. 319 patients recruited from 5 psychiatrists and a psychoeducational program completed three questionnaires assessing aspects of mood cycling. These were the Affective Lability Scale-Short Form (ALS-SF), Mood Disorders Questionnaire (MDQ), and the Eysenck Neuroticism scale. Patient scores on these instruments were submitted to three taxometric procedures (MAMBAC, MAXEIG, and L-Mode). Comparison curve fit indices (CCFIs) were calculated to distinguish taxonic versus dimensional latent structure. In addition, graphs were produced for each procedure and compared with those of categorical or dimensional prototypes. The CCFIs of the three procedures ranged from 0.25 to 0.27, consistent with dimensional structure. The graphs closely resembled dimensional prototypes. Mood instability and other types of cycling moods probably conform to a dimensional latent structure. Patients with disorders featuring mood cycling might benefit from common treatments.

DOES SCREENING WITH THE MDQ AND EPDS IMPROVE IDENTIFICATION OF BIPOLAR DISORDER IN AN OBSTETRICAL SAMPLE?

BACKGROUND

Women with bipolar disorder (BD) are at high risk for postpartum affective episodes and psychosis. Although validated screening tools are available for postpartum unipolar depression, few screening tools for hypomania/mania exist. Screening tools for BD in the postpartum period are essential for improving detection and planning appropriate treatment. We evaluated whether adding the Mood Disorders Questionnaire (MDQ) to the Edinburgh Postnatal Depression Scale (EPDS) increased the identification of BD in the early postpartum period.

METHODS

Women (N = 1,279) who delivered a live infant and screened positive on the EPDS and/or MDQ at 4-6 weeks postbirth were invited to undergo an in-home Structured Clinical Interview for DSM-IV (SCID).

RESULTS

Positive EPDS and/or MDQ screens occurred in 12% of the sample (n = 155). In home SCID diagnostic interviews were completed in 93 (60%) of the mothers with positive screens. BD was the primary diagnosis in 37% (n = 34). Women with BD screened positive on the EPDS and/or MDQ as follows: EPDS+/MDQ+ (n = 14), EPDS+/MDQ- (n = 17), and EPDS-/MDQ+ (n = 3). The MDQ identified 50% (17/34) of the women with BD and 6 additional cases of BD when the MDQ question regarding how impaired the mother perceived herself was excluded from the screen criterion.

CONCLUSION

Addition of the MDQ to the EPDS improved the distinction of unipolar depression from bipolar depression at the level of screening in 50% of women with traditional MDQ scoring and by nearly 70% when the MDQ was scored without the impairment criterion.

Different patterns of manic/hypomanic symptoms in depression: A pilot modification of the hypomania checklist-32 to assess mixed depression

BACKGROUND

There are no self-report scales that assess manic/hypomanic symptoms in patients with depression. The aim of this study was to explore the use of a modified screening instrument for bipolar disorder to assess current manic/hypomanic symptoms in patients with a depressive episode.

METHODS

The study sample consisted of 188 patients with Structured Clinical Interview for DSM-IV-TR disorders (SCID) confirmed bipolar or major depressive disorder. We modified the Hypomania Checklist-32 (mHCL-32) to assess current instead of lifetime symptoms. An Exploratory Factor Analysis (EFA) was conducted to identify clusters of mHCL-32 items that were endorsed concurrently. A Latent Class Analysis (LCA) was carried out to identify groups of patients with similar mHCL-32 item endorsement patterns.

RESULTS

The EFA identified 3 factors: factor #1 ("elation-disinhibition-increased goal directed activity"), factor #2 ("risk-taking-impulsivity-substance use") and factor #3 (distractibility-irritability). The LCA yielded 3 classes (2 showing manic/hypomanic features). While class #1 patients endorsed more items related to disinhibition and racing thoughts, class #2 patients recognized more items associated with irritability and substance use.

LIMITATIONS

Lack of an adequate gold standard measure of mixed depression to compare to, the cross-sectional design and the lack of a validation sample.

CONCLUSIONS

The mHCL-32 scale allowed a comprehensive and convergent delineation of hypomanic/manic symptoms in depression. Further validation of these findings is needed.

The status of screening measures for bipolar disorder

PURPOSE OF REVIEW

Screening measures for bipolar disorder are positioned as playing an important role in improving diagnostic accuracy. This review considers the principal screening measures developed over the past decade.

RECENT FINDINGS

Although the development and evaluation of bipolar screening measures were distinct between 2000 and 2010, there has been a decrease in research and evaluation in recent years. This article considers the main impetus for the development of screening measures for bipolar disorder and provides a description and critique of the principal measures used in both clinical and community settings.

SUMMARY

Screening measures have an important role in identifying bipolar disorder but are best positioned as a first-stage strategy rather than as definitive diagnostic measures. Although several have been developed and well validated in clinical settings, there is a distinct need for extension studies exploring their classificatory properties in community settings as well as clinical impact studies to determine their 'real world' utility.

e-HCL-32: a useful, valid and user friendly tool in the screening of bipolar II disorder

BACKGROUND AND OBJECTIVES

Bipolar type II (BDII) is a frequent disorder with high morbidity and mortality, characterized by depressive and hypomanic episodes. Early diagnosis can be effective in improving long-term prognosis. However, diagnosing BDII is challenging due to the difficulty in detecting past hypomanic episodes. The HCL-32 is a widely used and reliable screening instrument for the detection of past hypomanic episodes. Making this tool available to more patients could help diagnose and treat undetected cases of BDII earlier. New technologies such as the Internet have been previously used for this purpose with favorable outcomes. Accordingly, the objective of this study is to evaluate the acceptability, validity, reliability and equivalence of an online version of this questionnaire.

METHODS

From May 2012 to March 2013, 52 participants attending an outpatient mental health clinic completed a paper version of the HCL-32 (HCL-32) and its online version (e-HCL-32) within two weeks. After its completion, they were asked to answer a brief satisfaction survey.

RESULTS

No differences were found (HCL-32 mean total score=17.73 (SD=7.37), e-HCL-32 mean total score=18.28 (SD=7.09). T=-1.720, p=0.092, 95% CI=-1.21 to 0.09) between the results of the paper and pencil HCL-32 compared to its online version (e-HCL-32). The psychometric properties of the online version of the hypomania checklist (e-HCL-32) were good and comparable to the paper and pencil version. 80% of participants found online questionnaires to be easier to answer and more user-friendly.

CONCLUSION

The results of this study support the use of an online screening tool for the detection of previous hypomanic episodes (necessary for BDII diagnosis) as it showed to have a similar validity and reliability to the traditional paper and pencil method.

Lifetime mood spectrum symptoms among bipolar patients and healthy controls: a cross sectional study with the Mood Spectrum Self-Report questionnaire

BACKGROUND

The "spectrum" model has advantages for the conceptualization of mental disorders, representing a complementary approach to the currently available categorical systems. We carried out a study in order to assess lifetime mood symptoms among patients with bipolar disorder (BD) and healthy controls from a dimensional perspective.

METHODS

The Mood Spectrum Self-Report instrument (MOODS-SR) was administered to 101 bipolar patients (52 BD I, 32 BD II, and 17 BD NOS, 36 males/65 females, mean age+SD=36.10±13.34 years) and 38 healthy controls (16 males/22females, mean age+SD=35.18±13.70 years). The scores of the different MOOD-SR scales and subscales among patients and controls were compared using non-parametric tests (Mann-Whitney and Kruskal-Wallis).

RESULTS

Bipolar patients scored significantly higher than healthy controls on the total MOOD-SR scores (BD: mean±SD=98.65±22.17; HC: mean±SD=12.92±10.72; p<0.01) and all subdomains. Multiple comparisons revealed lower scores among controls when compared to each one of the subtypes of BD, also regarding the total scores and all subdomains (p<0.01). Comparisons across the different subtypes of BD revealed statistically significant higher scores among BD I patients when compared to BD II and BD NOS patients, only in regard to the total MOOD-SR scores (BD I: mean±SD=102.94±22.79; BD II: mean±SD=93.53±21.97; BD NOS: mean±SD= 94.88±18.68; p=0.03) and two subdomains: mood mania and energy mania.

CONCLUSIONS

These results, although preliminary, suggest that even though the MOODS-SR seems effective in distinguishing BD patients from HC, it is not as good in discriminating different subtypes of BD, especially in respect to lifetime depressive symptoms.

LIMITATIONS

Our sample size was small, and comprised by outpatients. The MOOD-SR measures only lifetime symptoms and does not take into account the progression of mood symptoms or the current mood state of patients.

[Screening for bipolar disorder in primary care patients with psychological symptoms]

Objetivo

Estimar la proporción de resultados positivos en el cribado del trastorno bipolar (TB) entre los pacientes de atención primaria que consultan por problemas de naturaleza psicológica, y analizar sus características.

Diseño

Estudio descriptivo transversal multicéntrico.

Emplazamiento

Diecinueve consultas de atención primaria en diferentes comunidades autónomas.

Pacientes

La muestra estuvo formada por 360 pacientes consecutivos de atención primaria con edades entre 18 y 70 años visitados por síntomas psicológicos.

Mediciones

El cribado para TB se realizó mediante el Mood Disorders Questionnaire. Se obtuvieron datos sobre calidad de vida (EuroQol-5D), impacto funcional (Sheehan Disability Inventory) y, mediante revisión de historias clínicas, datos sobre comorbilidad psiquiátrica y consumo de psicofármacos.

Resultados

Se obtuvo una proporción de cribados positivos del 11,9% (IC 95%: 8,8-15,7%). Solo en 2 de estos pacientes estaba registrado el diagnóstico de TB, y aunque más de la mitad recibían tratamiento con antidepresivos, solo 2 recibían tratamiento con estabilizadores del estado de ánimo. El cribado positivo se asocia a peor calidad de vida, a disfunción laboral, social y familiar, y a mayor estrés percibido.

Conclusiones

El cribado del TB en pacientes de atención primaria con otros problemas psicológicos da lugar a una notable proporción de resultados positivos, lo que indica que puede haber una prevalencia relevante de pacientes con TB, la mayor parte de ellos no diagnosticados y no tratados adecuadamente. Es necesario profundizar en la investigación para determinar el eventual papel que puede o debe asumir la atención primaria en la detección, el diagnóstico o el manejo de este trastorno.

Lifetime experiences of hypomanic symptoms are associated with delayed and irregular sleep-wake cycle and seasonality in non-clinical adult samples

OBJECTIVES

Disturbances of the sleep-wake cycle and seasonality have been reported in patients with bipolar disorder (BD). Considering that BD seems to be a spectrum condition in terms of clinical and biological characteristics, circadian and seasonal rhythm related to BD could be detected in non-clinical individuals with subthreshold bipolarity. The aim of this study was to screen past hypomanic symptoms in non-clinical samples and investigate their association with deviated sleep-wake cycle and seasonality.

METHODS

Lifetime history of hypomanic symptoms was assessed with the Hypomania Checklist-32 (HCL-32). Circadian preference, variability of sleep-wake time and seasonal changes in mood and behavior were evaluated on a lifetime-basis in non-clinical adult samples (n=313), using the Composite Scale of Morningness (CSM), the Sleep Timing Questionnaire (STQ), and the Seasonal Pattern Assessment Questionnaire (SPAQ).

RESULTS

Two subdomains of hypomanic symptoms were identified through factor analysis of HCL-32, i.e., "active/elated" factor and "irritable/risk-taking" factor. The HCL-32 total score (p<0.001) and the "active/elated" factor score (p=0.028) were weakly correlated only with seasonality, whereas the "irritable/risk-taking" factor score was associated not only with seasonality (p<0.001), but also with evening preference (p<0.001) and irregularity of sleep-wake times (p=0.001~0.011).

CONCLUSION

Circadian and seasonal characteristics related to BD are also associated with a past history of hypomanic symptoms in non-clinical samples, especially "irritable/risk-taking" symptoms, suggesting the existence of subclinical presentation of BD and their biological traits.

The Hypomania Checklist (HCL) - systematic review of its properties to screen for bipolar disorders

OBJECTIVE

Bipolar disorders (BDs) are often not recognised with potentially drastic consequences for the individuals and their families. In clinical practice self-reports can be used to screen to enhance recognition. We therefore present a systematic review of the screening properties for the Hypomania Checklist (HCL-32).

METHODS

A systematic literature search was conducted to identify all relevant studies looking at the screening properties of the HCL-32 in adults.

RESULTS

Out of 196 papers 21 papers reported data on 22 independent samples. We narratively reviewed these studies. Weighted estimated Sensitivity was 80% regardless of whether a BD diagnosis was compared to unipolar depression or any other non-bipolar diagnosis. Specificity indicated that the HCL-32 was better when comparing BD to unipolar depression (65.3%) than to any other diagnostic category (57.3%). Fewer studies provided estimates for predictive powers, leading to less reliable overall estimates for these indicators.

CONCLUSIONS

Despite some limitations, using the HCL-32 as a first screening in patients seeking help for depression can be recommended, but should never be used on its own for diagnosing. Future research should examine whether screening properties can be improved by developing an algorithm incorporating the negative consequences reported for different areas in the HCL-32.

Bipolar II disorder in patients with a current diagnosis of recurrent depression

OBJECTIVES

The prevalence of bipolar II disorder (BD-II) in Russia has never been studied. Therefore, we sought to identify patients meeting diagnostic criteria for BD-II among patients with a current diagnosis of recurrent depressive disorder (RDD) through the use of the Russian versions of the Hypomania Checklist (HCL-32) and Bipolarity Index scales for differentiating between BD-II and RDD.

METHODS

In a non-interventional diagnostic study, we selected 409 patients aged between 18 and 65 years from two medical settings with (i) a current diagnosis of RDD, (ii) an illness duration of at least three years, and (iii) at least two affective episodes. The diagnosis was based on clinical assessment and confirmed by the Russian version of the Mini International Neuropsychiatric Interview. All patients were assessed by the HCL-32, the Bipolarity Index, and the Personal and Social Performance Scale.

RESULTS

Among patients with a current diagnosis of RDD, 40.8% had a diagnosis of bipolar disorder (bipolar I disorder: 4.9%; BD-II: 35.9%). The average time lag from onset to a correct diagnosis of BD-II was 15 years and patients were treated only with antidepressants. The sensitivity of the Russian version of the HCL-32 at the optimal cutoff point (≥14.0) was 83.7%, and its specificity was 71.9%. The Bipolarity Index showed significant differences between the total scores of the patients with BD-II and RDD (31.8 versus 20.2; p < 0.0001). The optimal threshold was ≥22.0 (sensitivity 73.5%; specificity 72.3%).

CONCLUSIONS

In Russia, diagnostic errors are an important cause of the non-detection of bipolar disorder, particularly BD-II. The Russian version of the HCL-32 and the Bipolarity Index, as additional tools, could be useful for bipolarity screening.

Impact of axis-I comorbidity and suicidal behavior disorders on sensitivity and specificity of the Mood Disorder Questionnaire in complex depressed inpatients

OBJECTIVE

This study assessed the psychometric performance of the Mood Disorder Questionnaire (MDQ) and its modified MDQ7 version, to screen for bipolar disorders (BD) in depressive inpatients according to depression severity, number of current axis I psychiatric comorbidities and suicidal behavior disorders.

METHODS

Depressed adult inpatients (n=195) were consecutively enrolled. Psychiatric diagnoses were made using the standardized DSM-IV-TR structured interview MINI 5.0.0 and medical case notes. Depression severity was assessed with the Beck Depression Inventory and the Hamilton Depression Scale. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of each MDQ version were evaluated in the whole sample and according to depression severity, current axis I psychiatric comorbidities and suicidal behavior.

RESULTS

The occurrence and the number of axis I disorders affected performance of both versions. Among depressed patients with two or more comorbidities, PPV and NPV of the MDQ were 65% and 80%, respectively, and they were respectively 56.2% and 87.9% with MDQ7. Current suicidal behavior disorders also dramatically reduced the PPV of MDQ (from 81.2% to 63.3%) and MDQ7 (from 72.2% to 52.6%) but the NPV remained above 80%. The performance of both versions of the MDQ tended to improve with the severity of depression.

CONCLUSION

The MDQ is not a suitable screening instrument to diagnose BD in subjects with a complex major depressive episode and/or a current history of suicidal behavior. Nevertheless MDQ particularly in its modified version may be useful for ruling out the presence of BD among these complex patients.

Validation of the Russian version of the Hypomania Checklist (HCL-32) for the detection of Bipolar II disorder in patients with a current diagnosis of recurrent depression

BACKGROUND

There are no validated screening tools for Bipolar Disorder (BD) in Russia.

OBJECTIVE

To validate the Russian version of the HCL-32 for the detection of Bipolar II disorder (BD II) in patients with Recurrent Depressive Disorder (RDD).

METHODS

409 patients with a current diagnosis of RDD were recruited. The diagnosis was confirmed by the validated Russian version of the Mini International Neuropsychiatric Interview (MINI). Another investigator interviewed the patients using the НСL-32 questions.

RESULTS

The total HCL-32 score in patients with BD II was significantly higher than in patients with RDD: 18.2 (4.22) versus 10.85 (5.81) (p<0.001, d=1447). At the cut-off 14 points the sensitivity was 83.7%, specificity 71.9% (p<0.001). The Cronbach's alpha was 0.887 that means good internal consistency. The best discrimination was achieved with 8 items: decreased need for sleep, less shyness or inhibition, talkativeness, more jokes and puns, jumping thoughts distractibility, exhausting or irritating others and high and more optimistic mood. We proposed the reduced variant of the scale, that includes only these 8 variables, with sensitivity 90.5%, specificity 69.8% (AUC=0.88).

CONCLUSIONS

The Russian version of the HCL-32 displayed a good ratio of sensitivity to specificity and can be recommended as a validated screening instrument. An 8-item version of HCL needs further research.

LIMITATIONS

Limitations include the specific nature of the sample, the HCL-32 assessment carried out by a psychiatrist, no comparison with other BD screening scales. The results of the 8-item version may be sample and culture dependent.

A multinational study to pilot the modified Hypomania Checklist (mHCL) in the assessment of mixed depression

BACKGROUND

Mixed depression is a common, dimensional phenomenon that is increasingly recognized in unipolar and bipolar disorders. We piloted a modified version of the Hypomania Checklist (mHCL-32) to assess the prevalence and clinical correlates of concurrent manic (hypo) symptoms in depressed patients.

METHODS

The mHCL-32, Young Mania Rating Scale (YMRS) and Hamilton Rating Scale for Depression (HAMD-24) were utilized in the assessment of unipolar (UP=61) and bipolar (BP=44) patients with an index major depressive episode confirmed by the Structured Clinical Interview for DSM-IV (SCID). Differential mHLC-32 item endorsement was compared between UP and BP. Correlation analyses assessed the association of symptom dimensions measured by mHCL-32, YMRS and HAMD-24.

RESULTS

There was no significant difference between mood groups in the mean mHCL-32 and YMRS scores. Individual mHLC-32 items of increased libido, quarrels, and caffeine intake were endorsed more in BP vs. UP patients. The mHCL-32 active-elevated subscale score was positively correlated with the YMRS in BP patients and negatively correlated with HAMD-24 in UP patients. Conversely, the mHCL-32 irritable-risk taking subscale score was positively correlated with HAMD-24 in BP and with YMRS in UP patients.

LIMITATIONS

Small sample size and cross-sectional design.

CONCLUSION

Modifying the HCL to screen for (hypo) manic symptoms in major depression may have utility in identifying mixed symptoms in both bipolar vs. unipolar depression. Further research is encouraged to quantify mixed symptoms with standardized assessments.

Impulsivity in patients with panic disorder-agoraphobia: the role of cyclothymia

The relationship between Panic Disorder (PD) and impulsivity is not well explored. The present investigation aims to compare impulsivity, measured by different rating tools, in PD patients vs. healthy controls and to explore the influence of co-morbid Cyclothymic Disorder (CD) on the relationship between PD and impulsivity. Sixty-four subjects with PD and 44 matched controls underwent a diagnostic and symptomatological evaluations by the Mini Neuropsychiatric Interview (M.I.N.I) Plus 5.0; the Bech-Rafaelsen Depression and Mania Scale (BRDMS), the State-Trait Anxiety Inventory (STAI), the Hypomania Check List (HCL-32) and the Clinical Global Impression (CGI); the Questionnaire for the Affective and Anxious Temperament Evaluation of Memphis, Pisa, Paris and San Diego-Modified (TEMPS-M), the Separation Anxiety Sensitivity Index (SASI), the Interpersonal Sensitivity Symptoms Inventory (ISSI). Finally, psychometric and neurocognitive evaluations of impulsivity was carried out using the Barratt Impulsiveness Scale (BIS-11) and the Immediate and Delayed Memory Task (IMT/DMT). Subjects with PD were more impulsive than the controls in all the explored measures, reporting higher scores in symptomatological and temperamental scales. The comparison between PD patients with (Cyclo+) and without (Cyclo-) comorbid CD and controls showed that Cyclo+ are the most impulsive subjects in all the investigated measures and are characterized by the greatest symptomatological impairment, the highest scores in temperamental scales, and the highest levels of interpersonal sensitivity and separation anxiety. In our patients with PD, without lifetime comorbidity with major mood episodes, trait and state impulsivity may be related to the presence of comorbid cyclothymic mood instability.

Screening for Bipolar Disorder Symptoms in Depressed Primary Care Attenders: Comparison between Mood Disorder Questionnaire and Hypomania Checklist (HCL-32)

Objective. To describe the prevalence of patients who screen positive for bipolar disorder (BD) symptoms in primary care comparing two screening instruments: Mood Disorders Questionnaire (MDQ) and Hypomania Checklist (HCL-32). Participants. Adult patients presenting to their primary care practitioners for any cause and reporting current depression symptoms or a depressive episode in the last 6 months. Methods. Subjects completed MDQ and HCL-32, and clinical diagnosis was assessed by a psychiatrist following DSM-IV criteria. Depressive symptoms were evaluated in a subgroup with the Patient Health Questionnaire (PHQ-9). Results. A total of 94 patients were approached to participate and 93 completed the survey. Among these, 8.9% screened positive with MDQ and 43.0% with HCL-32. MDQ positive had more likely features associated with BD: panic disorder and smoking habit (P < .05). The best test accuracy was performed by cut-off 5 for MDQ (sensitivity = .91; specificity = .67) and 15 for HCL-32 (sensitivity = .64; specificity = .57). Higher total score of PHQ-9 was related to higher total scores at the screening tests (P < .001). Conclusion. There is a significant prevalence of bipolar symptoms in primary care depressed patients. MDQ seems to have better accuracy and feasibility than HCL-32, features that fit well in the busy setting of primary care.

Hypomanic symptoms assessed by the HCL-32 in patients with major depressive disorder: a multicenter trial across China

AIM

To investigate the results of the Hypomania Checklist-32 (HCL-32) administered as a screening instrument in clinical settings to mood disorders patients in the depressive phase.

METHODS

A total of 1487 patients diagnosed and being treated for major depressive disorder (MDD) in 13 mental health centers across China were self-rated by the HCL-32 and independently examined by the Mini International Neuropsychiatric Interview (MINI).

RESULTS

After examination by the MINI, 309 (20.8%) of the 1487 patients clinically diagnosed as having MDD satisfied DSM-IV criteria for bipolar disorder (BD): 118 (7.9%) for bipolar I disorder (BD-I) and 191 (12.8%) for bipolar II disorder (BD-II). The mean HCL-32 score of the BD patients was statistically higher than that of patients with unipolar depression (UD, major depressive disorder), BD-II higher than UD, while no significant difference between BD-I and BD-II. The HCL-32 distinguished between BD and UD (best cutoff score 14), between BD-II and UD (best cutoff 12). At the optimum cutoff of 12 between BD and UD, the sensitivity was 0.86, specificity 0.69.

LIMITATIONS

No standardized instruments were used to measure the severity of depressive symptoms. Depressed patients with a previous history of BD were excluded from this study.

CONCLUSIONS

The HCL-32 results in this multicenter study of patients in the depressive phase were similar to those of earlier, generally smaller-scale studies which subjects could be in any mood phases. A score of 12 could be used as the optimum cutoff between BD and UD to improve screening for BD-II if the HCL-32 was applied in clinical settings in China.

Are bipolar disorders underdiagnosed in patients with depressive episodes? Results of the multicenter BRIDGE screening study in Germany

BACKGROUND

Recent reports indicate that the prevalence of bipolar disorder (BD) in patients with an acute major depressive episode might be higher than previously thought. We aimed to study systematically all patients who sought therapy for major depressive episode (MDE) within the BRIDGE study in Germany, reporting on an increased number (increased from 2 in the international BRIDGE report to 5) of different diagnostic algorithms.

METHODS

A total of 252 patients with acute MDE (DSM-IV confirmed) were examined for the existence of BD (a) according to DSM-IV criteria, (b) according to modified DSM-IV criteria (without the exclusion criterion of 'mania not induced by substances/antidepressants'), (c) according to a Bipolarity Specifier Algorithm which expands the DSM-IV criteria, (d) according to HCL-32R (Hypomania-Checklist-32R), and (e) according to a criteria-free physician's diagnosis.

RESULTS

The five different diagnostic approaches yielded immensely variable prevalences for BD: (a) 11.6; (b) 24.8%; (c) 40.6%; (d) 58.7; e) 18.4% with only partial overlap between diagnoses according to the physician's diagnosis or HCL-32R with diagnoses according to the three DSM-based algorithms.

CONCLUSIONS

The diagnosis of BD in patients with MDE depends strongly on the method and criteria employed. The considerable difference between criteria-free physician's diagnosis and the remaining algorithms indicate the usefulness of criteria lists within the everyday clinical setting.

LIMITATIONS

Diagnoses based on DSM were only made with checklists. The diagnoses of (hypo-) manic episodes in the patient history were not systematically verifiable by indirect anamnesis.

Integrating bipolar disorder management in primary care

There is growing realization that persons with bipolar disorder may exclusively be seen in primary (general medical) care settings, notably because of limited access to mental health care and stigma in seeking mental health treatment. At least two clinical practice guidelines for bipolar disorder recommend collaborative chronic care models (CCMs) to help integrate mental health care to better manage this illness. CCMs, which include provider guideline support, self-management support, care management, and measurement-based care, are well-established in primary care settings, and may help primary care practitioners manage bipolar disorder. However, further research is required to adapt CCMs to support complexities in diagnosing persons with bipolar disorder, and integrate decision-making processes regarding medication safety and tolerability in primary care. Additional implementation studies are also needed to adapt CCMs for persons with bipolar disorder in primary care, especially those seen in smaller practices with limited infrastructure and access to mental health care.

Screening for bipolar disorder with the Mood Disorders Questionnaire in patients diagnosed as major depressive disorder - the experience in China

BACKGROUND

Bipolar disorder (BD) is often misdiagnosed as a major depressive disorder (MDD). This study aimed to test the usefulness of the screening tool, the Mood Disorders Questionnaire (MDQ), to identify BD patients misdiagnosed as MDD in Chinese clinical settings.

METHODS

A total of 1487 patients treated for MDD were consecutively examined in 13 mental health centers in China. The patients' socio-demographic and clinical characteristics were recorded using a standardized protocol and data collection procedure. The MDQ was completed by patients to identify symptoms characteristic of BD. DSM-IV diagnoses were established using the Mini International Neuropsychiatric Interview (MINI).

RESULTS

Three hundred-nine of the 1487 patients (20.8%) satisfied DSM-IV criteria for BD; 118 (7.9%) for BD-I and 191 (12.8%) for BD-II on the MINI. The optimal cut-off point on the MDQ to differentiate BD from MDD was 3, while cut-off points of 5 and 3 differentiated BD-I and BD-II from MDD, respectively. The maximum sensitivity was 0.31, 0.45 and 0.22 for differentiating BD, BD-I and BD-II from MDD, respectively.

CONCLUSIONS

The optimal cutoff points of the MDQ for screening BD in Chinese patients originally diagnosed as MDD were considerably lower than those in earlier studies. The routine clinical use of the MDQ as a screening scale for BD in Chinese patients treated for MDD does not seem to be justified.

Cross validation with the mood disorder questionnaire (MDQ) of an instrument for the detection of hypomania in Brazil: The 32 item hypomania symptom check-list, first Revision (HCI-32-R1)

BACKGROUND

Bipolar disorders are frequently diagnosed and treated as unipolar depression initially and accurate diagnosis is often delayed by 8 to 10years. It has been demonstrated that the bipolar spectrum disorders are associated with notable disability and that the current diagnostic gold standard, the Structured Clinical Interview for DSM-IV (SCID) is not sufficiently sensitive to the diagnosis of hypomania or subthreshold manic states. There is a need for better and simpler ways to identify these conditions.

METHODS

Hirschfeld et al. (2000) developed and tested a self-report scale for bipolar disorder: the Mood Disorder Questionnaire (MDQ). Recently, another scale has been developed by Angst to assess hypomanic symptoms and to increase the detection of suspected and of manifest, but undertreated, cases of bipolar disorders. In this Brazilian study, 200 patients with the putative diagnosis of "depression" were interviewed using the Structured Clinical Interview for DSM-IV, Axis I Disorders - Clinician Version (SCID-CV; First et al., 1997), as modified by Benazzi and Akiskal (2003) to increase the sensitivity to BP II disorders. Before the interview patients were screened by both HCI-32-R(1) and MDQ and asked to complete them.

RESULTS

The HCI-32-R(1) showed a sensitivity of 79.8% and a specificity of 60.5% for the cut-off of 14. A sensitivity of 68.1% and a specificity of 63% were obtained for the Mood Disorder Questionnaire for the cut-off of 7.

LIMITATIONS

Although not showing a good specificity, the MDQ seems to be a useful instrument for the screening phase, in which it is important that "cases" are recognized. The HCI-32-R(1) does not distinguish between BP I and BP II disorders. The sample size of patients should be increased in further studies.

CONCLUSIONS

The HCI-32-R(1) demonstrated two main factors identified as "active-elated" hypomania and "risk-taking/irritable" hypomania and showed to be a sensitive instrument for hypomanic symptoms. It is a simple and easy-to-use tool for the self-assessment of hypomanic symptoms and may be a valuable supplement to the clinician's interview. The Mood Disorder Questionnaire is a useful screening instrument for bipolar I, bipolar II disorders and other manifestations of bipolar spectrum. As such, this scale might increase the detection of under-treated cases of bipolar disorders. Further studies are needed to verify the accuracy of these tools in non-psychiatric settings and in the general population.

Undiagnosed bipolar disorder in patients treated for major depression in China

BACKGROUND

Bipolar disorder (BD) is a recurrent, complex illness and often misdiagnosed and treated as a major depressive disorder (MDD). This study set out (1) to investigate the proportion of BD in patients treated for MDD using DSM-IV diagnostic criteria; (2) to test the usefulness of the screening tool - the 32-item Hypomania Checklist (HCL-32) in Chinese patients; and (3) to assess whether MDD patients with subthreshold manic features (patients who screened positive for BD on the HCL-32, but did not meet the diagnostic criteria for DSM-IV BD as measured by Mini International Neuropsychiatric Interview (MINI)) differ from those with BD, and from those suffering from MDD without manic features in terms of basic demographic and clinical variables.

METHODS

A total of 1487 patients treated for MDD were consecutively examined in 13 mental health centers in China. The patients' socio-demographic and clinical characteristics were recorded using a standardized protocol and data collection procedure. The HCL-32 was self-completed by patients to identify hypomanic symptoms, and the MINI was used by clinicians to establish DSM-IV diagnoses.

RESULTS

The proportions of undiagnosed BD (all types), BD-I and BD-II were 20.8%, 7.9% and 12.8%, respectively. The HCL-32 had low positive predictive value (0.43). Compared to MDD patients without subthreshold manic features, MDD patients with subthreshold manic features were younger at onset, less likely to be married and had more depressive episodes on a seasonal basis, and more frequent depressive episodes overall. Compared to BD patients, MDD patients with subthreshold manic features had an older age at onset and less frequent depressive episodes and less family history of psychiatric disorders, appetite, weight gain and time spent sleeping, suicide ideation and attempts and psychotic symptoms.

CONCLUSIONS

At least one fifth of Chinese patients treated for MDD may have an undiagnosed BD. The HCL-32 is useful to identify broader subthreshold bipolar features. The findings need to be confirmed by longitudinal studies using more comprehensive, standardized instruments.

Comparison of the validity of the Chinese versions of the Hypomania Symptom Checklist-32 (HCL-32) and Mood Disorder Questionnaire (MDQ) for the detection of bipolar disorder in medicated patients with major depressive disorder

OBJECTIVE

The sensitivity and specificity of the Chinese versions of the Hypomania Symptom Checklist-32 (HCL-32) and Mood Disorder Questionnaire (MDQ) for detecting bipolar disorder in Taiwan were explored in this study.

METHODS

In total, 59 participants who were initially diagnosed with unipolar depression were recruited from an outpatient clinic and were screened for bipolar disorder using the HCL-32 and MDQ; each participant also underwent a diagnostic interview based on the Structured Clinical Interview for DSM-IV Axis disorder patients (SCID).

RESULTS

The results showed that the HCL-32 yielded the best combination of sensitivity (100%) and specificity (46.2%) at a cut-off point of 7/8, and the MDQ yielded the best combination of sensitivity (71.4%) and specificity (76.9%) at a cut-off point of 6/7.

CONCLUSION

The results of our study demonstrate that the HCL-32 and MDQ are of reasonable validity to distinguish between bipolar disorder and major depressive disorder. However small sample size may limit generalization of the results.

Different measures of impulsivity in patients with anxiety disorders: a case control study

The relationship between anxiety and impulsivity is controversial and not well explored. The present investigation aims to compare impulsivity, measured by different rating tools, in patients with anxiety disorders vs. healthy controls. Forty-seven subjects with different anxiety disorders and 45 matched controls underwent diagnostic and symptomatological evaluations by the Mini Neuropsychiatric Interview (M.I.N.I) Plus 5.0, Bech-Raphaelsen Depression and Mania Scale (BRDMS), State-Trait Anxiety Inventory (STAI), Hypomania Check List (HCL-32) and the Clinical Global Impression (CGI); temperamental evaluations by the Questionnaire for the Affective and Anxious Temperament Evaluation of Memphis, Pisa, Paris and San Diego-Modified (TEMPS-M), the Separation Anxiety Sensitivity Index (SASI), the Interpersonal Sensitivity Symptoms Inventory (ISSI); and psychometric and a neurocognitive evaluations of impulsivity using the Barratt Impulsiveness Scale (BIS-11) and the Immediate and Delayed Memory Task (IMT-DMT). Subjects with anxiety disorders were more impulsive than the controls in all the explored measures, with higher scores in symptomatological and, temperamental scales. Patients with anxiety disorders but without a lifetime history of comorbid major mood episodes had greater trait and state impulsivity than controls. Further investigations are needed to assess the extent to which impulsivity might or might not be directly related to the anxiety disorder.

The use of Mood Disorder Questionnaire, Hypomania Checklist-32 and clinical predictors for screening previously unrecognised bipolar disorder in a general psychiatric setting

Bipolar disorder is often unrecognised and misdiagnosed in the general psychiatric setting. This study compared the psychometric properties of the Mood Disorder Questionnaire (MDQ) and the Hypomania Checklist-32 (HCL-32), examined the clinical predictors of bipolar disorder and determined the best approach for screening previously unrecognised bipolar disorder in a general psychiatric clinic. A random sample of 340 non-psychotic outpatients with no previous diagnosis of bipolar disorder completed the MDQ and HCL-32 during their scheduled clinic visits. Mood and alcohol/substance use disorders were reassessed using a telephone-based Structured Clinical Interview for DSM-IV. We found that the HCL-32 had better psychometric performance and discriminatory capacity than the MDQ. The HCL-32's internal consistency and 4-week test-retest reliability were higher. The area under the curve was also greater than that of the MDQ at various clustering and impairment criteria. The optimal cut-off of the MDQ was co-occurrence of four symptoms with omission of the impairment criterion; for the HCL-32, it was 11 affirmative responses. Multivariable logistic regression found that bipolar family history was associated with an increased risk of bipolar disorder (odds ratio=4.93). The study showed that simultaneous use of the HCL-32 and bipolar family history was the best approach for detecting previously unrecognised bipolar disorder.

Discriminative hypomania checklist-32 factors in unipolar and bipolar major depressive patients

BACKGROUND

Although manic or hypomanic episodes define bipolar disorder (BD), most patients show a predominance of depressive symptomatology, often associated with delayed or disregarded BD diagnosis. The Hypomania Checklist-32 (HCL-32) has therefore been developed and tested internationally to facilitate BD recognition.

SAMPLING AND METHODS

Five hundred seventy-one (563 eligible) patients diagnosed with a major depressive episode according to DSM-IV criteria were consecutively enrolled in a cross-sectional, multicenter, observational study (Come To Me). Lifetime manic or hypomanic features were assessed by the HCL-32, and severity of depressive and anxious symptomatology was assessed using the Zung's self-report questionnaires for depression and anxiety.

RESULTS

Among the patients diagnosed with BD (n = 119), either type I or type II, the occurrence of (hypo)manic symptoms was significantly higher compared to major depressive disorder (MDD) symptoms according to HCL-32 total and subscale scores obtained using a score of 14, which ensured an optimal discrimination between BD and MDD with a sensitivity of 0.85 and a specificity of 0.78.

CONCLUSIONS

Although some false positives might occur, the HCL-32 was confirmed to be a useful instrument in the detection of past hypomania in MDD patients, finally contributing to proper therapeutic choices.

Screening for bipolar disorder among outpatients with substance use disorders

Background

Comorbidity of bipolar disorder and alcohol or substance abuse/dependence is frequent and has marked negative consequences on the course of the illness and treatment compliance. The objective of this study was to compare the validity of two short instruments aimed at screening bipolar disorders among patients treated for substance use disorders.

Methods

The Mood Disorder Questionnaire (MDQ) and the Hypomania Checklist-32 (HCL-32) were tested with reference to the mood section of the Structured Clinical Interview for DSM-IV axis I disorders (SCID) in 152 patients, recruited in two outpatient clinics providing specialized treatment for alcohol and opiate dependence.

Results

According to the SCID, 33 patients (21.7%) had a diagnosis within the bipolar spectrum (two bipolar I, 21 bipolar II and 10 bipolar not otherwise specified). The HCL-32 was more sensitive (90.9% vs. 66.7%) and the MDQ more specific (38.7% vs. 77.3%) for the whole sample. The MDQ displayed higher sensitivity and specificity in patients treated for alcohol than for opiate dependence, whereas the HCL-32 was highly sensitive but poorly specific in both samples. Both instruments had a positive predictive value under 50%.

Conclusions

Caution is needed when using the MDQ and HCL-32 in patients treated for substance use disorders.