Advanced Practice Registered Nurses: Gateway to Screening for Bipolar Disorder in Primary Care

A comparison of the 33-item Hypomania Checklist with the 33-item Hypomania Checklist-external assessment for the detection of bipolar disorder in adolescents

BACKGROUND

Adolescents with bipolar disorder (BD) are often misdiagnosed as having major depressive disorder (MDD), which delays appropriate treatment and leads to adverse outcomes. The aim of this study was to compare the performance of the 33-item Hypomania Checklist (HCL-33) with the 33-item Hypomania Checklist- external assessment (HCL-33-EA) in adolescents with BD or MDD.

METHODS

147 adolescents with BD and 113 adolescents with MDD were consecutively recruited. The HCL-33 and HCL-33-EA were completed by patients and their carers, respectively. The sensitivity, positive predictive value (PPV), specificity, negative predictive value (NPV), and area under the curve (AUC) were calculated and compared between the two instruments, using cut-off values based on the Youden's index.

RESULTS

The total scores of the HCL-33 and HCL-33-EA were positively and significantly correlated (rs = 0.309, P < 0.001). Compared to the HCL-33, the HCL-33-EA had higher sensitivity and NPV (HCL-33: sensitivity = 0.58, NPV = 0.53; HCL-33-EA: sensitivity = 0.81, NPV = 0.60), while the HCL-33 had higher specificity and PPV (HCL-33: specificity = 0.61, PPV = 0.66; HCL-33-EA: specificity = 0.37, PPV = 0.63).

CONCLUSION

Both the HCL-33 and HCL-33-EA seem to be useful for screening depressed adolescents for BD. The HCL-33-EA would be more appropriate for distinguishing BD from MDD in adolescents due to its high sensitivity in Chinese clinical settings.

The Rapid Mood Screener (RMS): a novel and pragmatic screener for bipolar I disorder

OBJECTIVE

Depressive episodes and symptoms of bipolar I disorder are commonly misdiagnosed as major depressive disorder (MDD) in primary care. The novel and pragmatic Rapid Mood Screener (RMS) was developed to screen for manic symptoms and bipolar I disorder features (e.g. age of depression onset) to address this unmet clinical need.

METHODS

A targeted literature search was conducted to select concepts thought to differentiate bipolar I from MDD and screener tool items were drafted. Items were tested and refined in cognitive debriefing interviews with individuals with self-reported bipolar I or MDD (n = 12). An observational study was conducted to evaluate predictive validity. Participants with clinical interview-confirmed bipolar I or MDD diagnoses (n = 139) completed a draft 10-item screening tool and other questionnaires. Data were analyzed to identify the smallest possible subset of items with optimized sensitivity and specificity.

RESULTS

Adults with confirmed bipolar I (n = 67) or MDD (n = 72) participated in the observational study. Ten draft screening tool items were reduced to 6 final RMS items based on the item-level analysis. When 4 or more items of the RMS were endorsed ("yes"), sensitivity was 0.88 and specificity was 0.80; positive and negative predictive values were 0.80 and 0.88, respectively. These properties were an improvement over the Mood Disorder Questionnaire in the same analysis sample while using 60% fewer items.

CONCLUSION

The pragmatic 6-item RMS differentiates bipolar I disorder from MDD in patients with depressive symptoms, providing real-world guidance to primary care practitioners on whether a more comprehensive assessment for bipolar I disorder is warranted.

Bipolar depression: the clinical characteristics and unmet needs of a complex disorder

Objective: We reviewed important clinical aspects of bipolar depression, a progressive psychiatric condition that is commonly treated in primary care. Bipolar depression is associated with considerable burden of illness, high suicide risk, and greater morbidity and mortality than bipolar mania. Methods: We identified articles relevant to our narrative review using a multistep search of the literature and applying terms that were relevant to bipolar depression or bipolar disorder. Results: Bipolar depression accounts for the majority of time spent unwell for patients with bipolar disorder; high rates of morbidity and mortality arise from full symptomatic episodes and interepisode subsyndromal symptoms. Bipolar depression is an important contributor to long-term dysfunction for patients with bipolar disorder due to psychosocial impairment, loss of work productivity and high rates of substance abuse. Missed and delayed diagnosis is prevalent due to overlapping symptoms with unipolar depression and other diagnoses. Medical comorbidities (i.e. cardiovascular disease, hypertension, obesity, metabolic syndrome) and psychiatric comorbidities (i.e. anxiety disorder, personality disorder, eating disorder, attention-deficit/hyperactivity disorder) are common. Currently, only three treatments are FDA-approved for bipolar depression; monotherapy antidepressants are not a recommended treatment option. Conclusions: Bipolar disorder is common among primary care patients presenting with depression; it is often treated exclusively in primary care. Clinicians should be alert for symptoms of bipolar disorder in undiagnosed patients, know what symptoms probabilistically suggest bipolar versus unipolar depression, have expertise in providing ongoing treatment to diagnosed patients, and be knowledgeable about managing common medication-related side effects and comorbidities. Prompt and accurate diagnosis is critical.