Research reportThree studies on self-report scales to detect bipolar disorder
Introduction
Bipolar disorder is associated with high health care costs, lost productivity, elevated medical comorbidity, hospitalization, and the risk of suicide (Andlin-Sobocki and Wittchen, 2005, Baldessarini and Tondo, 2003, Kupfer, 2005, Peele et al., 2003). The lifetime prevalence of bipolar I disorder is reported to be approximately 1% (Judd and Akiskal, 2003, Kessler et al., 1997, Kessler et al., 2005, Kessler et al., 1994, Narrow et al., 2002, Regier et al., 1993, Weissman et al., 1996). For bipolar II disorder, some authors argue that estimates of 1.1% (Merikangas et al., 2007) are artifactually low, due to poor sensitivity of diagnostic measures (Angst and Cassano, 2005). Estimates of the prevalence of cyclothymia range from 0.4% (American Psychiatric Association, 2000) up to 4% (Regeer et al., 2004).
Even though bipolar disorder affects many people, it is often misdiagnosed. Studies conducted in the United States and Europe indicate that 26 to 70% of people with bipolar disorder may either receive an incorrect diagnosis or go undiagnosed altogether. Proper diagnosis may not occur for a decade after bipolar symptoms emerge, especially for those with bipolar II disorder (Ghaemi et al., 2005, Lewis, 2004, Lish et al., 1994, Mantere et al., 2004). A significant percentage of those presenting with unipolar depression may actually suffer from some type of bipolar disorder (Dunner, 2003).
Several factors may contribute to this lack of recognition of the illness (Benazzi et al., 2004). Most people with bipolar disorder who seek treatment do so because of their depression rather than mania (Hirschfeld et al., 2005) and perceive their depression to be more troublesome than their mania (Calabrese et al., 2004). Some people with bipolar disorder lack insight into the presence or consequences of their manic symptoms. Hypomanic episodes, by definition, do not cause severe impairment or distress, so they are less likely to be defined as a problem by people who experience them. When people with bipolar disorder seek treatment for depression, their symptom profile may be virtually indistinguishable from that of unipolar depression (Cuellar et al., 2005). In addition, many clinicians do not screen for bipolar disorder, even when a client presents with depressive symptoms (Brickman et al., 2002).
Unfortunately, the consequences of misdiagnoses are serious. Misdiagnosis as unipolar depression can lead to antidepressant monotherapy, which may trigger mania or rapid cycling in up to 50% of people with bipolar disorder (Ghaemi et al., 2004).
One potential solution to the problem of misdiagnosis could be the use of brief self-report scales to alert providers to the possibility of bipolar disorder. This would allow clinicians to complete a more rigorous diagnostic assessment with patients who seem most likely to have a bipolar disorder. Several such scales have been developed, including the Hypomanic Personality Scale (HPS; Eckblad and Chapman, 1986), the Mood Disorder Questionnaire (MDQ; Hirschfeld et al., 2000), the Temperament Evaluation of Memphis, Pisa, Paris, and San Diego—Autoquestionnaire version (TEMPS-A; Akiskal et al., 2005), the Bipolar Spectrum Diagnostic Scale (BSDS; Ghaemi et al., 2005), the General Behavior Inventory (GBI; Depue et al., 1989), and the Hypomania Checklist (HCL; Angst et al., 2005).
Each of these scales has strengths. For example, they generally have high internal consistency, and each yields significantly higher scores in patient populations than among healthy controls. Several of them have demonstrated at least modest sensitivity and specificity. For instance, the MDQ had a sensitivity of .73 and a specificity of .90 in one study (Hirschfeld et al., 2000). More than three quarters of a sample of students scoring high on the HPS had a history of at least one hypomanic episode; none with low scores had a hypomanic history (Eckblad and Chapman, 1986). The GBI has shown a sensitivity of .78 and a specificity of greater than .98 in two studies (Depue et al., 1981, Klein et al., 1989). The HCL (32-item version) has more limited specificity in detecting bipolar disorder (Angst et al., 2005); however, this may reflect its goal of detecting hypomania, which is less easily distinguished from normal functioning. The TEMPS-A has been studied extensively in Europe, and was the subject of an issue of the Journal of Affective Disorders (Akiskal et al., 2005); however, sensitivity and specificity estimates for this measure have not yet been published.
Some measures are too long to be widely used as screeners. For example, although the GBI has been well-validated (Angst et al., 2005), its full 73-item version can take more than 20 min to complete. Shorter versions of the GBI have been developed (Lewinsohn et al., 2003, Meyer and Hautzinger, 2003), but have not been validated in other samples. In sum, successful detection of bipolar disorder via self-report scales faces difficult challenges. First, it is not clear that existing scales have adequate sensitivity to bipolar disorder for use in routine screening. Second, the length of some scales (e.g., the GBI) limits their utility for screening.
The studies reported here were designed to add to the literature on the detection of bipolar disorder by further testing measures that have shown promising sensitivity and specificity in previous research. Study 1 developed a brief version of the HPS and tested it across samples. The HPS was chosen because it has yet to be applied to clinical samples and may hold promise for detecting bipolar II disorder due to its attention to hypomanic traits. Study 2 used the small set of items derived from Study 1 in an advertising campaign to recruit research participants into a study on bipolar disorder. Study 3 involved administration of screening questionnaires (including the HPS-6 produced in Study 1 and tested in Study 2) to a large sample of undergraduates, yielding a sample enriched for vulnerability to bipolar disorder that was studied in detail. That study included the HPS due to its long-standing application to undergraduate populations, and the MDQ because it has been extensively studied in clinical settings. The only study to use the MDQ in an undergraduate population did not include a diagnostic interview to examine correspondence between the MDQ and bipolar diagnoses (Chandler et al., 2008). The complete GBI is too long to serve as a screening measure, but we included a shortened version, the GBI-15 (Meyer and Johnson, 2003) based on the existing psychometric evidence for the 73-item version.
Section snippets
Study 1
The goal of Study 1 was to develop a briefer version of the HPS that could be used to reliably screen for bipolar disorder. The original HPS has 48 true–false items and takes about 7 min to complete. The goal was to create a subset of items that could be completed in less than 2 min, which would be appropriate for advertisements or posters. Such a set of items then could be used to recruit potentially bipolar participants for studies through notices in papers or public transportation.1
Study 2
The goal of Study 2 was to determine whether advertising featuring items derived from Study 1 could be used to recruit research participants with bipolar disorder. Few studies have investigated the usefulness of self-report scales in the general population. What little research exists suggests that self-report screens are likely insensitive to bipolar disorder in the community (Hirschfeld et al., 2003).
Study 3
The first two studies focused on the usefulness of the HPS in detecting bipolar disorder. Few studies have directly compared the sensitivity and specificity of different self-report screening tools for bipolar disorder diagnoses. In one study, Youngstrom et al. (2004) found that adolescents with bipolar disorder scored .7 standard deviations higher on the GBI and the Youth Self-Report Form (Achenbach, 1991) than their non-bipolar counterparts. Sensitivity and specificity were not reported in
General discussion and future directions
This article presented results from three studies on the detection of bipolar disorder via brief self-report scales. In Study 1, the HPS was administered to an undergraduate and a clinic/community sample. This revealed a small subset of HPS items that correlated particularly well with bipolar diagnosis across samples, allowing creation of the briefer HPS-6. In Study 1, the HPS-6 had good sensitivity and modest specificity in both samples, although different cutoffs were required across samples.
Role of funding source
Funding for these studies was supported by grants from the National Institute of Mental Health (NIMH R01-075021), the National Science Foundation (BCS0544617), the Scottish Rite Schizophrenia Research Program, and University of Miami Seed Funding. None of these organizations played any further role in study design; in the collection, analysis, and interpretation of data; in the writing of the report; and/or in the decision to submit the paper for publication.
Conflict of interest
None of the authors have any conflicts of interest.
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