Validation of the Mood Disorder Questionnaire for screening for bipolar disorder in a UK sample

The utility of Mood Disorder Questionnaire for the detection of bipolar diathesis in treatment-resistant depression

BACKGROUND

Treatment-resistant depression is a heterogeneous entity. There are many variables associated with poor response to antidepressants, one of which is missed bipolarity. Therefore, the present study investigated the bipolar diathesis between patients with treatment-resistant (TR) depression and non-treatment-resistant (NTR) depression as assessed with the Mood Disorder Questionnaire (MDQ).

METHOD

The population studied included 1051 patients diagnosed with single or recurrent major depressive disorder. They were classified into a non-treatment-resistant group (481 patients) and a treatment-resistant group (570 patients). The psychiatrist, using information from the patient's medical history, psychiatric examination and available documentation, assessed each eligible patient. The symptoms of bipolarity were additionally assessed by the Mood Disorder Questionnaire.

RESULTS

A positive screen on the MDQ defined as endorsement of at least 6 of the 13 yes or no questions was an independent risk factor for treatment resistance.The total MDQ score was significantly higher in TR vs NTR (4.33 vs 2.66 points p<0.001) and the percentage of patients screened positive was significantly higher in TR than in NTR (13.7% vs 5.6% p<0.001). Factor analysis resulted in 2 factors with eigenvalues >1 explaining 91.5% of total variance.

CONCLUSIONS

Using the MDQ scale we confirmed the association between bipolarity and worse response to antidepressant drugs in patients with major depressive disorder.

Fibromyalgia and bipolar disorder: a potential problem?

OBJECTIVE

To screen patients with fibromyalgia for bipolar disorder and to determine if there were any clinical clues, other than the Mood Disorders Questionnaire (MDQ), which might suggest a diagnosis of comorbid bipolar disorder.

METHODS

A total of 128 consecutive new fibromyalgia patients referred to a tertiary care center rheumatology practice were enrolled and assessed using a standard clinical protocol that included the completion of four screening questionnaires: (i) MDQ for bipolar disorder, (ii) Beck Depression Inventory (BDI) for depression, (iii) Epworth Sleepiness Scale (ESS) for daytime sleepiness, and (iv) Fibromyalgia Impact Questionnaire Disability Index (FIQ-DI) to assess for functional capacity.

RESULTS

A quarter of the fibromyalgia subjects, 25.19%, had a positive screen for bipolar disorder (MDQ >or= 7); 78.12% were clinically depressed (BDI >or= 10); and 52.13% reported daytime sleepiness (ESS >or= 10). Fibromyalgia subjects who screened positive for bipolar disorder had more severe depression than those with a negative screen [median BDI: 26.0 (19.0, 32.0) versus 15.0 (9.0, 24.0), p < 0.001].

CONCLUSIONS

We report a high prevalence of positive testing for bipolar disorder in this fibromyalgia cohort. Clinical data and questionnaire instruments other than nonspecific high depression severity failed to identify these patients. Since the norepinephrine serotonin reuptake inhibitors duloxetine and milnacipran have been recently approved by the U.S. Food and Drug Administration for the treatment of fibromyalgia, and because patients with bipolar disorder may experience destabilization of mood when treated with such agents, patients with fibromyalgia should be systematically screened for bipolar disorder prior to treatment.

A different approach toward screening for bipolar disorder: the prototype matching method

Most screening scales for psychiatric disorders consist of a series of questions about the signs and symptoms of the disorder of interest, and to determine whether a patient screens positive, the scores of the individual items are summed and the total score is compared with an empirically derived threshold. A problem with the score summation approach toward case identification on screening scales is that different studies may find that different thresholds are optimal for distinguishing cases from noncases. An alternative approach toward screening is the prototype matching approach, in which respondents are asked to indicate how well their clinical history matches the described prototype. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we compared the symptom summation and prototype matching approaches toward screening for bipolar disorder in a large sample of psychiatric outpatients. Nine hundred sixty-one psychiatric outpatients were interviewed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition and completed the Bipolar Spectrum Disorders Scale (BSDS). The BSDS is a unique screening scale consisting of a prototypic description of bipolar disorder. The respondent checks off which items in the prototypic paragraph describes them and also answers a single multiple-choice question at the end of the paragraph asking how well the paragraph describes them. The results of a receiver operating curve analysis found that the score summation and prototype matching approaches toward screening on the BSDS performed equally well. These findings provide preliminary evidence that an alternative approach toward psychiatric screening, the prototype matching approach, is as effective as the traditional score summation method. This raises the intriguing possibility of developing a combined screening scale/educational instrument that can be formatted as a brochure and thus placed in clinicians' waiting rooms, thereby facilitating use of the measure.

Screening for bipolar disorder during pregnancy and the postpartum period

Bipolar disorder is a significant mental health problem among perinatal women; however, little attention has been devoted to methods of screening for bipolar disorder during this phase of women's life cycle. There is a need for reliable and valid screening instruments for perinatal women. This paper presents a review of 11 self-report measures used to screen bipolar disorder in the general population and discusses their applicability to screening among perinatal women. Published psychometric data, including reliability, sensitivity, specificity, and positive predictive value of each self-report instrument, is presented and critiqued. We make recommendations for screening in clinical practice and highlights priorities for future research. The need for more research in this area is emphasized.

Identification of bipolar disorder in women with postpartum depression

OBJECTIVE

No studies to date have assessed the pharmacological management of treatment-resistant postpartum depression. We reviewed the pharmacological treatment of postpartum depression in patients diagnosed with treatment-resistant 'unipolar' depression.

METHODS

We conducted a chart review of patients treated consecutively at a perinatal clinic. Treatment-resistant postpartum depression was defined as a failure to respond to at least one adequate antidepressant trial. Patients were diagnosed using the DSM-IV criteria, and the Clinical Global Impression-Improvement (CGI-I) rating scale was used to assess response to various pharmacological interventions.

RESULTS

The majority of patients (57%, 34/60) referred for postpartum depression actually suffered from bipolar disorder. All patients were on antidepressants at the time of referral, but by the end of the study 37% (22/60) continued on antidepressants alone or in combination with other medications. CGI-I ratings showed appreciable improvement in depression at the end of six months following the initial consultation. Very much improvement was noted in 65% (39/60) of patients, and 22% (13/60) were considered much improved. The most common change in medication was a switch to or addition of an atypical neuroleptic.

LIMITATIONS

Retrospective design, small sample size, and lack of a control group.

CONCLUSIONS

Management of treatment resistance in women with postpartum depression should be considered within the context of types of mood disorders. Atypical neuroleptics and mood stabilizers used alone or as adjuncts should be considered in the treatment of resistant postpartum depression in patients with a bipolar diathesis.

Performance of the mood disorders questionnaire in a psychiatric outpatient setting

OBJECTIVES

The Mood Disorders Questionnaire (MDQ) has been the most widely studied screening questionnaire for bipolar disorder, though few studies have examined its performance in a heterogeneous sample of psychiatric outpatients. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined the operating characteristics of the MDQ in a large sample of psychiatric outpatients presenting for treatment.

METHODS

A total of 534 psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV and asked to complete the MDQ. Missing data on the MDQ reduced the number of patients to 480, 10.4% (n = 52) of whom were diagnosed with bipolar disorder.

RESULTS

Based on the scoring guidelines recommended by the developers of the MDQ, the sensitivity of the scale was only 63.5% for the entire group of bipolar patients. The specificity of the scale was 84.8%, and the positive and negative predictive values were 33.7% and 95.0%, respectively. When impairment was not required to define a case on the MDQ, then sensitivity increased to 75.0%, specificity dropped to 78.5%, positive predictive value was 29.8%, and negative predictive value was 96.3%.

CONCLUSIONS

In a large sample of psychiatric outpatients, we found that the MDQ, when scored according to the developers' recommendations, had inadequate sensitivity as a screening measure. After the threshold to determine MDQ caseness was lowered by not requiring moderate or severe impairment, the sensitivity of the scale increased, but specificity decreased, and positive predictive value remained below 30%. These results raise questions regarding the MDQ's utility in routine clinical practice.

Validation of the Mood Disorder Questionnaire in the general population in Hong Kong

OBJECTIVE

The objective of the study was to determine the reliability and validity of a Chinese version of the Mood Disorder Questionnaire (MDQ) in the general population in Hong Kong.

METHODS

One thousand five hundred eighteen adults aged at least 18 years were randomly drawn from the general population and interviewed using a lay-administered version of the MDQ. A subsample of 114 randomly selected participants received a telephone-based Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition. Six subjects were diagnosed to have bipolar disorder (bipolar I = 1, bipolar II = 4, and bipolar not otherwise specified = 1), 13 had substance/alcohol use disorder, and 95 had neither bipolar nor substance/alcohol use disorder. We determined the internal consistency, factor structure, and concurrent validity of the Chinese MDQ.

RESULTS

The Cronbach alpha coefficient of the Chinese MDQ was 0.78. Principal component analysis with varimax rotation indicated a "euphoria-irritability-racing thoughts" factor, an "energized-activity" factor, and a "risky behavior" factor, which explained 46.6% of the rotated variance. There were significant differences in MDQ scores between the bipolar and non-bipolar non-substance/alcohol use disorder groups. The performance of the Chinese MDQ for detecting bipolar disorder was limited by a low sensitivity. Using the original cutoff criterion, defined as clustering of 7 or more symptoms that caused moderate or severe problems, the sensitivity was 0%, whereas the overall specificity was 95.4%. Lowering the cutoff criterion to a symptom score of at least 7 that caused minor or more problems yielded the best sensitivity (0.50) and specificity (0.92).

CONCLUSION

The Chinese MDQ is a reliable and valid measure of bipolar disorder in the community.

Reliability of the Mood Disorder Questionnaire: comparison with the Structured Clinical Interview for the DSM-IV-TR in a population sample

OBJECTIVE

The Mood Disorder Questionnaire (MDQ) is a widely used self-report screening instrument for the detection of bipolar disorder in clinical populations. The aim of the present study was therefore to investigate the reliability of this instrument.

METHODS

Screening results using the MDQ were compared with results obtained using the Structured Clinical Interview for DSM-IV-TR Research Version, Non-patient edition (SCID) in a community-based sample of 1066 women. Trained personnel, who were blind to the results of the MDQ screen, conducted clinical interviews.

RESULTS

Using the MDQ, 21 women screened positive for bipolar disorder, and using the SCID diagnoses, 24 women were confirmed with a diagnosis of bipolar disorder. Six women were detected on both instruments. Compared to the SCID, the sensitivity for the MDQ was 25%, specificity 99%, positive predictive value 28%, negative predictive value 98%, and a demonstrated kappa of 0.25. The MDQ failed to detect any of the 11 participants in the study with bipolar II disorder and missed seven of 13 participants with bipolar I disorder or bipolar not otherwise specified. Of the 21 women who screened positive using the MDQ, 19 had current or past psychopathologies other than bipolar disorder.

CONCLUSION

The MDQ has substantial limitations for detection of bipolar disorder, in particular bipolar II disorder, in non-clinical populations.

Usefulness of the Spanish version of the mood disorder questionnaire for screening bipolar disorder in routine clinical practice in outpatients with major depression

Background

According to some studies, almost 40% of depressive patients – half of them previously undetected – are diagnosed of bipolar II disorder when systematically assessed for hypomania. Thus, instruments for bipolar disorder screening are needed. The Mood Disorder Questionnaire (MDQ) is a self-reported questionnaire validated in Spanish in stable patients with a previously known diagnosis. The purpose of this study is to evaluate in the daily clinical practice the usefulness of the Spanish version of the MDQ in depressive patients.

Methods

Patients (n = 87) meeting DSM-IV-TR criteria for a major depressive episode, not previously known as bipolar were included. The affective module of the Structured Clinical Interview (SCID) was used as gold standard.

Results

MDQ screened 24.1% of depressive patients as bipolar, vs. 12.6% according to SCID. For a cut-off point score of 7 positive answers, sensitivity was 72.7% (95% CI = 63.3 – 82.1) and specificity 82.9% (95% CI = 74.9–90.9). Likelihood ratio of positive and negative tests were 4,252 y 0,329 respectively.

Limitations

The small sample size reduced the power of the study to 62%.

Conclusion

Sensitivity and specificity of the MDQ were high for screening bipolar disorder in patients with major depression, and similar to the figures obtained in stable patients. This study confirms that MDQ is a useful instrument in the daily clinical assessment of depressive patients.