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

Hypomania-Checklist-33: risk stratification and factor structure in a mixed psychiatric adolescent sample

BACKGROUND

The 33-item Hypomania Checklist (HCL-33) has been shown to distinguish between adolescent bipolar disorder (BD) and unipolar depression. To investigate the utility of the HCL-33 as a screening tool in routine diagnostics, the frequency and psychopathological characteristics of detected individuals in a mixed psychiatric sample necessitate more examination.

METHODS

The HCL-33, Children's Depression Inventory, Beck's Anxiety Inventory, and Strengths and Difficulties Questionnaire were completed by 285 children and adolescents (12-18 years) in a mixed psychiatric sample. Applying the proposed HCL-33 cut-off score of ≥ 18, individuals with depressive symptoms were divided into at-risk or not at-risk for BD groups. The factorial structure, sum and factor score correlations with psychopathology, and impact on daily functioning were assessed.

RESULTS

20.6% of the sample met at-risk criteria for BD. These individuals (n = 55) were older, more anxious, and showed more conduct problems vs the not at-risk group (n = 107). A two- and a three-factor model were pursued with the same Factor 1 ("active-elated"). Factor 2 ("risk-taking/irritable") was separated into 2a ("irritable-erratic") and 2b ("outgoing-disinhibited") in the three-factor model. Whereas higher Factor 2 and 2a scores correlated with a broad range of more severe symptomatology (i.e., depression, anxiety, hyperactivity), higher Factor 1 and 2b scores correlated with more emotional and conduct problems, respectively. 51.7% of the sample reported a negative impact from hypomanic symptoms on daily functioning.

LIMITATIONS

Cross-sectional design and data collection in a single mental health service.

CONCLUSIONS

The HCL-33 may be a useful tool to improve diagnostics, especially in adolescents with depressive symptoms additionally presenting with anxious symptoms and conduct problems.

Personality traits influence the effectiveness of hypomania checklist-32 in screening for bipolar disorder

BACKGROUND

It is clinically challenging to distinguish bipolar disorder (BD) from major depressive disorder (MDD) in the early stages. While the hypomania checklist-32 (HCL-32) is a proper auxiliary tool that is useful to differentiate between BD and MDD, there is currently no standard cut-off value. The variations in HCL-32 cut-off values could potentially be influenced by personality traits. Therefore, the aim of this study is to explore the effect of personality traits on the screening performance of HCL-32.

METHODS

In this retrospective cross-sectional study, 168 patients with BD or MDD were evaluated with the Eysenck Personality Questionnaire (EPQ) and HCL-32. The associations between demographic data, diagnosis and clinical rating scales were analyzed.

RESULTS

Diagnosis was not associated with extraversion but was related to neuroticism. HCL-32 scores in typical extraverted patients were higher in contrast to atypical extraverted patients. The best cut-off value for BD recognition of typical and atypical extraversion groups were 15 and 12.5, respectively. In patients with MDD, HCL-32 score of typical neuroticism was higher than the atypical type, but there was no difference in patients with BD. In typical neuroticism, there was no difference in HCL-32 scores between patients with MDD and BD. But among atypical neurotic patients, HCL-32 scores of BD were higher compared to MDD, with a cut-off value of 14.5.

LIMITATIONS

This study had a small sample size.

CONCLUSION

HCL-32 scores were affected by personality traits, with higher scores for typical extraversion and neuroticism. Clinicians should also consider the patients' personality traits when referring to HCL-32 scores, so as to increase the recognition rate of BD and eliminate false positives.

Structure of Hypomanic Symptoms in Adolescents With Bipolar Disorders: A Network Approach

BACKGROUND

Bipolar disorders (BD) are severe mental illnesses that are often misdiagnosed or under-diagnosed. The self-report 33-item Hypomania Checklist (HCL-33) and the 33-item Hypomania Checklist - external assessment (HCL-33-EA) are well-validated scales for BD symptom detection. This study compared the network structure, central symptoms, and network stability of hypomanic symptoms measured by the HCL-33 vs. the HCL-33-EA.

METHODS

This cross-sectional study was conducted from January to December 2019. Adolescents (aged between 12 and 18 years) with BD were recruited from the outpatient department of Child Psychiatry, First Affiliated Hospital of Zhengzhou University. All participants were asked to complete the HCL-33, and their caregivers completed the HCL-33-EA. Network analyses were conducted.

RESULTS

A total of 215 adolescents with BD and their family caregivers were recruited. Node HCL17 ("talk more," node strength = 4.044) was the most central symptom in the HCL-33 network, followed by node HCL2 ("more energetic," node strength = 3.822), and HCL18 ("think faster," node strength = 3.801). For the HCL-33-EA network model, node HCL27 ("more optimistic," node strength = 3.867) was the most central node, followed by node HCL18 ("think faster," node strength = 3.077), and HCL17 ("talk more," node strength = 2.998). In the network comparison test, there was no significant difference at the levels of network structure (M = 0.946, P = 0.931), global strength (S: 5.174, P = 0.274), or each specific edge (all P's > 0.05 after Holm-Bonferroni corrections) between HCL-33 and HCL-33-EA items. Network stabilities for both models were acceptable.

CONCLUSION

The nodes "talk more" and "think faster" acted as central symptoms in BD symptom network models based on the HCL-33 and HCL-33-EA. Although the most prominent central symptom differed between the two models ("talk more" in HCL-33 vs. "more optimistic" in HCL-33-EA model), networks based on each measure were highly similar and underscored similarities in BD symptom relations perceived by adolescents and their caregivers. This research provides foundations for future studies with larger sample sizes toward improving the accuracy and robustness of observed network structures.

Bipolar disorder: Prevalence, help-seeking and use of mental health care in England. Findings from the 2014 Adult Psychiatric Morbidity Survey

BACKGROUND

To date, the lifetime prevalence of Bipolar Disorder (BD) and BD patients' access to mental health care in England has not been systematically studied.

METHODS

We used data from the Adult Psychiatric Morbidity Survey 2014 (N = 7546). The Mood Disorders Questionnaire (MDQ) was used to screen for BD. Associations between sociodemographic and clinical variables and use of mental health services were investigated. Weighted regression modelling established factors associated with being in receipt of care for mental health problems over the last year.

RESULTS

The lifetime prevalence of BD in the community in England was 1.7%. Approximately 40% had not received mental health care in the last year, and only 16.9% had received BD specific treatment. 14.6% had asked for a specific form of help but not received it. Psychopathology differed between individuals who successfully sought care and those who didn't. Obtaining care was independently associated with female sex (p<0.0001, odds ratio(OR):4.65 (Confidence Interval (CI):2.18-10.30), unemployment (p = 0.02, OR: 2.65 (C.I: 1.23-5.88) and suicidal ideation (p = 0.04, OR: 3.36, (C.I: 1.04-10.89).

LIMITATIONS

The MDQ is less sensitive than some of the longer measures, especially in the general population. Some between-group comparisons may have suffered from limited power.

CONCLUSIONS

The lifetime prevalence of BD in England was similar to rates worldwide. Most people with BD had not received any specific treatment for the condition in the last year, while 1 in 7 had requested specific help but did not receive it. Secondary mental health services in England for BD appear suboptimal.

Validation of the 33-item Hypomania Checklist (HCL-33) in screening adolescents with bipolar disorder

BACKGROUND

Adolescents with bipolar disorder (BD) are often misdiagnosed with major depressive disorder (MDD), which delays the introduction of appropriate treatment resulting in adverse outcomes. This study examined the psychometric properties of the 33-item Hypomania Checklist (HCL-33) and its accuracy to distinguish BD from MDD in adolescents.

METHOD

A total of 248 participants (171 MDD and 77 BD patients) were recruited from a university-affiliated hospital in China. Depression was measured with the Hamilton Depression Rating Scale. All participants completed the assessment with the HCL-33.

RESULTS

A two-factor structure was found for the HCL-33, which explained 30.2% of the total variance. The internal consistency and split half reliability of the total scale were acceptable. The optimal cut-off value of 18 generated sensitivity of 0.52 and specificity of 0.73 for distinguishing BD from MDD.

CONCLUSION

The HCL-33 seems to be a useful screening instrument to distinguish BD from depressed adolescents. However, considering certain less than robust psychometric properties, the HCL-33 needs to be modified and further refined for adolescent patients.

The Co-Morbidity between Bipolar and Panic Disorder in Fibromyalgia Syndrome

About half of the patients with fibromyalgia (FM) had a lifetime major depression episode and one third had a panic disorder (PD). Because the co-morbidity between bipolar disorder (BD) and PD marks a specific subtype of BD we aimed to investigate if co-morbid BD/PD (comBD/PD) occurs more frequently than the single disorder in FM patients and evaluate the clinical significance and timing of this co-morbidity. Further, we explored the role of co-morbid subthreshold BD and PD. In 118 patients with FM, lifetime threshold and sub-threshold mood disorders and PD were diagnosed with Diagnostic and Statistical Manual of Mental Disorders-IV-Text Revision (DSM-IV-TR) Clinical Interview. Demographic and clinical variables were compared in co-morbid BD/PD (comBD/PD) and not co-morbid BD/PD (nocomBD/PD) subgroups. The co-morbidity BD/PD was seen in 46.6% of FM patients and in 68.6% when patients with minor bipolar (MinBD) and sub-threshold panic were included. These rates are higher than those of the general population and BD outpatients. There were no statistically significant differences between threshold and sub-threshold comBD/PD and nocom-BD/PD subgroups in demographic and clinical parameters. In the majority of patients (78.2%), the onset of comBD/PD preceded or was contemporary with FM. These findings support the hypothesis that comBD/PD is related to the development of FM in a subgroup of patients.

Are existing self-ratings of acute manic symptoms in adults reliable and valid?-A systematic review

BACKGROUND

Depression research historically uses both self- and clinician ratings of symptoms with significant and substantial correlations. It is often assumed that manic patients lack insight and cannot accurately report their symptoms. This delayed the development of self-rating scales for mania, but several scales now exist and are used in research. Our objective is to systematically review the literature to identify existing self-ratings of symptoms of (hypo)mania and to evaluate their psychometric properties.

METHODS

PubMed, Web of Knowledge, and Ovid were searched up until June 2018 using the keywords: "(hypo)mania," "self-report," and "mood disorder" to identify papers which included data on the validity and reliability of self-rating scales for (hypo)mania in samples including patients with bipolar disorder.

RESULTS

We identified 55 papers reporting on 16 different self-rating scales claiming to assess (hypo)manic symptoms or states. This included single item scales, but also some with over 40 items. Three of the scales, the Internal State Scale (ISS), Altman Self-Rating Mania Scale (ASRM), and Self-Report Manic Inventory (SRMI), provided data about reliability and/or validity in more than three independent studies. Validity was mostly assessed by comparing group means from individuals in different mood states and sometimes by correlation to clinician ratings of mania.

CONCLUSIONS

ASRM, ISS, and SRMI are promising self-rating tools for (hypo)mania to be used in clinical contexts. Future studies are, however, needed to further validate these measures; for example, their associations between each other and sensitivity to change, especially if they are meant to be outcome measures in studies.

Improving Knowledge and Increasing Use of a Screening Tool in an Outpatient Psychiatric Clinic

Less than half of providers use screening tools to diagnose adult psychiatric patients. The bipolar population is specifically vulnerable to an inaccurate diagnosis. The goal of this project was to improve use of screening tools, specifically the HCL-32 in a rural adult psychiatric clinic. Following the end of the project, guidelines were analyzed to determine factors that could have improved the outcome. A pre-survey was administered to the 11 participating providers. Following the survey, a 10-minute educational session was given to each provider. Two months following the education, a post-survey was conducted. A chart review was completed to confirm post-survey results.

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.

Psychometric variables of the EMUN-AR scale using Rasch analysis

Introduction: Self-report scales have been considered to be useful for evaluating and monitoring symptoms of manic-depressive illnesses. The EMUN-AR scale is one of such scales but it has not been validated. Objective: To validate the EMUN-AR scale using Rasch models. Materials and methods: The EMUN-AR scale measures 26 items to assess comprehensively symptoms of manic-depressive illnesses in three domains: Frequency, severity, and level of disturbance caused by the symptoms. To test the psychometric properties of this scale, we used the exploratory factorial and Rasch analyses. The Rasch analysis included unidimensionality, reliability, item fit, threshold ordering, and person-item maps. Results: The study included 267 hospitalized patients, most of them with a manic episode diagnosis (n=204, 76.4%), and receiving pharmacological treatment. The factor structure was summarized in four domains: Activation, inhibition, depressive ideation, and maladaptive behavior. The Rasch analysis supported unidimensionality of the EMUN-AR factors, satisfactory levels of reliability, and appropriate item fit, except for one of the items measuring death or suicidal thoughts. However, the scale did not measure adequately the mild forms of the illness given its redundant and unordered thresholds. Conclusion: The EMUN-AR was modified in two aspects: An item whose marginal indicators were poorly adjusted and the reduction in the number of categories. In its current form, the EMUN-AR is appropriate for measuring severe forms of the illnesses, but it does not adequately measure the mild forms of manic-depressive illnesses.

Genetic risk for bipolar disorder and psychopathology from childhood to early adulthood

BACKGROUND

Studying the phenotypic manifestations of increased genetic liability for Bipolar Disorder (BD) can increase understanding of this disorder.

AIMS

We assessed whether genetic risk for BD was associated with childhood psychopathology and features of hypomania in young adulthood within a large population-based birth cohort.

METHODS

We used data from the second Psychiatric Genetics Consortium Genome Wide Association Study (GWAS) for Bipolar Disorder to construct a polygenic risk score (PRS) for each individual in the Avon Longitudinal Study of Parents and Children (ALSPAC). Linear and logistic regression models were used to assess associations between the BD-PRS and emotional/behavioural difficulties, attention deficit hyperactivity disorder (ADHD) and borderline personality disorder (BPD) traits in childhood, as well as hypomania in early adulthood (sample sizes from 2654 to 6111).

RESULTS

The BD-PRS was not associated with total hypomania score, but was weakly associated with a binary measure of hypomania (OR = 1.13, 95%CI 0.98,1.32; p = 0.097), and particularly at higher hypomania symptom thresholds (strongest evidence OR = 1.33, 95%CI 1.07, 1.65; p = 0.01). The BD-PRS was also associated with ADHD (OR = 1.31, 95%CI 1.10, 1.57; p = 0.018), but not with other childhood psychopathology.

LIMITATIONS

The PRS only captures common genetic variation and currently explains a relatively small proportion of the variance for BD.

CONCLUSIONS

The BD-PRS was associated with ADHD in childhood, and weakly with adult hypomania, but not with other psychopathology examined. Our findings suggest that genetic risk for BD does not appear to manifest in childhood to the same extent as schizophrenia genetic risk has been reported to do.

Associations between schizophrenia genetic risk, anxiety disorders and manic/hypomanic episode in a longitudinal population cohort study

BACKGROUND

Studies involving clinically recruited samples show that genetic liability to schizophrenia overlaps with that for several psychiatric disorders including bipolar disorder, major depression and, in a population study, anxiety disorder and negative symptoms in adolescence.AimsWe examined whether, at a population level, association between schizophrenia liability and anxiety disorders continues into adulthood, for specific anxiety disorders and as a group. We explored in an epidemiologically based cohort the nature of adult psychopathology sharing liability to schizophrenia.

METHOD

Schizophrenia polygenic risk scores (PRSs) were calculated for 590 European-descent individuals from the Christchurch Health and Development Study. Logistic regression was used to examine associations between schizophrenia PRS and four anxiety disorders (social phobia, specific phobia, panic disorder and generalised anxiety disorder), schizophrenia/schizophreniform disorder, manic/hypomanic episode, alcohol dependence, major depression, and - using linear regression - total number of anxiety disorders. A novel population-level association with hypomania was tested in a UK birth cohort (Avon Longitudinal Study of Parents and Children).

RESULTS

Schizophrenia PRS was associated with total number of anxiety disorders and with generalised anxiety disorder and panic disorder. We show a novel population-level association between schizophrenia PRS and manic/hypomanic episode.

CONCLUSIONS

The relationship between schizophrenia liability and anxiety disorders is not restricted to psychopathology in adolescence but is present in adulthood and specifically linked to generalised anxiety disorder and panic disorder. We suggest that the association between schizophrenia liability and hypomanic/manic episodes found in clinical samples may not be due to bias.Declarations of interestNone.

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.

Cannabis Use and Hypomania in Young People: A Prospective Analysis

BACKGROUND

Cannabis use in young people is common and associated with psychiatric disorders. However, the prospective link between cannabis use and bipolar disorder symptoms has rarely been investigated. The study hypothesis was that adolescent cannabis use is associated with hypomania in early adulthood via several potential etiological pathways.

METHODS

Data were used from the Avon Longitudinal Study of Parents and Children, a UK birth cohort study. The prospective link between cannabis use at age 17 and hypomania at age 22-23 years was tested using regression analysis, adjusted for gender, early environmental risk factors, alcohol and drug use, and depression and psychotic symptoms at age 18 years. Path analysis examined direct and indirect effects of the link and whether gender, childhood family adversity, or childhood abuse are associated with hypomania via an increased risk of cannabis use.

RESULTS

Data were available on 3370 participants. Cannabis use at least 2-3 times weekly was associated with later hypomania (OR = 2.21, 95% CI = 1.49-3.28) after adjustment. There was a dose-response relationship (any use vs weekly). Cannabis use mediated the association of both childhood sexual abuse and hypomania, and male gender and hypomania. The cannabis use-hypomania link was not mediated by depression or psychotic symptoms.

CONCLUSIONS

Adolescent cannabis use may be an independent risk factor for future hypomania, and the nature of the association suggests a potential causal link. Cannabis use mediates the link between childhood abuse and future hypomania. As such it might be a useful target for indicated prevention of hypomania.

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.

"Always Look on the Bright Side of Life!" - Higher Hypomania Scores Are Associated with Higher Mental Toughness, Increased Physical Activity, and Lower Symptoms of Depression and Lower Sleep Complaints

Background: In the present study, we explored the associations between hypomania, symptoms of depression, sleep complaints, physical activity and mental toughness. The latter construct has gained interest for its association with a broad variety of favorable behavior in both clinical and non-clinical samples.

Subjects and Methods: The non-clinical sample consisted of 206 young adults (M = 21.3 years; age range: 18–24 years; 57.3% males). They completed questionnaires covering hypomania, mental toughness, symptoms of depression, physical activity, and sleep quality.

Results: Higher hypomania scores were associated with higher mental toughness, increased physical activity, lower symptoms of depression and lower sleep complaints. No gender differences were observed. Higher hypomania scores were predicted by higher scores of mental toughness subscales of control and challenge, and physical activity.

Conclusion: The pattern of results suggests that among a non-clinical sample of young adults, self-rated hypomania scores were associated with higher scores on mental toughness and physical activity, along with lower depression and sleep complaints. The pattern of results further suggests that hypomania traits are associated with a broad range of favorable psychological, behavioral and sleep-related traits, at least among a non-clinical sample of young adults.

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.

The association between self-reported and clinically determined hypomanic symptoms and the onset of major mood disorders

BACKGROUND

Hypomanic symptoms may be a useful predictor of mood disorder among young people at high risk for bipolar disorder.

AIMS

To determine whether hypomanic symptoms differentiate offspring of parents with bipolar disorder (high risk) and offspring of well parents (control) and predict the development of mood episodes.

METHOD

High-risk and control offspring were prospectively assessed using semi-structured clinical interviews annually and completed the Hypomania Checklist-32 Revised (HCL-32). Clinically significant sub-threshold hypomanic symptoms (CSHS) were coded.

RESULTS

HCL-32 total and active or elated scores were higher in control compared with high-risk offspring, whereas 14% of high-risk and 0% of control offspring had CSHS. High-risk offspring with CSHS had a fivefold increased risk of developing recurrent major depression (P=0.0002). The median onset of CSHS in high-risk offspring was 16.4 (6-31) years and was before the onset of major mood episodes.

CONCLUSIONS

CSHS are precursors to major mood episodes in high-risk offspring and could identify individuals at ultra-high risk for developing bipolar disorder.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Childhood interleukin-6, C-reactive protein and atopic disorders as risk factors for hypomanic symptoms in young adulthood: a longitudinal birth cohort study

BACKGROUND

There are no existing longitudinal studies of inflammatory markers and atopic disorders in childhood and risk of hypomanic symptoms in adulthood. This study examined if childhood: (1) serum interleukin-6 (IL-6) and C-reactive protein (CRP); and (2) asthma and/or eczema are associated with features of hypomania in young adulthood.

METHOD

Participants in the Avon Longitudinal Study of Parents and Children, a prospective general population UK birth cohort, had non-fasting blood samples for IL-6 and CRP measurement at the age of 9 years (n = 4645), and parents answered a question about doctor-diagnosed atopic illness before the age of 10 years (n = 7809). These participants completed the Hypomania Checklist at age 22 years (n = 3361).

RESULTS

After adjusting for age, sex, ethnicity, socio-economic status, past psychological and behavioural problems, body mass index and maternal postnatal depression, participants in the top third of IL-6 values at 9 years, compared with the bottom third, had an increased risk of hypomanic symptoms by age 22 years [adjusted odds ratio 1.77, 95% confidence interval (CI) 1.10-2.85, p < 0.001]. Higher IL-6 levels in childhood were associated with adult hypomania features in a dose-response fashion. After further adjustment for depression at the age of 18 years this association remained (adjusted odds ratio 1.70, 95% CI 1.03-2.81, p = 0.038). There was no evidence of an association of hypomanic symptoms with CRP levels, asthma or eczema in childhood.

CONCLUSIONS

Higher levels of systemic inflammatory marker IL-6 in childhood were associated with hypomanic symptoms in young adulthood, suggesting that inflammation may play a role in the pathophysiology of mania. Inflammatory pathways may be suitable targets for the prevention and intervention for bipolar disorder.

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.

Factor structure and reliability of the Italian adaptation of the Hypomania Check List-32, second revision (HCL-32-R2)

OBJECTIVE

To assess the psychometric properties of the Italian adaptation of the Hypomania-Check-List 32-item, second revision (HCL-32-R2) for the detection of bipolarity in major depressive disorder (MDD) treatment-seeking outpatients.

METHODS

A back-to-back Italian adaption of the "Bipolar Disorders: Improving Diagnosis, Guidance, and Education" English module of the HCL-32-R2 was administered between March 2013 and October 2014 across twelve collaborating sites in Italy. Diagnostic and Statistical Manual Fourth edition (DSM-IV) diagnoses were made adopting the mini-international neuropsychiatric interview, using bipolar disorder (BD) patients as controls.

RESULTS

In our sample (n=441, of whom, BD-I=68; BD-II=117; MDD=256), using a cut-off of 14 allowed the HCL-32-R2 to discriminate DSM-IV-defined MDD patients between "true unipolar" (HCL-32-R2(-)) and "sub-threshold bipolar depression" (HCL-32-R2(+)) with sensitivity=89% and specificity=79%. Area under the curve was .888; positive and negative predictive values were 75.34% and 90.99% respectively. Owing to clinical interpretability considerations and consistency with previous adaptations of the HCL-32, a two-factor solution (F1="hyperactive/elated" vs. F2="irritable/distractible/impulsive") was preferred using exploratory and confirmatory factor analyses, whereas items n.33 ("I gamble more") and n.34 ("I eat more") introduced in the R2 version of the scale slightly loaded onto F2 and F1 respectively. Cronbach׳s α=.88 for F1 and .71 for F2.

LIMITATIONS

No cross-validation with any additional validated screening tool; treatment-seeking outpatient sample; recall bias; no systematic evaluation of eventual medical/psychiatric comorbidities, current/lifetime pharmacological history, neither record of severity of current MDE.

CONCLUSIONS

Our results seem to indicate fair accuracy of HCL-32 as a screening instrument for BD, though replication studies are warranted.

Childhood IQ and risk of bipolar disorder in adulthood: prospective birth cohort study

BACKGROUND

Intellectual ability may be an endophenotypic marker for bipolar disorder.

AIMS

Within a large birth cohort, we aimed to assess whether childhood IQ (including both verbal IQ (VIQ) and performance IQ (PIQ) subscales) was predictive of lifetime features of bipolar disorder assessed in young adulthood.

METHOD

We used data from the Avon Longitudinal Study of Parents and Children (ALSPAC), a large UK birth cohort, to test for an association between measures of childhood IQ at age 8 years and lifetime manic features assessed at age 22-23 years using the Hypomania Checklist-32 (HCL-32; n=1881 individuals). An ordinary least squares linear regression model was used, with normal childhood IQ (range 90-109) as the referent group. We adjusted analyses for confounding factors, including gender, ethnicity, handedness, maternal social class at recruitment, maternal age, maternal history of depression and maternal education.

RESULTS

There was a positive association between IQ at age 8 years and lifetime manic features at age 22-23 years (Pearson's correlation coefficient 0.159 (95% CI 0.120-0.198), P>0.001). Individuals in the lowest decile of manic features had a mean full-scale IQ (FSIQ) which was almost 10 points lower than those in the highest decile of manic features: mean FSIQ 100.71 (95% CI 98.74-102.6) v. 110.14 (95% CI 107.79-112.50), P>0.001. The association between IQ and manic features was present for FSIQ, VIQ and for PIQ but was strongest for VIQ.

CONCLUSIONS

A higher childhood IQ score, and high VIQ in particular, may represent a marker of risk for the later development of bipolar disorder. This finding has implications for understanding of how liability to bipolar disorder may have been selected through generations. It will also inform future genetic studies at the interface of intelligence, creativity and bipolar disorder and is relevant to the developmental trajectory of bipolar disorder. It may also improve approaches to earlier detection and treatment of bipolar disorder in adolescents and young adults.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2015. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

Factor structure and reliability of the Arabic adaptation of the Hypomania Check List-32, second revision (HCL-32-R2)

OBJECTIVE

To assess the psychometric properties of the Arabic adaptation of the Hypomania-Check-List 32-item, second revision (HCL-32-R2) for the detection of bipolarity in major depressive disorder (MDD) inpatients suffering a current major depressive episode (MDE).

METHOD

The "Bipolar Disorders: Improving Diagnosis, Guidance, and Education" Arabic module of the HCL-32-R2 was administered to mother-tongue Arabic MDE inpatients between March 2013 and October 2014. Diagnostic and Statistical Manual Fourth edition (DSM-IV) diagnoses were made adopting the mini-international neuropsychiatric interview, using bipolar disorder (BD) patients as controls.

RESULTS

In our sample (n=500, of whom, BD-I=329; BD-II=70; MDD=101), using a cut-off of 17 allowed the HCL-32-R2 to discriminate DSM-IV-defined MDD patients between "true unipolar" (HCL-32-R2(-)) and "sub-threshold bipolar depression" (HCL-32-R2(+)) with sensitivity=82% and specificity=77%. Area under the curve was .883; positive and negative predictive values were 93.44% and 73.23% respectively. Owing to clinical interpretability considerations and consistency with previous adaptations of the HCL-32, a two-factor solution (F1="hyperactive/elated" vs. F2="irritable/distractible/impulsive") was preferred using exploratory and confirmatory factors analyses. Item n.33 ("I gamble more") and n.34 ("I eat more") introduced in the R2 version of the HCL-32 loaded onto F1, though very slightly. Cronbach's alphas were F1=.86 and F2=.60.

LIMITATIONS

No cross-validation with any additional validated screening tool. Inpatients only sample; recall bias; no systematic evaluation of eventual medical/psychiatric comorbidities, current/lifetime pharmacological history, or record of severity of current MDE.

CONCLUSIONS

In our sample, the HCL-32 fairly discriminated between MDD and BD-I but not BD-II, therefore soliciting for replication studies for use in Arabic-speaking depressed inpatients.

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.