Misuse of the Mood Disorders Questionnaire as a case-finding measure and a critique of the concept of using a screening scale for bipolar disorder in psychiatric practice

Genetic examination of the Mood Disorder Questionnaire and its relationship with bipolar disorder

The Mood Disorder Questionnaire (MDQ) is a common screening tool for bipolar disorder that assesses manic symptoms. Its utility for genetic studies of mania or bipolar traits has not been fully examined. We psychometrically compared the MDQ to self-reported bipolar disorder in participants from the United Kingdom National Institute of Health and Care Research Mental Health BioResource. We conducted genome-wide association studies of manic symptom quantitative traits and symptom subgroups, derived from the MDQ items (N = 11,568-19,859). We calculated genetic correlations with bipolar disorder and other psychiatric and behavioral traits. The MDQ screener showed low positive predictive value (0.29) for self-reported bipolar disorder. Neither concurrent nor lifetime manic symptoms were genetically correlated with bipolar disorder. Lifetime manic symptoms had a highest genetic correlation (rg  = 1.0) with posttraumatic stress disorder although this was not confirmed by within-cohort phenotypic correlations (rp  = 0.41). Other significant genetic correlations included attention deficit hyperactivity disorder (rg  = 0.69), insomnia (rg  = 0.55), and major depressive disorder (rg  = 0.42). Our study adds to existing literature questioning the MDQ's validity and suggests it may capture symptoms of general distress or psychopathology, rather than hypomania/mania specifically, in at-risk populations.

Using Screening Scales for Bipolar Disorder in Epidemiologic Studies: Lessons Not Yet Learned

BACKGROUND

In a recent issue in the journal, Humpston, Bebbington, and Marwaha (2021) reported the results of the first large epidemiological study of bipolar disorder in England. The prevalence estimate of bipolar disorder was based on the Mood Disorders Questionnaire (MDQ), a self-administered screening scale for a lifetime history of mania/hypomania. Humpston and colleagues found that the prevalence of bipolar disorder in England was similar to the rates in other parts of the world, and they stated that most individuals with bipolar disorder in England did not receive treatment for the disorder in the past year. A better understanding of the statistics of screening and the performance of the MDQ would indicate that the conclusions drawn from the epidemiological study are not justified.

METHODS

I review the principles and statistics of diagnostic screening and how screening is distinguished from case-finding. I then review the performance of the MDQ in the general population and calculate the positive predictive value of the MDQ in the study by Humpston and colleagues.

RESULTS

The developers of the MDQ reported a sensitivity of 28.1% and specificity of 97.2% in the general population based on a cutoff score of 7. Using this same cutoff, Humpston and colleagues reported the prevalence of "probable" bipolar disorder was 1.7%. Based on these data, the positive predictive value of the MDQ would be only 14.8%.

LIMITATIONS

Humpson et al. did not compare the MDQ to a diagnostic interview in their study; thus, the performance of the MDQ was estimated from another general population study.

CONCLUSIONS

When studying a disorder with a relatively low prevalence, it is near impossible for a screening test to have sufficient positive predictive value to be used to validly compare the individuals who do and do not screen positive. Most of the individuals whom Humpston et al. considered to have "probable" bipolar disorder would not have received the diagnosis had they been directly interviewed. Thus, the results of the Humpston et al. study are not a valid indicator of the correlates of bipolar disorder in the general population of England.

Positive and Negative Activation in the Mood Disorder Questionnaire: Associations With Psychopathology and Emotion Dysregulation in a Clinical Sample

The Mood Disorder Questionnaire is a screening measure for bipolar disorder, previously found to comprise separate Positive and Negative Activation subscales. We sought to replicate these factors and examine their associations with a range of psychopathology. To further explicate the nature of Negative Activation, we examined associations with the Difficulties in Emotion Regulation Scale, a measure of emotion dysregulation. The sample consisted of 1,787 participants from an outpatient treatment facility. Confirmatory factor analysis replicated the existence of Positive and Negative Activation subscales. Logistic regressions, as hypothesized, found that Positive Activation was positively associated only with bipolar disorder, while Negative Activation was associated with almost all disorders. The Impulse and Goals subscales of the Difficulties in Emotion Regulation Scale were uniquely associated with Negative Activation, suggesting it may specifically assess impulsive behavior in emotional situations. The findings suggest that it may be important to attend to both Mood Disorder Questionnaire subscales.

Screening for Bipolar Disorder and Finding Borderline Personality Disorder: A Replication and Extension

The authors' group previously reported that patients who screened positive on the Mood Disorders Questionnaire (MDQ), the most frequently studied screening scale for bipolar disorder, were as likely to be diagnosed with borderline personality disorder (BPD) as with bipolar disorder. A limitation of that study was that the authors examined the performance of the MDQ in patients presenting for various psychiatric disorders, including depression. The recognition of bipolar disorder and its differential diagnosis with BPD is of greatest clinical relevance in depressed patients. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, the authors attempted to replicate their initial findings in a new sample of psychiatric outpatients, and they also examined the performance of the MDQ in depressed patients. The results of the present study were consistent with the original report, thereby indicating that the MDQ is not effective in helping distinguish bipolar disorder from BPD.

Factors associated with false positives in MDQ screening for bipolar disorder: Insight into the construct validity of the scale

BACKGROUND

Identifying bipolar patients in the first phases of the illness is essential to establish adequate treatment. The goal of this study was to examine the discriminant ability of the Mood Disorders Questionnaire (MDQ) in recognizing bipolar patients referred to a tertiary care structure.

METHODS

Between 2006 and 2012, we assessed 843 individuals referred to the Mood Disorders Program by family physicians in the community. The Structured Clinical Interview for DSM-IV-TR (SCID) was used to assess diagnoses. A nurse collected the information about lifetime symptoms of (hypo)mania in 759 individuals using the MDQ. Univariate chi-square test and logistic regression were used for the statistical analysis.

RESULTS

Overall, 86% of the sample had a current anxiety or depressive disorder. When compared to the diagnoses formulated through the SCID, the sensitivity of the MDQ was 75.0%, the specificity was 74%, the positive predictive value was 55%, and the negative predictive value was 88%. Among non-bipolar patients, current post-traumatic stress disorder, borderline personality disorder, current or early remission substance use disorder, and the history of childhood abuse were independently associated with false positive screening using the MDQ.

LIMITATIONS

Individuals with current substance use disorders were under-represented, whether or not the patients were aware of their diagnosis of bipolar disorder was not recorded, and the history of childhood abuse was collected based on an open interview.

CONCLUSIONS

The self-rated measure of the symptoms listed by the MDQ seems to measure a dimension shared by both bipolar disorder and other conditions characterized by affective instability and impulsivity.

Improving the Screening Instrument of Bipolar Spectrum Disorders: Weighted Korean Version of the Mood Disorder Questionnaire

Objective

It is not easy to diagnose bipolar disorders accurately in the clinical setting. Although Korean version of the Mood Disorder Questionnaire (K-MDQ) is easily administered, it still has weakness regarding case finding. In this study, we suggest a new weighted version of the K-MDQ to increase its screening power.

Methods

Ninety-five patients with bipolar disorders and 346 controls (patients with schizophrenia, patients with depressive disorders, patients with anxiety disorders, and subjects without any psychiatric disease) were enrolled in this study. The subjects received brief information on the K-MDQ, and then independently completed the questionnaire.

Results

Using odds ratios, we constructed a new weighted K-MDQ (W-K-MDQ). Item 1 (feel so good or hyper) was weighted 7 times and item 4 (less sleep) 3.5 times. Item 7 (easily distracted) and item 11 (more interested in sex) were excluded. Part 2 (simultaneity) and 3 (functional impairment) were also excluded as in the original K-MDQ. The sensitivity of the W-K-MDQ with a cutoff value of 10 was enhanced to 0.789. The area under the receiver operating characteristic curve was increased to 0.837.

Conclusion

We suggested a new formula for K-MDQ using 11 of its items. The W-K-MDQ can be easily applied with good sensitivity to screen for bipolar disorders in clinical settings in Korea. Further evaluations with larger samples are needed to establish the usefulness of the W-K-MDQ.

Explicating the structure and relations of the Mood Disorder Questionnaire: Implications for screening for bipolar and related disorders

BACKGROUND

The Mood Disorder Questionnaire (MDQ; Hirschfeld et al., 2000) is a widely used screening measure in bipolar disorder research. Although this measure assesses a heterogeneous range of content, only limited prior research utilizing relatively small sample sizes has examined its factor structure.

METHODS

The MDQ's structure was examined in 700 participants reporting current psychiatric treatment. We extended prior structural work on the MDQ by explicating relations between factors and a wide range of psychopathology and personality measures.

RESULTS

The MDQ items were best captured by a two-factor structure consisting of dimensions labeled Positive Activation and Negative Activation. These two factors showed very different patterns of associations with personality, other psychopathology, and ratings of significant impairment, the last of which is a requirement for a positive MDQ screen using traditional scoring methods.

LIMITATIONS

Our study did not include clinician or informant ratings of bipolar disorder, preventing us from examining associations with such scores.

CONCLUSIONS

Our findings indicate that although the MDQ items cohere to define a total score, their structure is best modeled by meaningful Positive Activation and Negative Activation factors. Researchers and clinicians should be aware of these distinct sets of MDQ content, as high scorers on Positive Activation are less likely to identify past symptoms as problematic and show distinct clinical profiles from high scorers on Negative Activation.

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.

Relationship between Childhood Maltreatment, Suicidality, and Bipolarity: A Retrospective Study

OBJECTIVE

The aims of current study were to determine whether childhood maltreatment contributes to the occurrence of major depressive disorder (MDD) with bipolarity or suicidality.

METHODS

In total, 132 outpatients diagnosed with MDD between 2014 and 2015 on the medical records were included. The subjects were divided into two groups according to the presence of childhood maltreatment (CM group) and no childhood maltreatment (NCM group). Depression severity and bipolarity were identified using Beck Depression Inventory (BDI) and the Korean version of Mood Disorder Questionnaire (K-MDQ) respectively on the medical records. In addition, the baseline loud dependence of auditory evoked potentials of 36 patients on medical records were analyzed.

RESULTS

The mean total BDI, BDI item 9 (suicide ideation), and total K-MDQ score were significantly higher in the CM group than the NCM group. The number of subjects with bipolarity was significantly higher in the CM than in the NCM group. Furthermore two thirds subjects experienced the significant maltreatment during childhood. The central serotonergic activity of the CM group was also lower than that of the NCM group.

CONCLUSION

The findings of this study support that there is a relationship between childhood maltreatment and bipolarity or suicidality in patients with MDD.

Integrating Different Factorial Solutions of a Psychometric Tool Via Social Network Analysis

Abstract. Evaluating the factorial structure of a psychometric test is crucial to capture the complexity of a psychological phenomenon. Indeed, for the same test, several studies may find different factorial solutions which, in turn, may be explained by within and/or between sample variability. In this paper we introduce a novel quantitative approach to combine different factorial solutions of the same test. We propose to use a method based on Social Network Analysis to create and statistically evaluate an integrated factorial structure based on the information provided by previous researches. We present an application to the Mood Disorder Questionnaire by considering different factorial structures reported in the literature. The integrated factorial solution indicates the presence of three factors supporting the multidimensionality of the test. The role of single items in the composition of factors is also evaluated and discussed in terms of differences and similarities between the five original studies and the new integrated model. From an applied perspective, our approach may be useful to assist researchers in summarizing different factorial solutions for the same test efficiently. Furthermore, the resulting integrated factor solution could serve as baseline model to validate the structure of the test by applying confirmatory factor techniques to new data.

Extreme Appraisals of Internal States and Duration of Remission in Remitted Bipolar Patients

INTRODUCTION

To identify dysfunctional attitudes seen in bipolar disorder (BPD) is important for the cognitive theories of BPD and corresponding psychosocial interventions. Cognitions are seen as vulnerability factors in the development and maintenance of BPD. The present study aims to contribute to the cognitive literature on BPD by examining depressive and hypomanic attitudes and their contribution to the prediction of BPD diagnosis as well as by exploring the relationship between dysfunctional cognitions and clinical features (types of episodes experienced, duration of illness, and duration of remission).

METHODS

One hundred and eighteen remitted bipolar patients and 103 healthy controls completed the Mood Disorder Questionnaire (MDQ), Turkish Brief-Hypomanic Interpretations and Positive Predictions Inventory (HAPPI), and Dysfunctional Attitudes Scale.

RESULTS

The bipolar group had significantly higher depressive and hypomanic attitudes than the control group. No significant differences were found regarding the types of episodes experienced and duration of illness. However, both types of attitudes decreased as the duration of remission increased. They were also found to contribute to the prediction of bipolar diagnosis together with the screening of the MDQ.

CONCLUSION

The results pointed out that dysfunctional cognitions may be utilized as possible indicators for the risk of relapse in clinical groups and vulnerability for BPD among other populations.

Screening for bipolar spectrum disorders: A comprehensive meta-analysis of accuracy studies

BACKGROUND

Bipolar spectrum disorders are frequently under-recognized and/or misdiagnosed in various settings. Several influential publications recommend the routine screening of bipolar disorder. A systematic review and meta-analysis of accuracy studies for the bipolar spectrum diagnostic scale (BSDS), the hypomania checklist (HCL-32) and the mood disorder questionnaire (MDQ) were performed.

METHODS

The Pubmed, EMBASE, Cochrane, PsycINFO and SCOPUS databases were searched. Studies were included if the accuracy properties of the screening measures were determined against a DSM or ICD-10 structured diagnostic interview. The QUADAS-2 tool was used to rate bias.

RESULTS

Fifty three original studies met inclusion criteria (N=21,542). At recommended cutoffs, summary sensitivities were 81%, 66% and 69%, while specificities were 67%, 79% and 86% for the HCL-32, MDQ, and BSDS in psychiatric services, respectively. The HCL-32 was more accurate than the MDQ for the detection of type II bipolar disorder in mental health care centers (P=0.018). At a cutoff of 7, the MDQ had a summary sensitivity of 43% and a summary specificity of 95% for detection of bipolar disorder in primary care or general population settings.

LIMITATIONS

Most studies were performed in mental health care settings. Several included studies had a high risk of bias.

CONCLUSIONS

Although accuracy properties of the three screening instruments did not consistently differ in mental health care services, the HCL-32 was more accurate than the MDQ for the detection of type II BD. More studies in other settings (for example, in primary care) are necessary.

Borderline personality disorder: a disorder in search of advocacy

Compared with bipolar disorder, borderline personality disorder (BPD) is as frequent (if not more frequent), as impairing (if not more impairing), and as lethal (if not more lethal). Yet, BPD has received less than one-tenth the funding from the National Institutes of Health than has bipolar disorder. More than other reviewers of the literature on the interface between bipolar disorder and BPD, Paris and Black (Paris J and Black DW (2015) Borderline Personality Disorder and Bipolar Disorder: What is the Difference and Why Does it Matter? J Nerv Ment Dis 203:3-7) emphasize the clinical importance of correctly diagnosing BPD and not overdiagnosing bipolar disorder, with a focus on the clinical feature of affective instability and how the failure to recognize the distinction between sustained and transient mood perturbations can result in misdiagnosing patients with BPD as having bipolar disorder. The review by Paris and Black, then, is more of an advocacy for BPD than other reviews in this area have been. In the present article, the author will illustrate how the bipolar disorder research community has done a superior job of advocating for and "marketing" their disorder compared with researchers of BPD. Specifically, researchers of bipolar disorder have conducted multiple studies highlighting the problem with underdiagnosis, written commentaries about the problem with underdiagnosis, developed and promoted several screening scales to improve diagnostic recognition, published numerous studies of the operating characteristics of these screening measures, attempted to broaden the definition of bipolar disorder by advancing the concept of the bipolar spectrum, and repeatedly demonstrated the economic costs and public health significance of bipolar disorder. In contrast, researchers of BPD have almost completely ignored each of these issues and thus have been less successful in highlighting the public health significance of the disorder.

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.

Characteristics of bipolar symptoms in psychiatric patients: pattern of responses to the Korean version of the Mood Disorder Questionnaire

INTRODUCTION

Bipolar disorders are relatively frequent but easily misdiagnosed. The Korean version of the Mood Disorder Questionnaire (K-MDQ) is a screening instrument for bipolar disorders. The aim of this study was to establish the pattern of responses to the K-MDQ for several psychiatric disorders.

METHODS

The subjects for this study were 345 patients with bipolar disorders, schizophrenia, depressive disorders or anxiety disorders, as determined using the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, and 96 controls from five hospitals. The subjects completed the questionnaire by themselves.

RESULTS

The total K-MDQ score was higher in the bipolar disorder group than the other groups. Although the mean K-MDQ score differed significantly between the bipolar disorder group and the other groups, the distributions of total scores for the groups overlapped, and in particular with the schizophrenia group. The area under the receiver operating characteristics curve was relatively high for the bipolar disorder group and the other subjects, but it was less than 0.8 between the bipolar disorder group, and the schizophrenia and control groups.

DISCUSSION

There are some distinguishing features of the K-MDQ pattern for each disorder, but their similarities were significant. This made it difficult to differentially diagnose the disorder using only the total K-MDQ score. The diagnostic power of the K-MDQ can only be improved in the clinical setting by utilizing reinforcing criteria to diagnose bipolar disorders. Clinicians should be cautious in their interpretation of the K-MDQ, and the use of additional data is essential.

Screening for bipolar depression in family medicine practices: prevalence and clinical correlates

BACKGROUND

To compare individuals in primary care (PC) who screen positive for bipolar depression to those who screened positive for unipolar depression on mental health care ouctomes, PC service utilization, medical comorbidities, suicidal ideation, health-related quality of life (HRQoL) and psychosocial functioning.

METHODS

In this cross-sectional study, participants (N=1197) answered self-reported measures of depressive symptoms (Center for epidemiologic studies depression scale), HRQoL (World Health Organization Quality of Life instrument-Abbreviated version), medical comorbidity (functional comorbidity index) and functioning (Functional Assessment Short test). Participants were partitioned into 'bipolar' and 'unipolar' depression groups based on a predefined cutoff on the Brazilian mood disorder questionnaire.

RESULTS

The prevalence of bipolar depression was in PC was 4.6% (95% CI: 3.4-5.8). Participants with bipolar depression were more likely to endorse suicidal ideation, present with more medical comorbidities, report a worse physical HRQoL and have a higher rate of PC services utilization as compared to participants who screened positive for unipolar depression. Only six (10.9%) participants were recognized by the general practitioner as having a diagnosis of bipolar depression.

LIMITATIONS

The cross-sectional design prevents firm causal inferences from being drawn. A positive screen for BD does not substantiate the actual diagnosis. Co-morbid mental disorders were not accessed.

CONCLUSIONS

Bipolar depression is common and under-recognized in Brazilian PC services. A positive screen for bipolar depression was associated with worse clinical outcomes and greater PC service utilization.

Comparing factor structure of the Mood Disorder Questionnaire (MDQ): In Italy sexual behavior is euphoric but in Asia mysterious and forbidden

BACKGROUND

The introduction of screening questionnaires, such as the Mood Disorder Questionnaire (MDQ), has stimulated clinical and epidemiological studies on bipolar disorders. In this work, we studied the item response pattern of the MDQ in the Italian population and compared the results with those of the validation of the MDQ in Asian studies (Chinese and Korean), analyzing similarities and differences among the populations studied.

METHODS

The sample was made up of 2278 participants, distributed as follows: 56.6% females, 50.8% living in the north-central Italy, and 33.7% living in rural areas. The factor analysis was run on the matrix of tetrachoric correlations. The psychometric properties of the MDQ were also studied using the Rasch logistic model.

RESULTS

The parallel analysis found two significant components. The first includes symptoms referring to acceleration, danger and irritability as risky behaviors, social interaction problems and mental flow. The second includes symptoms referring to self-confidence and energy. With respect to the Korean/Chinese results, the Italian sample, item 11 ("much more sex"), appears related to self-confidence and energy, while in Asia it is connected with items expressing risky behaviors and irritability.

LIMITATIONS

Differences in the frequency of comorbid disorders in Asian and Italian populations should be considered. The results should be confirmed and compared with those of other populations.

CONCLUSIONS

Cultural differences appear to be associated with a different symptomatic expression of bipolar spectrum disorders. Future research will investigate the role of gene-environment interaction in the genesis of these differences.

Subclinical psychotic experiences and bipolar spectrum features in depression: association with outcome of psychotherapy

BACKGROUND

Subthreshold psychotic and bipolar experiences are common in major depressive disorder (MDD). However, it is unknown if effectiveness of psychotherapy is altered in depressed patients who display such features compared with those without. The current paper aimed to investigate the impact of the co-presence of subclinical psychotic experiences and subclinical bipolar symptoms on the effectiveness of psychological treatment, alone or in combination with pharmacotherapy.

METHOD

In a naturalistic study, patients with MDD (n = 116) received psychological treatment (cognitive behavioural therapy or interpersonal psychotherapy) alone or in combination with pharmacotherapy. Depression and functioning were assessed six times over 2 years. Lifetime psychotic experiences and bipolar symptoms were assessed at the second time point.

RESULTS

Subclinical psychotic experiences predicted more depression over time (β = 0.20, p < 0.002), non-remission [odds ratio (OR) 7.51, p < 0.016] and relapse (OR 3.85, p < 0.034). Subthreshold bipolar symptoms predicted relapse (OR 1.16, p < 0.037).

CONCLUSIONS

In general, subclinical psychotic experiences have a negative impact on the course and outcome of psychotherapy in MDD. Effects of subclinical bipolar experiences were less prominent.

The prevalence of bipolar disorder in general primary care samples: a systematic review

OBJECTIVE

To obtain an estimate of the prevalence of bipolar disorder in primary care.

METHODS

We used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method to conduct a systematic review in January 2013. We searched seven databases with a comprehensive list of search terms. Included articles had a sample size of 200 patients or more and assessed bipolar disorder using a structured clinical interview or bipolar screening questionnaire in random adult primary care patients. Risk of bias in each study was also assessed.

RESULTS

We found 5595 unique records in our search. Fifteen studies met our inclusion criteria. The percentage of patients with bipolar disorder found on structured psychiatric interviews in 10 of 12 studies ranged from 0.5% to 4.3%, and a positive screen for bipolar disorder using a bipolar disorder questionnaire was found in 7.6% to 9.8% of patients.

CONCLUSION

In 10 of 12 studies using a structured psychiatric interview, approximately 0.5% to 4.3% of primary care patients were found to have bipolar disorder, with as many as 9.3% having bipolar spectrum illness in some settings. Prevalence estimates from studies using screening measures that have been found to have low positive predictive value were generally higher than those found using structured interviews.

The presentation, recognition and management of bipolar depression in primary care

Bipolar disorder is a mood disorder characterized by episodes of major depression and mania or hypomania. Most patients experience chronic symptoms of bipolar disorder approximately half of the time, most commonly subsyndromal depressive symptoms or a full depressive episode with concurrent manic symptoms. Consequently, patients with bipolar depression are often misdiagnosed with major depressive disorder. Individual patient characteristics and population screening tools may be helpful in improving recognition of bipolar depression in primary care. Health risk behaviors including tobacco use, sedentary activity level and weight gain are highly prevalent in patients with bipolar disorder, as are the comorbid chronic diseases such as diabetes mellitus and cardiovascular disease. Patients with bipolar illness have about an eight-fold higher risk of suicide and a two-fold increased risk of death from chronic medical illnesses. Recognition of bipolar depression and its associated health risk behaviors and chronic medical problems can lead to the use of appropriate interventions for patients with bipolar disorder, which differ in important ways from the treatments used for major depressive disorder. The above topics are reviewed in detail in this article.

Problematic boundaries in the diagnosis of bipolar disorder: the interface with borderline personality disorder

It is clinically important to recognize both bipolar disorder and borderline personality disorder (BPD) in patients seeking treatment for depression, and it is important to distinguish between the two. The most studied question on the relationship between BPD and bipolar disorder is their diagnostic concordance. Across studies approximately 10 % of patients with BPD had bipolar I disorder and another 10 % had bipolar II disorder. Likewise, approximately 20 % of bipolar II patients were diagnosed with BPD, though only 10 % of bipolar I patients were diagnosed with BPD. While the comorbidity rates are substantial, each disorder is, nonetheless, diagnosed in the absence of the other in the vast majority of cases (80-90 %). In studies examining personality disorders broadly, other personality disorders were more commonly diagnosed in bipolar patients than was BPD. Likewise, the converse is also true: other axis I disorders such as major depression, substance abuse, and post-traumatic stress disorder are more commonly diagnosed in patients with BPD than is bipolar disorder. Studies comparing patients with BPD and bipolar disorder find significant differences on a range of variables. These findings challenge the notion that BPD is part of the bipolar spectrum. While a substantial literature has documented problems with the under-recognition and under-diagnosis of bipolar disorder, more recent studies have found evidence of bipolar disorder over-diagnosis and that BPD is a significant contributor to over-diagnosis. Re-conceptualizing the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, diagnostic criteria for bipolar disorder as a type of test, rather than the final word on diagnosis, shifts the diagnostician from thinking solely whether a patient does or does not have a disorder to considering the risks of false-positive and false-negative diagnoses, and the ease by which each type of diagnostic error can be corrected by longitudinal observation.

The prevalence of bipolar disorder in primary care patients with depression or other psychiatric complaints: a systematic review

BACKGROUND

Bipolar disorder prevalence in primary care patients with depression or other psychiatric complaints has been measured in several studies but has not been systematically reviewed.

OBJECTIVE

To systematically review studies measuring bipolar disorder prevalence in primary care patients with depression or other psychiatric complaints.

METHODS

We conducted a systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses method in January 2013. We searched 7 databases using a comprehensive list of search terms. Included articles had a sample size of 200 patients or more and assessed bipolar disorder using a structured clinical interview or bipolar screening questionnaire in adult primary care patients with a prior diagnosis of depression or had an alternate psychiatric complaint.

RESULTS

Our search yielded 5595 unique records. Seven cross-sectional studies met our inclusion criteria. The percentage of primary care patients with bipolar disorder was measured in 4 studies of patients with depression, 1 study of patients with trauma exposure, 1 study of patients with any psychiatric complaint, and 1 study of patients with medically unexplained symptoms. The percentage of patients with bipolar disorder ranged from 3.4%-9% in studies using structured clinical interviews and from 20.9%-30.8% in studies using screening measures.

CONCLUSIONS

Bipolar disorder likely occurs in 3%-9% of primary care patients with depression, a trauma exposure, medically unexplained symptoms, or a psychiatric complaint. Screening measures used for bipolar disorder detection overestimate the occurrence of bipolar disorder in primary care owing to false positives.

Usefulness of the combined application of the Mood Disorder Questionnaire and Bipolar Spectrum Diagnostic Scale in screening for bipolar disorder

OBJECTIVE

This study aimed to examine whether combined application of the Mood Disorder Questionnaire (MDQ) and Bipolar Spectrum Diagnostic Scale (BSDS) is more effective than exclusive application of either tool in screening for bipolar disorder (BD).

METHOD

The MDQ and BSDS were completed by a total of 113 patients diagnosed with BD and major depressive disorder who were experiencing a current major depressive episode. The initial diagnosis of the subject was confirmed during a 1-year follow-up period. When each MDQ and BSDS optimal cutoff score was calculated, a modified scoring method for the MDQ that considered only one item was used to increase its performance in this population. The following three combinations of the cutoff scores for the two tools were used to screen for BD: (A) The score on either the MDQ or BSDS was greater than or equal to the cutoff score; (B) the scores on both the MDQ and BSDS were greater than or equal to the cutoff score; and (C) Reducing either cutoff score by 1 point resulted in the MDQ and BSDS scores being greater than or equal to the cutoff score. The sensitivity, specificity, positive predictive value, and negative predictive value of the three methods, the MDQ, and the BSDS were compared for screening BD.

RESULTS

The sensitivity and specificity of the MDQ were 0.741 and 0.844, respectively, and those for the BSDS were 0.731 and 0.742, respectively. These indicators for the combined application of the MDQ and BSDS were as follows, respectively: method A 0.901 and 0.688, method B 0.580 and 0.875, and method C 0.691 and 0.844. Method A was superior to using one measure alone as well as to methods B and C with regard to sensitivity and negative predictive values. Method A also showed a higher sensitivity for BD subtypes than did the individual tools. Compared with the use of individual instruments, method A showed a similar positive predictive value.

CONCLUSION

This study suggests that combined use of the MDQ and BSDS is more effective than the individual use of either of these measures in screening for BD. The data also showed that when both tools were used, the most effective interpretation of the results in terms of screening for BD was achieved when positive scores were defined as those that were equal to or greater than the cutoff for the MDQ or BSDS.