The Farsi version of the Hypomania Check-List 32 (HCL-32): applicability and indication of a four-factorial solution

Replicability of the five-factor structure of DSM-5 and ICD-11 trait systems and their associations with binge eating and bipolar spectrum psychopathology

Since the research on contemporary personality models-and psychopathology-mainly originate from the Western world, we aimed to test the factorial structure of two trait systems assessed with the Personality Inventory for DSM-5 (PID-5) in a non-Western sample and to compare the extracted models' relative associations with binge eating disorder (BED) and bipolar spectrum disorder (BSD) symptoms. A community sample (N = 516; 72% female) was administered the PID-5, which can operationalize both the DSM-5 and ICD-11 systems. The factor structures of both systems were tested using exploratory structural equation modeling (ESEM). The congruence coefficients of all factor loadings with international studies were calculated. The Binge Eating Scale (BES), Bipolar Spectrum Diagnostic Scale (BSDS), and Hypomania Checklist-32-Revised (HCL-32) were used to measure the criterion variables. Linear regression models were used for comparing the DSM-5 and ICD-11 systems in predicting the BED and BSD. The findings supported five-factor solutions for both trait systems. Both systems significantly predicted dimensional measures of both BED and BSD (all p < 0.001). The present findings support an acceptable five-factor structure for both personality systems in the non-Western sample. Different algorithms of maladaptive domains on both systems are related to binge eating and bipolar spectrum psychopathology.

Use of the 33-Item Hypomania Checklist (HCL-33) to Distinguish Bipolar Disorder From Major Depressive Disorder in Older Adults

BACKGROUND

Bipolar disorder (BD) is often misdiagnosed as major depressive disorder (MDD) in older patients. This study examined the psychometric properties of the 33-item Hypomania Checklist (HCL-33) and its accuracy to differentiate BD from MDD among older adults.

METHOD

A total of 215 depressed older patients were recruited; 107 were diagnosed with BD (71 with BD-type I and 36 with BD-type II) and 108 with MDD. Principal components analysis (PCA) was used to explore the factor structure of the HCL-33. Cronbach's alpha was calculated to test the internal consistency. Intra-class correlation coefficient (ICC) was used to measure test-retest reliability. The receiver operating characteristic (ROC) analysis was used to generate the optimal cut-off value to differentiate between BD and MDD.

RESULTS

Two factors were identified in the PCA analysis accounting for 33.9% of the total variance. The Cronbach's alpha value for the HCL-33 was 0.912, with 0.922 for factor I and 0.664 for factor II. The test-retest reliability was excellent (ICC: 0.891). The optimal cut-off of the HCL-33 total score for discriminating between MDD and BD was 14, with a sensitivity of 88.8% and specificity of 82.4%.

CONCLUSION

The HCL-33 had satisfactory reliability and validity and could be used to distinguish BD from MDD in older adults.

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.

Comparing the Self- and External Assessment Versions of the HCL-33 as Screening Instruments for Bipolar Disorder in Older Depressed Patients

Objectives: The misdiagnosis of bipolar disorder (BD) as major depressive disorder (MDD) is common in depressed older adults. The self-rated HCL-33 and its external assessment version (HCL-33-EA) have been developed to screen for hypomanic symptoms. This study compared the screening ability of these two instruments to discriminate BD from MDD. Methods: A total of 215 patients (107 with BD and 108 with MDD) and their carers were recruited. Patients and their carers completed the HCL-33 and HCL-33-EA, respectively. The consistency of the total score and the positive response to each item between the two scales was calculated with the intraclass correlation coefficient (ICC) and Cohen's kappa coefficient separately. Receiver operating characteristics (ROC) curves were drawn for both instruments. The optimal cut-off points were determined according to the maximum Youden's Index. The areas under the ROC curve (AUC) of the HCL-33 and HCL-33-EA were calculated separately and compared. The sensitivity and specificity at the optimal cut-off values were also calculated separately for the HCL-33 and HCL-33-EA. Results: The intraclass correlation coefficient (ICC) between the total scores of the HCL-33 and HCL-33-EA was 0.823 (95% CI = 0.774-0.862). The positive response rate on all items showed high agreement between the two instruments. ROC curve analysis demonstrated that the total scores of both HCL-33 and HCL-33-EA differentiated well between MDD and BD, while there was no significant difference in the AUCs between the two scales (Z = 0.422, P = 0.673). The optimal cutoff values for the HCL-33 and HCL-33-EA were 14 and 12, respectively. With the optimal cutoff value, the sensitivities of the HCL-33 and HCL-33-EA were 88.8% and 93.5%, and their specificities were 82.4% and 79.6%. Conclusion: Both the HCL-33 and HCL-33-EA had good screening ability for discriminating BD from MDD in depressed older adults.

The Globalization of Biological Psychiatry and the Rise of Bipolar Spectrum Disorder in Iran

In recent years, psychiatry in Iran witnessed a dramatic increase in the use of the diagnosis of bipolar spectrum disorder (BSD). This qualitative study maps the journey of the BSD diagnosis from the West to Iran, examines the controversy surrounding the diagnosis and its treatment, and explores some of the structural factors that facilitate and maintain the widespread use of the BSD diagnosis in Iran and related practices of prescribing neuroleptic and mood stabilizers. The study methods include archival research and semi-structured interviews with 25 prominent Iranian psychiatrists in the field of mood disorders. Results show the importance of factors in addition to economics in driving changes in diagnostic fashion. Most psychiatrists interviewed reported what they viewed as an over-diagnosis of bipolar disorder and over-prescription of mood stabilizers and atypical antipsychotics among Iranian psychiatrists over the past decade. In addition to the influence of leading figures of American psychiatry, the dominance of Western psychiatric classifications and textbooks in Iran's psychiatry, and indirect intervention by pharmaceutical companies, local structural and political factors have played a significant role in the Iranian psychiatric system's embrace of the new concept of bipolarity. In Iran, the medicalization of social conflict has been embraced by government, families, and psychiatrists for cross-cutting purposes. These challenges and the continued controversy over the adoption of American psychiatric fads in a non-Western country like Iran point to the importance of elaborating a more ecosocial and cultural view of psychiatric practice to disentangle some of the complex trade-offs involved in adopting particular modes of diagnostic practice.

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.

Screening bipolar disorders in a general hospital: Psychometric findings for the Persian version of mood disorder questionnaire and bipolar spectrum diagnostic scale

Background: Mood Disorder Questionnaire (MDQ) and Bipolar Spectrum Diagnostic Scale (BSDS) are used to screen patients with bipolar disorders and have been examined in some psychiatric settings. The present study aimed to assess the validity and reliability of these 2 tools on inpatients in a general hospital.

Methods: In a cross-sectional study in 2011, a total of 207 inpatients admitted to different wards of Rasoul Akram hospital, Tehran, were selected by systematic random sampling. Demographic questionnaire, MDQ, and BSDS were completed. Also, Structured Clinical Interview for DSM-IV axis I disorders (SCID-I) was performed for all participants within 72 hours. The SCID-I was used as the gold standard of psychiatric diagnoses to identify the predictive validity of the 2 screening tests. Sensitivity and specificity indices were identified using Roc curve. The 2 screening tools were recompleted by 20% of the patients (n=43) after 3-7 days to measure test-retest reliability using paired t test and correlation between measures in 2 separate occasions.

Results: In this study, 101 female and 106 male (m=36.9±15.5 yrs.) patients were entered the study, of them 56 (32 males) had bipolar disorder according to SCID-I. The most common bipolar disorder was bipolar disorder type II (9.7%). Pearson’s test showed a high test-retest reliability for both MDQ (r=0.72, p<0.001) and BSDS (r=0.77, p<0.001). For MDQ, the scores 5 (sensitivity=0.60; specificity=0.73) and 6 (sensitivity=0.56; specificity=0.77) were the best cutoff points. Positive and negative predictive values for the mentioned cutoff points were 0.45 and 0.83 (for the score 5) and 0.48 and 0.82 (for the score 6), respectively. The best cutoff point for BSDS was 11 with the sensitivity, specificity, and positive and negative predictive values of 0.74, 0.69, 0.47, and 0.87.

Conclusion: The Persian versions of MDQ and BSDS have acceptable validity and reliability to screen Persian patients with bipolar spectrum disorders in a general hospital.

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.

Factorial structure and familial aggregation of the Hypomania Checklist-32 (HCL-32): Results of the NIMH Family Study of Affective Spectrum Disorders

BACKGROUND

There is substantial evidence that bipolar disorder (BD) manifests on a spectrum rather than as a categorical condition. Detection of people with subthreshold manifestations of BD is therefore important. The Hypomania Checklist-32 (HCL-32) was developed as a tool to identify such people.

PURPOSE

The aims of this paper were to: (1) investigate the factor structure of HCL-32; (2) determine whether the HCL-32 can discriminate between mood disorder subtypes; and (3) assess the familial aggregation and cross-aggregation of hypomanic symptoms assessed on the HCL with BD.

PROCEDURES

Ninety-six probands recruited from the community and 154 of their adult first-degree relatives completed the HCL-32. Diagnosis was based on semi-structured interviews and family history reports. Explanatory factor analysis and mixed effects linear regression models were used.

FINDINGS

A four-factor ("Activity/Increased energy," "Distractibility/Irritability", "Novelty seeking/Disinhibition, "Substance use") solution fit the HCL-32, explaining 11.1% of the total variance. The Distractibility/Irritability score was elevated among those with BP-I and BP-II, compared to those with depression and no mood disorders. Higher HCL-32 scores were associated with increased risk of BD-I (OR = 1.22, 95%CI 1.14-1.30). The "Distractibility/Irritability" score was transmitted within families (β = 0.15, p = 0.040). However, there was no familial cross-aggregation between mood disorders and the 4 HCL factors.

CONCLUSIONS

Our findings suggest that the HCL-32 discriminates the mood disorder subtypes, is familial and may provide a dimensional index of propensity to BD. Future studies should explore the heritability of symptoms, rather than focusing on diagnoses.

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.

"I love you forever (more or less)" - stability and change in adolescents' romantic love status and associations with mood states

Objective:

Experiencing romantic love is an important part of individual development. Here, we investigated stability and change in romantic love and psychological correlates, including mood states, anxiety, and sleep, among Iranian adolescents over a period of 8 months.

Method:

Two hundred and one adolescents who had taken part in a previous study were contacted; 157 responded. Participants completed a questionnaire covering sociodemographic data, current state of love, and mood, including symptoms of depression, anxiety (state and trait), and hypomania. They also completed a sleep and activity log.

Results:

Of 64 participants formerly in love, 45 were still in love; of 86 participants not in love at baseline, 69 were still not in love (overall stability, 76%); 17 had fallen in love recently while 19 were no longer in love. Significant and important changes in mood and anxiety were observed in that experiencing romantic love was associated with higher anxiety scores. Hypomania scores increased in those newly in love, and decreased in those in a longer-lasting romantic relationship. Sleep and sleep-related variables were not associated with romantic love status.

Conclusion:

These findings suggest that, among Iranian adolescents, the state of love is fairly stable, and that love status seems to be associated with specific states of mood and anxiety.

Levels of mania and cognitive performance two years after ECT in patients with bipolar I disorder - results from a follow-up study

BACKGROUND

There is limited evidence on the long-term outcomes for patients with bipolar I disorder (BP-I-D) and treated with ECT. Therefore, we asked whether mania scores and cognitive performance at the end of ECT treatment (baseline/BL) predicted mania scores, cognitive performance, recurrence, treatment adherence, and mood (depression; hypomania) two years later (follow-up/FU).

METHOD

38 patients with BP-I-D undergoing ECT at baseline were followed up two years later. A brief psychiatric and cognitive assessment (Mini Mental State Examination; short-term verbal memory test) was performed; patients completed questionnaires covering recurrence, treatment adherence, and mood (depression; hypomania).

RESULTS

High cognitive performance at BL predicted high cognitive performance at FU; low mania scores at BL predicted low mania scores at FU. By FU, cognitive performance had increased and mania scores decreased. Mania scores and cognitive performance at BL did not predict recurrence, or adherence to medication, or mood (depression; hypomania).

CONCLUSIONS

The pattern of results suggests that after two years of successful treatment of acute mania with ECT, cognitive impairment, measured by MMSE and a short-term verbal memory test, is not impaired and mood symptom recurrence seems to be improved. Mania scores and cognitive performance at the end of ECT treatment predicted neither mood (depression; hypomania), nor recurrence, or adherence to medication two years later.

Validity and test-retest reliability of the Persian version of the Montgomery-Asberg Depression Rating Scale

BACKGROUND AND AIMS

The Montgomery-Asberg Depression Rating Scale (MADRS) is an expert's rating tool to assess the severity and symptoms of depression. The aim of the present two studies was to validate the Persian version of the MADRS and determine its test-retest reliability in patients diagnosed with major depressive disorders (MDD).

METHODS

In study 1, the translated MADRS and the Hamilton Depression Rating Scale (HDRS) were applied to 210 patients diagnosed with MDD and 100 healthy adults. In study 2, 200 patients diagnosed with MDD were assessed with the MADRS in face-to-face interviews. Thereafter, 100 patients were assessed 3-14 days later, again via face-to-face-interviews, while the other 100 patients were assessed 3-14 days later via a telephone interview.

RESULTS

Study 1: The MADRS and HDRS scores between patients with MDD and healthy controls differed significantly. Agreement between scoring of the MADRS and HDRS was high (r=0.95). Study 2: The intraclass correlation coefficient (test-retest reliability) was r=0.944 for the face-to-face interviews, and r=0.959 for the telephone interviews.

CONCLUSION

The present data suggest that the Persian MADRS has high validity and excellent test-retest reliability over a time interval of 3-14 days, irrespective of whether the second assessment was carried out face-to-face or via a telephone interview.

THE VALIDITY OF THE MOOD DISORDER QUESTIONNAIRE FOR SCREENING BIPOLAR DISORDER: A META-ANALYSIS

We conducted a meta-analysis to review the diagnostic accuracy of the Mood Disorder Questionnaire (MDQ) among patients with mood disorders. We used a bivariate random effects model to calculate summary sensitivity and specificity. Twenty-one studies were included. At the standard or modified cutoff value of 7, summary sensitivity was .62 and summary specificity was .85. When we pooled 11 studies including both patients with bipolar disorder (BD) and those with unipolar depression, the summary sensitivity was .76 and summary specificity was .81. However, among the six studies that excluded patients with known BD, the summary sensitivity was significantly reduced to .37 and summary specificity was .88. There were no significant differences on the diagnostic accuracy of the MDQ between studies from Eastern and Western countries after adjusting for various clinical correlates. The overall diagnostic accuracy of the MDQ was relatively good. However, when the MDQ is applied among patients with depression without previous diagnoses of BD, its sensitivity was significantly reduced. This suggests that when the MDQ is applied among this population, its optimal cutoff value should be adjusted to enhance its sensitivity.

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.

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 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.

Bipolar II disorder in patients with a current diagnosis of recurrent depression

OBJECTIVES

The prevalence of bipolar II disorder (BD-II) in Russia has never been studied. Therefore, we sought to identify patients meeting diagnostic criteria for BD-II among patients with a current diagnosis of recurrent depressive disorder (RDD) through the use of the Russian versions of the Hypomania Checklist (HCL-32) and Bipolarity Index scales for differentiating between BD-II and RDD.

METHODS

In a non-interventional diagnostic study, we selected 409 patients aged between 18 and 65 years from two medical settings with (i) a current diagnosis of RDD, (ii) an illness duration of at least three years, and (iii) at least two affective episodes. The diagnosis was based on clinical assessment and confirmed by the Russian version of the Mini International Neuropsychiatric Interview. All patients were assessed by the HCL-32, the Bipolarity Index, and the Personal and Social Performance Scale.

RESULTS

Among patients with a current diagnosis of RDD, 40.8% had a diagnosis of bipolar disorder (bipolar I disorder: 4.9%; BD-II: 35.9%). The average time lag from onset to a correct diagnosis of BD-II was 15 years and patients were treated only with antidepressants. The sensitivity of the Russian version of the HCL-32 at the optimal cutoff point (≥14.0) was 83.7%, and its specificity was 71.9%. The Bipolarity Index showed significant differences between the total scores of the patients with BD-II and RDD (31.8 versus 20.2; p < 0.0001). The optimal threshold was ≥22.0 (sensitivity 73.5%; specificity 72.3%).

CONCLUSIONS

In Russia, diagnostic errors are an important cause of the non-detection of bipolar disorder, particularly BD-II. The Russian version of the HCL-32 and the Bipolarity Index, as additional tools, could be useful for bipolarity screening.

The use of 15-point hypomanic checklist in differentiating bipolar I and bipolar II disorder from major depressive disorder

OBJECTIVES

Individuals with bipolar disorder (BP) are often misdiagnosed with major depressive disorder (MDD). In this study, we developed a Chinese version of 15-point hypomania scale (HCL-15) in order to determine its sensitivity and specificity in the diagnosis of BP and BP-II in particular.

METHODS

A total of 623 individuals suffering a major depressive episode (MDE) were systematically interviewed with both Structured Clinical Interview for DSM-IV-TR Axis I Disorders, Patient Edition, and HCL-15. A cutoff score of 8 or more in HCL-15 was suggested for BP.

RESULTS

Of the 623 depressed patients, 115 (18.5%) actually required a diagnosis of BP-I, and another 159 (25.5%) could be more appropriately diagnosed with BP-II, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria. The sensitivity of 15-HCL in detection of BP-II was 0.78 and 0.46 for BP-I; the specificity was 0.9 and 0.69, respectively. The specificity of HCL-15 for BP versus MDD was as high as 0.93. Approximately 60%-80% of all questions in the HCL-15 questionnaire revealed positive responses from patients, while items 11 and 12, measuring the consumption of alcohol, coffee and cigarettes, demonstrated a low positive response rate.

CONCLUSIONS

The HCL-15 assessment scale was fairly sensitive and highly specific for a BP-II diagnosis but not for a BP-I diagnosis. Some items in the HCL-15 symptom list need to be further modified to better fit Chinese culture and customs. The HCL-15 scale could be a useful tool in clinical practice for screening individuals with BP-II in order to avoid a misdiagnosis of MDD.

Validation of the Russian version of the Hypomania Checklist (HCL-32) for the detection of Bipolar II disorder in patients with a current diagnosis of recurrent depression

BACKGROUND

There are no validated screening tools for Bipolar Disorder (BD) in Russia.

OBJECTIVE

To validate the Russian version of the HCL-32 for the detection of Bipolar II disorder (BD II) in patients with Recurrent Depressive Disorder (RDD).

METHODS

409 patients with a current diagnosis of RDD were recruited. The diagnosis was confirmed by the validated Russian version of the Mini International Neuropsychiatric Interview (MINI). Another investigator interviewed the patients using the НСL-32 questions.

RESULTS

The total HCL-32 score in patients with BD II was significantly higher than in patients with RDD: 18.2 (4.22) versus 10.85 (5.81) (p<0.001, d=1447). At the cut-off 14 points the sensitivity was 83.7%, specificity 71.9% (p<0.001). The Cronbach's alpha was 0.887 that means good internal consistency. The best discrimination was achieved with 8 items: decreased need for sleep, less shyness or inhibition, talkativeness, more jokes and puns, jumping thoughts distractibility, exhausting or irritating others and high and more optimistic mood. We proposed the reduced variant of the scale, that includes only these 8 variables, with sensitivity 90.5%, specificity 69.8% (AUC=0.88).

CONCLUSIONS

The Russian version of the HCL-32 displayed a good ratio of sensitivity to specificity and can be recommended as a validated screening instrument. An 8-item version of HCL needs further research.

LIMITATIONS

Limitations include the specific nature of the sample, the HCL-32 assessment carried out by a psychiatrist, no comparison with other BD screening scales. The results of the 8-item version may be sample and culture dependent.

In Iranian female and male adolescents, romantic love is related to hypomania and low depressive symptoms, but also to higher state anxiety

BACKGROUND

Experiencing romantic love is important in individual development. Little is known about romantic love among adolescents in non-Western countries. The aim of the present study was to explore romantic love among Iranian male and female adolescents.

METHOD

A total of 201 adolescents (mean age: 17.73 years) took part in the study; of these, 81 indicated they were experiencing romantic love at the time of survey, and 120 indicated they were not in love. Participants answered questionnaires related to affective states (hypomania, depressive symptoms, state and trait anxiety) and exercise, and completed a sleep log for seven consecutive nights.

RESULTS

Compared to controls, participants in love displayed favourable hypomania scores, fewer depressive symptoms and increased concentration during the day. However, participants in love also had higher state anxiety scores. Moreover, hypomanic-like stages increased with duration of relationship in female, but not in male participants.

CONCLUSIONS

The pattern of results suggests a favourable association between being currently in love and emotional and cognitive processes. Sleep, however, seemed unrelated to this specific state.

Discriminative hypomania checklist-32 factors in unipolar and bipolar major depressive patients

BACKGROUND

Although manic or hypomanic episodes define bipolar disorder (BD), most patients show a predominance of depressive symptomatology, often associated with delayed or disregarded BD diagnosis. The Hypomania Checklist-32 (HCL-32) has therefore been developed and tested internationally to facilitate BD recognition.

SAMPLING AND METHODS

Five hundred seventy-one (563 eligible) patients diagnosed with a major depressive episode according to DSM-IV criteria were consecutively enrolled in a cross-sectional, multicenter, observational study (Come To Me). Lifetime manic or hypomanic features were assessed by the HCL-32, and severity of depressive and anxious symptomatology was assessed using the Zung's self-report questionnaires for depression and anxiety.

RESULTS

Among the patients diagnosed with BD (n = 119), either type I or type II, the occurrence of (hypo)manic symptoms was significantly higher compared to major depressive disorder (MDD) symptoms according to HCL-32 total and subscale scores obtained using a score of 14, which ensured an optimal discrimination between BD and MDD with a sensitivity of 0.85 and a specificity of 0.78.

CONCLUSIONS

Although some false positives might occur, the HCL-32 was confirmed to be a useful instrument in the detection of past hypomania in MDD patients, finally contributing to proper therapeutic choices.