Today, I review, link to, and excerpt from Assessment Tools for Adult Bipolar Disorder [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. Clin Psychol (New York). 2009 Jun 1;16(2):188–201. doi: 10.1111/j.1468-2850.2009.01158.x
There are 81 similar articles in PubMed.
The above resource has been cited by 22 articles in PubMed.
All that follows is from the above resource.
Abstract
This article reviews the current state of the literature on the assessment of bipolar disorder in adults. Research on reliable and valid measures for bipolar disorder has unfortunately lagged behind assessment research for other disorders, such as major depression. We review diagnostic tools, self-report measures to facilitate screening for bipolar diagnoses, and symptom severity measures. We briefly review other assessment domains, including measures designed to facilitate self-monitoring of symptoms. We highlight particular gaps in the field, including an absence of research on the reliable diagnosis of bipolar II and milder forms of disorder, a lack of empirical data on the best ways to integrate data from multiple domains, and a shortage of measures targeting a broader set of illness-related constructs relevant to bipolar disorder.
Keywords: adult, assessment, bipolar, diagnosis, screening, severity
The goal of this review is to summarize measures that are useful for the assessment of bipolar disorder among adults. We will focus, in particular, on measures pertinent to screening, diagnosis, and symptom monitoring. With the apparent success of lithium in treating bipolar disorder, research on the disorder languished until the 1990s. Interest in bipolar disorder assessment has been renewed in recent decades. Nonetheless, research on the accurate assessment of bipolar disorder is relatively sparse when compared with other disorders such as major depression. We begin by describing the forms of bipolar disorder, then turn to available measures for its diagnosis, including both interview and self-report measures. Later sections discuss interviews and scales used for assessing symptom severity, including self-monitoring.
NATURE OF BIPOLAR DISORDER
Several types of bipolar disorder are recognized by the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (APA, 2000), differentiated by the severity and duration of manic symptoms. A diagnosis of bipolar I disorder is made based on a single lifetime episode of mania, which is in turn defined by euphoric or irritable mood, along with at least three additional symptoms (or four if mood is only irritable) that result in marked social or vocational impairment. The duration criterion for mania specifies that symptoms must last one week or require hospitalization. Bipolar II disorder, in contrast, is defined by a history of at least one hypomanic episode and at least one major depressive episode. Criteria for hypomania are similar to those of mania, but in milder form: instead of impairment, a hypomanic episode is marked by a distinct change in functioning. Cyclothymic disorder is an even milder subtype of bipolar disorder, and is diagnosed based on a period of at least two years of recurrent mood swings. By definition, these mood swings must be in both the “up” and the “down” directions, but do not meet full criteria for mania, hypomania, or depression. In addition, the symptomatic two-year period cannot include any two-month span that is free of mood swings.
Symptoms that are secondary to drugs such as cocaine, or medical conditions such as thyroid problems, will generally yield a diagnosis of substance-induced mood disorder or bipolar disorder not otherwise specified. Those with a vulnerability to bipolar disorder may become manic when prescribed antidepressants without an accompanying mood stabilizer (Ghaemi, Lenox, & Baldessarini, 2001), yielding a diagnosis of substance-induced mood disorder with manic features.
Large epidemiological studies indicate a prevalence of 1% for bipolar I disorder and an additional 3% for bipolar II disorder (Kessler, Berglund, Demler, Jin, & Walters, 2005). As many as three quarters of those with bipolar I disorder have also experienced an episode of major depression (Karkowski & Kendler, 1997; Kessler, Rubinow, Holmes, Abelson, & Zhao, 1997). Comorbidity rates with anxiety disorders and substance abuse disorders have been reported as high as 93% and 61%, respectively (Kessler et al., 1997; Regier et al., 1990), underscoring the need for effective assessments and treatments of bipolar disorder to take comorbid conditions into account.
Twin studies suggest that heritability accounts for more than 90% of the variability in the development of bipolar disorder (Kieseppä, Partonen, Haukka, Kaprio, & Lönnqvist, 2004), leading many researchers to focus on medications such as lithium for treatment (Prien & Potter, 1990). The course of the disorder, however, may be strongly affected by psychosocial variables. Manic episodes may be triggered by sleep disturbance (Leibenluft et al., 1996) or excessive pursuit of goals (Johnson, 2005). Depressive episodes within bipolar disorder share common triggers with unipolar depression, such as negative life events, maladaptive cognitive styles, and lack of social support (Johnson & Kizer, 2002). Thus psychotherapy may serve as an effective addition to medication in the treatment of bipolar disorder (Johnson & Leahy, 2004; Rizvi & Zaretsky, 2007).
ASSESSMENT TOOLS FOR DIAGNOSIS
The diagnosis of bipolar disorder is based on a review of symptoms and potential medical explanations for those symptoms, as there is no biological marker for the disorder. In clinical practice, symptoms are frequently reviewed in an unstructured manner. It should be noted, though, that when practitioners do not use structured diagnostic tools, as many as half of comorbid conditions go undetected (Zimmerman & Mattia, 1999). Furthermore, many practitioners report that they do not routinely screen for bipolar disorder even among people with a history of major depression, many of whom would meet the diagnostic criteria for bipolar disorder (Brickman, LoPicollo, & Johnson, 2002). Due to informal or poor screening, the average time between onset of symptoms and formal diagnosis is more than seven years (Lish, Dime-Meenan, Whybrow, Price, & Hirschfeld, 1994; Mantere, Suiminen, Leppamaki, Arvilommi, & Isometsa, 2004). Improper diagnosis has serious repercussions because antidepressant treatment without mood-stabilizing medication can trigger iatrogenic mania (Ghaemi et al., 2001).
Several semistructured interviews have been developed to assess bipolar disorder in adults. The two most commonly used measures are the Structured Clinical Interview for DSM-IV (SCID) and the Schedule for Affective Disorders and Schizophrenia (SADS). We will not focus here on the Composite Interview Diagnostic Interview (CIDI; Robbins et al., 1988), which has been developed and used mostly in epidemiological surveys (e.g., Kessler & Zhao, 1999). Briefly, there is some evidence that the CIDI may systematically underdiagnose bipolar disorder (e.g., Kessler, Rubinow, Holmes, Abelson, & Zhao, 1997), but more recent work has since validated it against the SCID (Kessler et al., 2006). The SCID and the SADS both provide interview probes, symptom thresholds, and information about exclusion criteria (i.e., medical or pharmacological conditions that may induce mania). They differ, however, in the criteria they were designed to assess. The SCID is designed to help assess diagnoses according to the DSM-IV, whereas the SADS is designed to assess diagnoses according to the Research Diagnostic Criteria (RDC). RDC criteria are stricter in that psychotic symptoms are more likely to yield a diagnosis of schizoaffective disorder than would be applied in the DSM-IV criteria; within the DSM-IV criteria, psychotic symptoms must be present for at least two weeks outside of episode to be considered evidence of schizoaffective disorder. Further details about these measures are provided next. We begin by describing the measures and their psychometric characteristics for assessing bipolar I disorder. We then turn toward some specific issues that complicate the assessment of milder forms of bipolar disorder. Table 1 summarizes some of the well-supported measures for the diagnosis of bipolar disorder.
Table 1.
Summary of Validated Bipolar Disorder Assessment Tools for Diagnosis
Name Primary setting Format Notes Structured Clinical Interview for DSM-IV Both clinical and research settings Semistructured interview Consists of separate modules relevant to particular disorders; can be relatively time-consuming; good reliability/validity data Schedule for Affective Disorders and Schizophrenia—Lifetime Version Both clinical and research settings Semistructured interview Consists of separate modules relevant to particular disorders; can be relatively time-consuming; good reliability/validity data General Behavior Inventory Research settings Self-report Different versions have different lengths and cutoffs (e.g., 52- to 73-item length); items can be hard to understand due to complex wording and syntax; publicly available Mood Disorder Questionnaire Research settings Self-report Very brief inventory (15 items); appears more useful in clinical rather than community populations; publicly available The SCID (Spitzer, Williams, Gibbon, & First, 1992) is recommended as a routine part of clinical intake procedures. The SCID is a semistructured interview that is divided into modules to cover different diagnoses. The modular design allows for the interview to be easily tailored to capture relevant diagnoses for a given research or clinical situation. Each SCID module contains probes to cover each of the core symptoms, and interviewers can use clinical judgment in gathering supplemental information if probes do not provide sufficient information for reliable symptom assessment. A clinician’s version is available through American Psychiatric Publishing (First, Spitzer, Gibbon, & Williams, 1997). The SCID, and more specifically its bipolar disorder module, demonstrated good interrater reliability both in a large international multisite trial (Williams et al., 1992) and in at least 10 other major trials (Rogers, Jackson, & Cashel, 2001). In patient samples, reliability for current and lifetime diagnoses of bipolar disorder has been adequate to excellent, ranging from .64 to .92; establishing reliability for the SCID in community samples is more difficult due to low base rates of the disorder (Williams et al., 1992). Compared to other structured interviews including the Diagnostic Interview Schedule (DIS) and the Composite International Diagnostic Interview (CIDI), and to clinicians not using a structured interview, diagnoses of bipolar disorder based on the SCID appear substantially more reliable. Results of one study indicated that the percentage of agreements with the gold standard were higher for the SCID as compared to standard clinician interviews (Basco et al., 2000). In a sample of twins, diagnoses of bipolar disorder made using the SCID showed similar concordance rates between monozygotic and dizygotic twins compared to traditional twin studies using standard diagnostic interviews (Kieseppä, et al., 2004).
The SADS (Endicott & Spitzer, 1978) was designed to assess a broad range of Axis I diagnoses. For each diagnosis, the probes focus on the symptoms for the most recent episode and then capture a broad overview of past episodes. The reliability and validity of the SADS has been established across 21 studies (see Rogers, Jackson, & Cashel, 2001, for a review). The SADS has demonstrated good to excellent reliability for both symptoms and diagnoses (Andreasen et al., 1981). Specifically, mania diagnoses have achieved good interrater reliability and achieved good test–retest reliability over 5 to 10 years among adults (Coryell et al., 1995; Rice et al., 1986). SADS diagnoses of bipolar disorder correlate robustly with other measures of mania (Secunda et al., 1985), and the SADS appears to validly capture diagnoses across different cultural and ethnic groups within the United States (Vernon & Roberts, 1982).
Diagnostic Assessment of Bipolar II Disorder in Adults
Hypomania is unique among DSM syndromes, in that by definition it does not cause any functional impairment. Perhaps because of this quality, the presence of at least one major depressive episode is also required to achieve a diagnosis of bipolar II disorder. This presents a unique diagnostic challenge: the hypomanic episodes that separate bipolar II disorder from unipolar depression are by definition of only limited severity, making this a hard diagnosis to reliably detect. Complicating this picture is the fact that there are important disagreements in the field regarding the best criteria for hypomanic episodes. For instance, current DSM criteria require three or four symptoms, in addition to elevated or irritable mood, lasting at least four days. In contrast, RDC criteria only require three symptoms lasting two days. Given this uncertainty and relative lack of severity of hypomania, it is not surprising that the accurate assessment of bipolar II disorder is more difficult to achieve than bipolar I disorder.
Given that hypomania is almost always accompanied by less distress than depressive episodes, one might be tempted to focus on detecting depression. There is evidence, however, that the diagnosis of hypomania (and hence, bipolar II disorder) is important above and beyond the detection of depression. Diagnoses of bipolar II disorder are accompanied by increased mood lability (Akiskal et al., 1995) and a family history of bipolar II disorder (Rice et al., 1986). In addition, at least three studies have demonstrated that people with bipolar II disorder are at a higher risk for suicide than are those with bipolar I disorder or unipolar depression (Dunner, 1996). It is possible that the low mood of depression, combined with the impulsivity of hypomania, may be especially likely to lead to suicide attempts. In addition to suicide risk, the misdiagnosis of bipolar II disorder can have harmful pharmacological implications. The prescription of antidepressants, which is likely if bipolar II disorder is misdiagnosed as unipolar depression, may cause or exacerbate manic symptoms (Ghaemi et al., 2001). Thus, identification of bipolar II disorder may be pivotal in administering effective treatments.
The above-described difficulties in assessing hypomanic symptoms have manifested in low reliability for the SADS in detecting bipolar II disorder (Andreasen et al., 1981), even when interviewers rate the same tapes (Keller et al., 1981). Some research groups have achieved better estimates, however (Simpson et al., 2002; Spitzer & Endicott, 1978). Beyond the inconsistent estimates of interrater reliability, test–retest reliability over six months to two years likewise has been low for bipolar II disorder and cyclothymic disorder alike (Andreasen et al.; Rice et al., 1986). In one study, only 40% of participants with bipolar II disorder according to the SADS at baseline experienced any manic or hypomanic episodes over the ensuing 10 years (Coryell et al., 1995). This lack of ability to accurately detect bipolar II disorder is not limited to the SADS. In one study, a SCID interview missed one third of bipolar II cases identified by expert clinical interview (Dunner & Tay, 1993; Simpson et al., 2002). In sum, the best available diagnostic interviews are limited in their psychometric characteristics for the diagnosis of bipolar II disorder.
The above-described difficulties in assessing hypomanic symptoms have manifested in low reliability for the SADS in detecting bipolar II disorder (Andreasen et al., 1981), even when interviewers rate the same tapes (Keller et al., 1981). Some research groups have achieved better estimates, however (Simpson et al., 2002; Spitzer & Endicott, 1978). Beyond the inconsistent estimates of interrater reliability, test–retest reliability over six months to two years likewise has been low for bipolar II disorder and cyclothymic disorder alike (Andreasen et al.; Rice et al., 1986). In one study, only 40% of participants with bipolar II disorder according to the SADS at baseline experienced any manic or hypomanic episodes over the ensuing 10 years (Coryell et al., 1995). This lack of ability to accurately detect bipolar II disorder is not limited to the SADS. In one study, a SCID interview missed one third of bipolar II cases identified by expert clinical interview (Dunner & Tay, 1993; Simpson et al., 2002). In sum, the best available diagnostic interviews are limited in their psychometric characteristics for the diagnosis of bipolar II disorder.
These difficulties have led some researchers to suggest that interviews aimed at detecting bipolar II disorder should start with questions about behavioral activation and increases in goal-directed behaviors rather than mood (Akiskal & Benazzi, 2005). Although promising, such approaches have not yet been fully validated.
In sum, a set of issues mars diagnosis of bipolar II disorder. Persons who meet criteria for bipolar II disorder may be at high risk for suicidality, and they may experience a worsening of manic symptoms if prescribed antidepressants. On the other hand, available tools do not detect bipolar II disorder reliably. Thus a major goal for ongoing research is to develop ways to reliably capture diagnoses of bipolar II disorder.
Self Report Measures
The most reliable and valid way to obtain a diagnosis of bipolar disorder is through a structured interview with a trained clinician (Akiskal, 2002). Nonetheless, given the time commitment involved in conducting structured interviews, several self-report measures have been developed to help clinicians identify persons most likely to meet criteria for bipolar disorders. It should be emphasized that these measures do not provide diagnostic accuracy, but, rather, might help identify people who should warrant more careful diagnostic interviews.
The General Behavior Inventory (GBI) was designed to cover the core symptoms of bipolar disorder, including both depressive and manic symptoms (Depue et al., 1981). Different versions range from 52 to 73 items (e.g., Depue et al., 1981; Depue & Klein, 1988; Mallon, Klein, Bornstein, & Slater, 1986). Items on each version assess symptom intensity, duration, and frequency on a scale ranging from 1 (“never or hardly ever”) to 4 (“very often or almost constantly”). Although the GBI has the most robust psychometric properties of the available self-report screeners, the multiple versions make generalizations regarding psychometric properties difficult.
The full 73-item version of the GBI has demonstrated excellent internal consistency and adequate test–retest reliability. It has demonstrated sensitivity to bipolar disorder of approximately 75% and specificity greater than 97% (Depue & Klein, 1988; Depue et al., 1989; Klein, Dickstein, Taylor, & Harding, 1989; Mallon et al., 1986) in clinical and nonclinical samples. Cutoff scores, however, have not been consistent across studies, further limiting the generalizability of the scale. At present, the GBI appears to be a useful screening tool for bipolar disorder, but future research to establish norms and cutoffs would increase its utility.