In addition to today’s resource, please see:
- Linking To And Excerpting From StatPearls’ Bipolar Disorder
Posted on May 27, 2025 by Tom Wade MD - Linking To And Excerpting From “Assessment Tools For Adult Bipolar Disorder”
Posted on May 27, 2025 by Tom Wade MD
Today, I review, link to, and excerpt from The Rapid Mood Screener (RMS): a novel and pragmatic screener for bipolar I disorder [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. Curr Med Res Opin. 2021 Jan;37(1):135-144. doi: 10.1080/03007995.2020.1860358. Epub 2021 Jan 6.
There are 111 similar articles in PubMed.
The above article has been cited by 10 articles in PubMed.
All that follows is from the above article.
Abstract
Objective: Depressive episodes and symptoms of bipolar I disorder are commonly misdiagnosed as major depressive disorder (MDD) in primary care. The novel and pragmatic Rapid Mood Screener (RMS) was developed to screen for manic symptoms and bipolar I disorder features (e.g. age of depression onset) to address this unmet clinical need.
Methods: A targeted literature search was conducted to select concepts thought to differentiate bipolar I from MDD and screener tool items were drafted. Items were tested and refined in cognitive debriefing interviews with individuals with self-reported bipolar I or MDD (n = 12). An observational study was conducted to evaluate predictive validity. Participants with clinical interview-confirmed bipolar I or MDD diagnoses (n = 139) completed a draft 10-item screening tool and other questionnaires. Data were analyzed to identify the smallest possible subset of items with optimized sensitivity and specificity.
Results: Adults with confirmed bipolar I (n = 67) or MDD (n = 72) participated in the observational study. Ten draft screening tool items were reduced to 6 final RMS items based on the item-level analysis. When 4 or more items of the RMS were endorsed (“yes”), sensitivity was 0.88 and specificity was 0.80; positive and negative predictive values were 0.80 and 0.88, respectively. These properties were an improvement over the Mood Disorder Questionnaire in the same analysis sample while using 60% fewer items.
Conclusion: The pragmatic 6-item RMS differentiates bipolar I disorder from MDD in patients with depressive symptoms, providing real-world guidance to primary care practitioners on whether a more comprehensive assessment for bipolar I disorder is warranted.
Keywords: Mood Disorder Questionnaire; Rapid Mood Screener; bipolar I disorder; major depressive disorder; misdiagnosis; screening tool.
Introduction
Bipolar I disorder is a chronic and debilitating mental illness that is characterized by a mixture of manic, depressive, and subsyndromal symptoms [Citation1]. Although the presence or history of at least one fully syndromal manic episode is required for a diagnosis of bipolar I disorder [Citation2], depressive symptoms are the more common presentation. Delayed or missed diagnosis of bipolar disorder is exceedingly common; the delay between the onset of illness and diagnosis of bipolar disorder was reported to be 6–13 years [Citation3,Citation4]. In a large survey of individuals with bipolar disorder, 69% of respondents reported being initially misdiagnosed, with patients receiving an average of 3.5 misdiagnoses before the correct bipolar disorder diagnosis was made [Citation4]. Not surprisingly, unipolar depression was cited as the most common misdiagnosis (60%). As a matter of fact, 1 in 4 patients treated for major depressive disorder (MDD) may actually have bipolar disorder, which is a clinical concern given the importance of early intervention and appropriate treatment [Citation5,Citation6]. As timely and accurate diagnoses are precursors of good clinical outcomes, the high rate of missed bipolar disorder diagnosis is a critical unmet need, which provides an incentive for routine and systematic bipolar disorder screening of all patients who present with depressive symptoms [Citation7].
It has been reported that up to 40% of patients with bipolar disorder are treated exclusively in primary care [Citation8], suggesting that primary care providers, including nurse practitioners, are uniquely positioned to detect and diagnose the bipolar disorder early in the illness trajectory [Citation9]. In a survey of primary care providers, respondents reported that almost one-third of their patients were being treated for a mental health issue, with depression the most common psychiatric condition treated [Citation10]. Further, up to 10% of all visits to primary care are related to depression and as many as 64% of all clinical encounters for depression occur in primary care [Citation11]. In a study that reported on the consulting patterns of adults with a positive bipolar disorder screening result, the most frequently consulted specialty for bipolar disorder symptoms was primary care (41%); of note, primary care providers made an incorrect diagnosis or did not identify bipolar disorder 78% of the time [Citation12].
The importance of timely and accurate diagnosis of bipolar I disorder cannot be overstated. Untreated bipolar disorder may result in poor outcomes such as persistent symptoms, impaired functioning, recurrences, cognitive impairment, comorbidities, neurobiological changes, and increased suicidality, while early identification and prompt treatment have been associated with improved outcomes across symptomatic and functional domains [Citation13–15]. Although mania is the hallmark of a bipolar I diagnosis, there are challenges to quickly identifying prior manic symptoms. As such, screening for other clinical features that are more likely to be associated with bipolar I disorder than with MDD may help clinicians differentiate these diagnoses. For example, not only are clinical characteristics such as early age of depression onset, prior negative response to antidepressant treatment, and positive bipolar family history prognostic for bipolar I disorder, they are also likely to be collected in routine patient evaluation [Citation16]. Differentiating bipolar I disorder and MDD is a clinical priority as appropriate pharmacologic management differs depending on the disorder. Most importantly, if patients with bipolar I disorder are treated with a conventional antidepressant as monotherapy, they may be at risk for mood destabilization or treatment-emergent mania [Citation17].
Evidence of frequent misdiagnosis and diagnostic delay suggests that the use of a brief, clinically validated, patient-administered, and easy-to-use screening tool for bipolar I disorder would be a welcome addition to clinical practice. Although various bipolar disorder screening tools are available, there are impediments to their use in primary care settings, including length and reliance on screening for manic symptoms only. Given that office visits in primary care are usually very short, a bipolar I disorder screening tool should ideally have only a small number of easily understood items that can be completed and scored quickly so that results are immediately informative to the clinician and the patient. While screening for MDD appears to be commonplace, with 82% of healthcare providers reporting that they currently use an MDD screening tool, only 32% reported screening for bipolar disorder (data on file, AbbVie) even though historical and contemporary screening is recommended to rule out bipolar disorder before a diagnosis of MDD is made. For example, although most primary care nurse practitioners see patients with depressive symptoms, only half reported using a screening tool to assess for bipolar disorder; cited barriers to screening included uncertainty about when to screen, insufficient knowledge of bipolar disorder symptoms, lack of screening tools, and lack of time to screen during a visit [Citation18].
Using a bipolar I disorder screening tool should help clinicians triage those patients for whom further workup for bipolar I disorder may be required, thus providing better patient care more efficiently. The Rapid Mood Screener (RMS) for bipolar I disorder is a novel and pragmatic patient-reported screening tool that utilizes easily understood terminology to screen for manic symptoms and bipolar depression risk factors in less than 2 min during or outside of a clinical visit (e.g. online, via electronic medical record system, waiting room). Designed to help clinicians identify patients with bipolar I disorder, the RMS may be an efficient and accurate bipolar I disorder screening option that could easily be integrated into a busy primary care setting.
Methods
Qualitative evaluation
Concept selection and item development
The RMS was developed in a multistep process beginning with a targeted literature search to identify concepts that differentiate bipolar I disorder from MDD. A search of the literature was conducted to identify relevant articles cited in PubMed (1 March 2019); results were limited to English language articles published in the previous 10 years. Multiple combinations of terms related to bipolar disorder and MDD indications (e.g. bipolar, unipolar, depression, depressive) and diagnosis (e.g. differential diagnosis, diagnostic conversion) were searched. Reference lists from retrieved articles were manually searched for additional articles of interest. Existing bipolar disorder tools and diagnostic criteria were also reviewed.
A multidisciplinary group of 6 mental health and psychometric experts then participated in two modified Delphi consensus panels. During Panel 1 (pre-panel online activity and web conference [30 April 2019]), participants reviewed the identified concepts and ranked them in order of the ones that would best identify patients with a diagnosis of MDD who may instead have bipolar I disorder. During Panel 2 (pre-panel online activity and in-person or web conference [20 May 2019]) participants further refined the reduced concept list developed during Panel 1 proceedings and again ranked them by their potential to differentiate patients with bipolar I disorder from those with MDD. Patient-friendly item wording, and specific thresholds (e.g. age of depression onset, number of episodes) and variations (e.g. comorbidities, family history) were explored and determined for draft screening tool items. All decisions related to item reduction and selection were made based on a consensus from the majority of participants (i.e. at least 4 of 6). A pool of bipolar I disorder screening tool items were drafted for subsequent qualitative evaluation.
Cognitive interviews
Two rounds of in-depth qualitative cognitive debriefing interviews were conducted with adults who were identified from databases belonging to qualitative research firms. Participants had a self-reported clinician-provided diagnosis of bipolar I disorder or MDD; individuals with bipolar II disorder were excluded. Participant feedback was used to test and refine wording as needed to improve draft item clarity and interpretability. The qualitative interviews also provided further support for the content validity of the bipolar I disorder screening tool draft items.
Quantitative evaluation
To test the final set of draft screening tool items, a multisite, cross-sectional, observational study was conducted in adults with a clinically confirmed diagnosis of bipolar I disorder or MDD. The study protocol was approved by the institutional review board (IRB; RTI International IRB) and written informed consent was obtained from participants. Data collected from study participants were used to identify screening tool items that had the greatest potential to optimize the sensitivity and specificity of the bipolar I disorder screening tool being developed. Based on the totality of item permutations and numeric thresholds that were evaluated, the best combination of items was identified, with a goal of high accuracy while using the fewest possible number of items and maintaining high sensitivity and specificity.
Participants
Using a standardized recruitment form, medical recruiters selected potential study participants from databases belonging to qualitative research firms located in the United States (North Carolina, Texas, Colorado, Florida, and California); social network initiatives were also used to recruit participants as needed. In-person interviews were scheduled for people who were eligible and interested.
At the screening, participants had to be at least 18 years of age, with a self-reported clinician-provided diagnosis of bipolar I disorder or MDD, current or past depressive symptoms, and current use of an antidepressant, atypical antipsychotic, or mood-stabilizing medication. The diagnosis of bipolar disorder had to be specified as bipolar I disorder or a past manic episode of at least 7 days’ duration had to be reported. Participants were excluded if they had been hospitalized or admitted to the emergency room due to mental health issues in the past 30 days, or if they were currently experiencing a manic episode.
Study measures
For participants who met inclusion criteria at screening, the self-reported diagnosis was confirmed by a Mini-International Neuropsychiatric Interview (MINI) structured clinical interview [Citation19]. Two MINI modules were administered for diagnostic purposes (depressive disorder [Module A] and bipolar disorder [Module C]), and 2 modules were administered to rule out other diagnoses (any psychotic disorder [Module K] and medical, organic, or drug causes [Module O]). A MINI question related to repeated thoughts about death and suicide was not administered to minimize emotional risk to study participants and preempt discussion of the topic given the nonclinical study setting. The items of the draft bipolar I disorder screening tool were administered to participants; more clinical information was elicited via self-reported responses to additional questions that provided numeric variations (e.g. number of episodes, age of onset, prior number of antidepressants) and content permutations (e.g. comorbidities, family mental health history) for some draft items. Additional study measures included the 15-item Mood Disorder Questionnaire (MDQ) to screen for bipolar disorder [Citation20] and the 20-item Center for Epidemiologic Studies Depression Scale (CES-D), used to assess the severity of depressive symptoms over the prior week [Citation21].
MINI diagnostic interviews were conducted by 4 Ph.D. level clinicians, including a licensed clinical psychologist, who had participated in training activities to ensure rater accuracy and consensus; interviewers collaborated throughout the interview process to monitor rating agreement and address discrepancies. All other study measures were participant reported.
Statistical analysis
See this section of the article.
Discussion
Screening for bipolar I disorder in patients with depression is an appropriate and judicious strategy to help primary care practitioners identify when a more comprehensive assessment for bipolar I disorder is warranted. The RMS was developed with the goal of creating a pragmatic and highly accurate tool that screens for bipolar I disorder using carefully constructed items with clear and precise wording. The 6 items of the RMS were selected based on multiple considerations, including clinical validity, optimized sensitivity and specificity, and pragmatism. Item permutations and numeric thresholds tested via the draft screener tool were evaluated to identify the combination of items that provided an optimal balance of test characteristics using the fewest possible number of items. To screen for characteristics that are associated with bipolar I disorder, the RMS asks about the number of prior depressive episodes (Item 1), the onset of depression before the age of 18 years (Item 2), and discontinuation of an antidepressant because it caused the respondent to feel highly irritable or hyper (Item 3). To screen for past manic symptoms, the RMS asks if there has ever been a week in which the respondent was more talkative than normal with racing thoughts (Item 4), felt unusually happy, outgoing, or energetic (Item 5), or needed much less sleep than usual (Item 6). Based on qualitative feedback, all items were precisely worded to provide easy interpretation and clarity so respondents could readily identify events that may indicate past manic characteristics. Since symptoms of bipolar I disorder may first present early in life, no timeframe restrictions were used, with the exception of the question designed to establish the early onset of depression (i.e. before 18 years), which is characteristic of bipolar I disorder. While an early life (childhood) mood episode might generate an affirmative RMS response that is not related to bipolar I disorder, RMS questions are designed to create an opportunity for comprehensive dialogue. Although endorsing 4 or more items yielded the best test characteristics signaling a very high likelihood of bipolar disorder, it should be noted that 3 “yes” answers also signaled a higher likelihood for bipolar disorder than MDD. A positive screen would be followed up with a more comprehensive diagnostic evaluation. Based on the small number of items and easily interpreted wording, the RMS is estimated to take less than 2 minutes to complete by a patient.
As many patients with bipolar disorder are treated in primary care settings [Citation8] and upwards of half of these patients present with depressive symptoms [Citation16], it is imperative that clinicians have the knowledge and tools to differentiate bipolar I depression from MDD. Misdiagnosis of bipolar I disorders as MDD is especially concerning given the potential for inappropriate treatment with antidepressant monotherapy and the long attendant delay in receiving appropriate treatment. A longer duration of untreated bipolar illness has been associated with worse outcomes, including a greater frequency of episodes and increased risk of hospitalization and suicidality, further supporting the clinical relevance of timely diagnosis and treatment with an approved pharmacological agent [Citation13–15]. The urgent need for timely and accurate diagnosis is further highlighted by findings that multiple mood episodes and longer duration illness are associated with less effective neuroprotective mechanisms and more apparent harmful biological changes [Citation14]; for example, it has been shown that the incidence of manic episodes was related to volume decrease in frontal brain regions [Citation22]. Since identifying prior manic symptoms is challenging and may require robust dialogue to help patients identify past mood elevation, using the RMS, a screening tool with well-crafted and precisely worded manic symptom items, as well as items that characterize other bipolar I disorder features, may be a distinct clinical advantage for identifying bipolar I disorder in patients with depressive symptoms.
Although other self-reported bipolar disorder screening tools are available, reliance on screening for manic symptoms only or length may be obstacles to use in the clinic. For example, the MDQ, which was also administered in the RMS observational study, consists of 15 total items, and screens for manic symptoms, manic symptoms clusters, and level of impairment to identify bipolar I or II disorder. For a positive screen, 7 of 13 MDQ manic symptom items must be endorsed, and in 2 additional items, patients must affirm that several of these symptoms have occurred during the same time period and caused at least moderate impairment. In contrast, the RMS consists of 6 items and requires an endorsement of 4 or more of the items to identify patients who may potentially have bipolar I disorder. Other available self-report bipolar screening tools of note include the 48-item Hypomanic Personality Scale (HPS) [Citation23], the 32-item Mania/Hypomanic Checklist (HCL-32) [Citation24], the Bipolar Spectrum Diagnostic Scale (BSDS) [Citation25], and the Mood Spectrum Self-Report (MOODS-SR) [Citation26]. Obvious disadvantages that may limit the usefulness of the HPS and the HCL-32 in clinical practice include length and reliance on hypomanic/manic symptoms. Further, although the BSDS (19 items in paragraph form) and MOODS-SR (161 items) include depressive symptoms, they too are long and potentially more complicated than a simple checklist because of their scoring and formats. While the General Behavior Inventory (GBI) also screens for both depressive and manic symptoms [Citation27–29] and its psychometric properties have been estimated in clinical and non-clinical samples [Citation27,Citation30,Citation31], its utility is also restricted by length (52–73 items) and multiple versions that provide inconsistent cut-off scores for positive screening, which limits its generalizability.
Since few studies provide direct comparisons of screener tools administered in the same analysis population, RMS and MDQ test properties estimated in the observational study are of particular interest. When 4 or more RMS items were endorsed, indicating a positive screen for bipolar I disorder, the C-index was 0.87, sensitivity was 0.88, and specificity was 0.80. By comparison, when the MDQ screened positive for bipolar disorder in the same study sample, the C-index was 0.82, sensitivity was 0.86, and specificity was 0.78. In addition to these test characteristics, the RMS may also be more convenient than the MDQ in a clinical practice setting. Namely, the RMS has less than half the number of items than the MDQ, it screens for both bipolar I disorder features and manic symptoms, it uses a simpler scoring algorithm, and it is estimated to take less time to complete than the commonly cited 5 minute completion time for the MDQ [Citation32–34]. Further, the RMS is precisely worded to better differentiate manic symptoms, which is an important consideration since it may be difficult to elicit confirmation of a prior manic episode from a patient with bipolar I disorder.
The ultimate value of a bipolar I disorder screening tool depends on a clinician’s willingness to employ it in their practice. In a survey of 200 HCPs who were asked about bipolar disorder screening tools (data on file, AbbVie), 85% of respondents indicated that although they were familiar with the MDQ, only 29% currently use it. Most HCPs (81%) reported that they would be more likely to use the RMS than the MDQ, with the RMS significantly outperforming the MDQ across the most valued bipolar disorder screening tool attributes (e.g. easily answered questions, practical to use, easy scoring, the minimal number of questions). Further, over two-thirds of respondents thought that the RMS was better than other screening tools and 84% believed that the new RMS would have a positive impact on their practice. Of particular clinical relevance, almost half of primary care providers indicated that they would screen a greater percentage of their patients because of the RMS and 76% stated that they would be likely to use it to screen new patients with depressive symptoms. Overall, survey responses indicated that the RMS would be a valuable addition to clinical practice settings, with a majority of primary care providers indicating that this pragmatic and patient-friendly tool would encourage them to screen more patients with depressive symptoms.
Limitations of this study include its reliance on participants recruited from qualitative research facilities, which may limit generalizability to real-world samples. Additionally, since the RMS was designed to identify bipolar I disorder among patients who may have been misdiagnosed or initially thought to have MDD, participants with bipolar II disorder were not included in the study; the RMS is not validated in bipolar II/hypomania. As is the case with any new screening tool, additional evaluation of RMS test characteristics is warranted.
The RMS is a practical new bipolar I disorder screening tool that was developed to help clinicians rapidly identify patients with depressive symptoms who may have bipolar I disorder instead of MDD. Designed with the objective of combining pragmatism and accuracy, the RMS uses a small number of succinctly worded patient-friendly items to minimize respondent burden and maximize the potential for use in a busy clinical setting. When compared with the MDQ in the same analysis sample, the RMS had better test characteristics while using 60% fewer items. To the authors’ knowledge, no prior study evaluating a bipolar disorder screening tool has yielded better collective specificity and sensitivity than the values estimated for the RMS in this study. Screening with the RMS is a practical and efficient new way to help address the all too common problem of misdiagnosing bipolar I disorder as MDD in patients with depressive symptoms. Although a screening tool does not provide a diagnosis, patients who score 4 or more on the brief self-report RMS questionnaire have a strong probability of bipolar I, thus alerting primary care physicians that more thorough evaluation is needed.
