Download Review of Self-Report Instruments for Bipolar Mania and Hypomania Symptoms and more Study notes Psychiatry in PDF only on Docsity!
A review of self-report and interview-based instruments to assess maniaand hypomania symptoms
Una rassegna degli strumenti autovalutativi ed eterovalutativi per valutare i sintomi maniacali
e ipomaniacali
P. Rucci, S. Calugi, M. Miniati^1 , A. Fagiolini^2
Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum University of Bologna; 1 Department of Psychiatry, Neurobiology, Pharmacology and Biotechnology, University of Pisa, Italy; 2 Department of Mental Health and Neuroscience, University of Siena School of Medicine
Summary
Objective The aim of this paper is to provide an overview of the self-re- port and interview-based instruments to assess mania/hypoma- nia symptoms and related features, with a focus on 7 selected instruments in widespread use to illustrate their psychometric properties, comparative performance and pros and cons.
Methods A systematic search strategy was devised and queried on Med- line from 1973 to 2012 using the terms mania, hypomania, instrument, scale, questionnaire, interview, validity, reliability, psychometric properties and adults, elderly, aged. To be includ- ed, a study had to be published in a peer-reviewed journal or book in English or Italian.
Results Of the 17 self-report instruments identified, two (the Mood Dis- order Questionnaire (MDQ) and the Hypomania Checklist- (HCL-32), received the most research attention. Although the psychometric properties of these instruments are good, their use as screening instruments to detect hypomania in the commu- nity or in patients with depression is partially limited by their low positive predictive value, related to the low prevalence of this condition. Nonetheless, they can be efficiently used to rule out the presence of hypomania. The Altman Self-Rating Mania Scale is increasingly being used to monitor mania symptoms over time by phone or email in patients diagnosed with bipolar
disorder because it consists of only 5 items. When the aim is early detection of manic/hypomanic symptoms that a patient may have experienced during their lifetime, the 33-item subset of the MOODS-SR seems promising because it includes the key psychopathology dimensions that better discriminate bipolar from unipolar disorder. Of the interview-based instruments, the Young Mania Rating Scale and the Bech-Rafaelsen Mania Scale are the most widely used outcome measures in clinical trials. Although they were developed more than 30 years ago, they continue to be the gold standard for research purposes. The two instruments have a similar coverage, although the YMRS is preferred over the BR- MAS because it includes an item on insight.
Conclusions Although no instrument can replace the need for accurate clini- cal diagnosis based on patient history, we argue that the in- creasing use of self-report instruments to screen bipolar disorder in patients presenting with depression or to monitor mania/hy- pomania symptoms over time may contribute to increasing the use of routine standardized assessment. Measurement-based care as the standard of care has the potential to transform psy- chiatric practice, move psychiatry into the mainstream of medi- cine, and ultimately improve the quality of care for patients with psychiatric illness.
Key words Mania • Hypomania • Bipolar spectrum • Rating scales • Interview • Questionnaire • Validity • Reliability
Original article
Correspondence Paola Rucci, Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, via San Giacomo 12, 40126 Bologna, Italy • Tel. +39 051 2094837 • Fax 051-2094839 • E-mail: paola.rucci2@unibo.it
Journal of Psychopathology 2013;19:143-
Introduction
Bipolar disorder is a serious illness associated with sig-
nificant psychosocial morbidity and excess mortality.
Recent research carried out by World Health Organiza-
tion World Mental Health Survey Initiative in community
adults from 11 countries worldwide indicated that bipolar
disorder, when defined to include milder variants such
as bipolar II disorder and subthreshold bipolar disorder,
has a lifetime prevalence of 2.4% 1. Studies carried out
in psychiatric and primary care settings have found that
bipolar disorder is sometimes under-recognized, particu-
larly in patients presenting for treatment of depression 2-5.
Even for those patients diagnosed with bipolar disorder,
the time lag between initial treatment seeking and correct
diagnosis often exceeds 10 years 6 7.
The treatment and clinical implications of the failure to
recognize bipolar disorder in depressed patients include
the under-prescription of mood stabilizers, an increased
P. Rucci et al.
mat (self-report or interview-based) and are sorted in de-
creasing order by year of publication. The seven selected
instruments are in boldface.
Self-report questionnaires
The first author who strongly supported the use of self-
report rating scales to assess the presence and/or severity
of manic symptoms was Altman, who in 1997 developed
the Altman Self-Rating Mania Scale 19 , consisting of 5
items rated on a Likert scale of 0-4. In his commentary
in 1998 20 , he examined the extent to which the severity
of illness, the presence of psychosis or the lack of insight
may threaten the reliability of a self-report measure. After
comparing his measure against interview-based instru-
ments (CARS-M, MRS), he concluded that ‘self-rating
mania scales are both reliable and valid for patients with
manic symptoms, including those with psychotic features
and those having little or no insight into their illness.’
This scale has recently gained a renewed popularity
and is used in the US, together with the Quick Inven-
tory of Depressive Symptoms (QIDS), to monitor manic
and depressive symptoms over time through weekly text
messages and e-mails 21 22^. These studies suggested that
text message-based symptom monitoring during routine
follow-up may be a reliable alternative to in-person in-
terviews.
Among the self-report instruments developed to im-
prove the detection of bipolar disorders, the Mood
Disorder Questionnaire (MDQ) and the Hypomania
Checklist-32 (HCL-32) have currently received most
research attention.
Below we summarize the characteristics and psychomet-
ric properties of these 2 scales and the Bipolar Spectrum
Diagnostic Scale (BSDS) and the Mood Spectrum Ques-
tionnaire (MOODS-SR), which were developed to detect
softer forms of bipolar disorders or isolated symptoms
of manic-hypomanic spectrum co-occurring with other
axis-I disorders.
The other instruments listed in Table I include the Self-
Report Manic Inventory (SRMI) and the Altman Self-rat-
ing Mania Scale (ASRM) designed specifically for assess-
ing the manic pole of the illness and seven bipolarity rat-
ing scales: Visual Analogue Mood Scale (VAMS), Internal
State Scale (ISS), Depression-Happiness Scale (D-HS),
Manic Depressiveness Scale, Affective Self Rating Scale
(ASRS), Hypomania Attitudes and the Positive Predictions
Inventory (HAPPI) and Multidimensional Assessment of
Thymic States (MAThyS). Moreover, Table I shows in-
struments that assess temperament, character and manic
personality, the Temperament evaluation of Memphis,
Pisa, Paris and San Diego (TEMPS-A) and the Affective
Temperament Questionnaire (ATQ) and two rating scales
developed to assess multiple psychiatric disorders, the
risk of rapid, cycling and increased costs of care 7-10.
When symptomatic, patients with bipolar disorder are
much more likely to experience symptoms of depression
and anxiety rather than symptoms of mania or hypoma-
nia 11. It is therefore frequent that, when presenting for
treatment, patients with bipolar disorder are not in the
manic or hypomanic phases of the illness. This suggests
that manic phases, especially when brief or not charac-
terized by impulse dyscontrol, need to be elicited with
retrospective assessment, considering the frequent lack
of subjective suffering, enhanced productivity, ego-syn-
tonicity and diurnal or seasonal rhythmicity associated
with several manic/hypomanic symptoms 12.
Recommendations for improving the detection of bipo-
lar disorder include careful clinical evaluations inquiring
about a history of mania and hypomania and the use of
screening questionnaires 13-16. A systematic classification
of self-report and interview-based instruments to assess
mania and hypomania might help the clinician to make
the most appropriate instrument selection for the different
research and clinical purposes 17.
In 2009, Picardi 18 reviewed the rating scales for bipo-
lar disorder, according to the type of symptoms to be as-
sessed (depressive, manic, psychotic) and the purpose of
the instrument (screening, early identification). The aim
of this paper is to provide a broader overview of the ex-
isting self-report questionnaires and of interview-based
clinical instruments to assess mania symptoms and re-
lated features, with a focus on 7 selected instruments
in widespread use to illustrate their comparative perfor-
mance and pros and cons.
Methods
A systematic search strategy was devised and queried on
Medline from 1973 to 2012 including the terms mania,
hypomania, bipolar spectrum, mood spectrum, instru-
ment, rating scale, questionnaire, interview and validity,
reliability, psychometric properties.
To be included, a study had to be published in a peer-
reviewed journal or book and in English.
Results
The Medline search yielded a total of 43 studies, retrieved
from journal articles, describing 31 instruments, 17 self-
report and 14 interview-based.
Table I summarizes the characteristics and the psycho-
metric properties of the instruments identified, including
the internal consistency, concurrent/discriminant valid-
ity, inter-rater reliability and factor structure (when appli-
cable and when available). The assessment instruments
for manic symptoms are classified according to their for-
P. Rucci et al.
TABLE I. Psychometric properties of manic/hypomanic symptom rating scales. The seven instruments described in the text are in boldface.
Proprietà psicometriche delle
scale di valutazione dei sintomi maniacali/ipomaniacali. I sette strumenti descritti nel testo sono in grassetto
ADMINISTRATION: SELF-REPORT
Year
Instrument
Internal consistency
Concurrent/ discriminant validity
Factor analysis
Description/Aim
Inter-raterreliability
References
Concise As-sociatedSymptomsTracking ScaleSelf-report(CAST-SR)
Alpha = 0.81 (17 item)Alpha = 0.78 (16 item)
The 5 CAST-SRdomains correlatedwell with otherstandard measuresof depressive sever-ity and assessmentof potential pre-cursors symptoms(BAI, HDRS, PDSQ,QIDS-C)
5 factors:IrritabilityAnxietyManiaInsomniaPanic
The CAST includes questionsabout irritability, anxiety, ma-nia, insomnia and panic do-mains thought to be associatedwith increased risk for suicide-related events and behaviours.The items in the CAST weredesigned to be rated using aLikert scale
My MoodMonitor (M-3)Checklist
The M-3 bipolar modulehad a somewhat higher sen-sitivity (0.88; 95% CI, 0.77-0.95) but a lower specificity(0.70; 95% CI, 0.66-0.74).The anxiety module had asensitivity of 0.82 (95% CI,0.75-0.87) and a specificityof 0.78 (95% CI, 0.74-0.81),whereas the PTSD modulehad a sensitivity of 0.88(95% CI, 0.74-0.96) and aspecificity of 0.76 (95% CI,0.73-0.80)
M-3 Checklist is a 23-item self-report symptom checklist thatinquires whether during the past2 weeks the patient experiencedsymptoms of major depressivedisorder, generalized anxietydisorder, panic disorder, socialanxiety disorder, PTSD andobsessive compulsive disorder.The M-3 also inquires about alifetime history of symptoms ofbipolar spectrum disorder. Atthe end of the symptom check-list, the M-3 poses 4 functionalimpairment questions.The M-3 is developed to screenfor multiple psychiatric disor-ders in primary care
AffectiveTemperamentQuestionnaire(ATQ)
Hyperthymia: alpha = 0.68Cyclothymia: alpha = 0.83Dysthymia: alpha = 0.
3 factors:HyperthymiaCyclothymiaDysthymia
Was designed to capture the es-sence of the criteria of Akiskaland Mallya (criteria defining 4affective temperaments: hyper-thymic, irritable, cyclothymic,and dysthymic) in a self-ratingform
Hyperthymia andcyclothymia weremore prevalentamong individualswith BP than amongindividuals withMDD or no historyof a mood disorder.Dysthymia occurredat a relatively simi-lar rate among indi-viduals with MDDor BP
A review of self-report and interview-based instruments to assess mania and hypomania symptoms
Affective SelfRating Scale
The subscales for maniaand depression showedhigh internal consistencywith Cronbach’s alphasof 0.89 for the depressionsubscale and 0.91 for themania subscale
Depression sub-scoreMADRS (r = 0.74)HIGH-C (r = 0.15)CGI-BP-D(r = 0.68)CGI-BP-M(r = -0.01)Mania subscoreMADRS (r = 0.25)HIGH-C (r = 0.80)CGI-BP-D(r = 0.10)CGI-BP-M(r = 0.73)
4 factors
Measurement of intensity ofcurrent affective symptoms(depressive manic and mixedstates)
Multidimen-sional As-sessment ofThymic States(MAThyS)
Alpha = 0.
The MATHYS totalscore is moderatelycorrelated of boththe MADRS scale(depressive score;r = -0.45) and theMAS scale (manicscore; r = 0.56)
5 factors:Emotional reac-tivityMotivation andpsychomotorfunctionSensory percep-tionInterpersonalcommunicationCognition
Discriminate between differentsub-populations among patientssuffering from bipolar disorders.The instrument is designed asa multi-dimensional assistedself-administered questionnairecomprising 20 items relating toindividual states as perceivedby patients for the precedingweek
HypomaniaAttitudesand PositivePredictionsInventory(HAPPI;61-item ver-sion)
Cronbach’s alpha rangedfrom 0.83 for IncreasingActivation to Avoid Failureand Grandiose Appraisalsof Ideation to .90 for So-cial Self-Criticism. Internalconsistency was Cron-bach’s .97 for the overallscale
HAPPI was signifi-cantly and positive-ly related to pro-spective ISS Activa-tion, Conflict andDepression. Therewas also a negativerelationship be-tween HAPPI andISS Well-being
Factors:Social Self-CriticismIncreasing Acti-vation to AvoidFailureSuccess Activa-tion & TriumphOver FearLoss of ControlGrandiose Ap-praisals of Ide-ationRegaining Au-tonomy
The HAPPI was developed toassess the multiple, extreme,and personalized beliefs key toan integrative cognitive modelof bipolar depression and moodswings. The model postulatedthat bipolar symptoms are de-veloped and maintained byinterpreting physiological, af-fective, and cognitive changesto internal states, and perceivedbehavioral changes, as hav-ing extreme personal meaning.These appraisals are multiple,positive and negative, and cantherefore be conflicting
59, 60 (continues)
A review of self-report and interview-based instruments to assess mania and hypomania symptoms
Mood Disor-der Question-naire (MDQ)
Alpha = 0.
The Mood Disorder Question-naire is a self-report, single-page inventory that screens fora lifetime history of a manic orhypomanic syndrome by in-cluding 13 yes/no items derivedfrom both the DSM-IV criteriaand clinical experience
Manic De-pressivenessScale
The Cronbach a for thedepressive items was 0.63and for the maniaitems was 0.
The subscalesdistinguish well be-tween the patientsand the controlgroup
Detection of people who atsome point in their lives had ex-perienced behaviours or actionstypical of bipolar disorders. Thistype of scale allows not only theassessment of past or presentexperiences with this disorderbut can also be used as an indi-cator of cyclothymic syndromesor attenuated forms
The Depres-sion-Happi-ness Scale
Alpha = 0.
Higher scores onthe D–H S wereassociated withhigher scores onthe OHI,
r =
p <
.001, and lower scores on the BDI, r =
p <
confirming the con-struct validity of thescale
This is a self-report scale whichcontains 25 items representinga mix of affective, cognitive,and bodily experiences. Higherscores on the scale indicate ahigher frequency of positivethoughts, feelings, and bodilyexperiences and a lower fre-quency of negative thoughts,feelings, and bodily experiences
Altman Self-rating ManiaScale
Alpha:mania = 0.79psychosis = 0.65irritability = 0.
The Pearson cor-relation coefficientbetween ASRM ma-nia subscale scoresand MRS totalscores was r = .718(p < .001) and be-tween ASRM maniasubscale scores andCARS-M maniasubscale scoresr = .766 (p < .001)
3 factors:ManiaPsychosisIrritability
Brief self-rating mania scale,compatible with DSM-IVcriteria, used to measure thepresence and severity of manicsymptoms for research or clini-cal purposes
(continues)
P. Rucci et al.
ADMINISTRATION: SELF-REPORT
Year
Instrument
Internal consistency
Concurrent/ discriminant validity
Factor analysis
Description/Aim
Inter-raterreliability
References
Self-ReportManic Inven-tory (SRMI)
Alpha = 0.
The discriminationanalysis shows thatthe questionnaireseems to differenti-ate well betweenmanic and non-manic subjects(71% of the sam-ples are well clas-sified)Test-retest reli-ability:(r = 0.93 for manicsubjects and 0.73for the wholesample
2 factors: EnergizedDysphoria H
edonistic Euphoria
Includes the symptoms of maniaas described in the DSM-III-Rand also in some authoritativeworks together with the authors’experience. The 47 items con-tained in the scale are answeredthrough items with true/falseoptions. An insight question isadded to these 47 items
Internal StateScale
Alpha: from 0.81 to 0.92on the four factors
The activation sub-scale gave a strongcorrelation withthe Manic RatingScale by Young(r = 0.60). The De-pression Index cor-related with that ofHamilton (r = 0.84)as did that of Well-being (r = 0.73)
4 factors:DepressionIndexWellbeingActivationPerception ofConflict
Instrument for assessment ofmanic and depressive symptomsby patients and their families
Visual Ana-logue MoodScale
VAMS correlatedwith the SDS andseveral subscalesof the Clyde MoodScaleThe VAMS digit-symbol combina-tion was able todistinguish patientswith affective dis-order from others,better than othertests used
The VAMS is a rectangularcard 100 mm by 35 mm onwhich the following instructionis printed: ‘How is your moodright now? A mark on the linetoward the left represents yourworst mood, toward the right,your best.’ The VAMS score isdetermined by measuring thedistance in millimetres from theleft end of the card to the pa-tient’s mark
(Table I follows)
P. Rucci et al.
ADMINISTRATION: INTERVIEW-BASED
Year
Instrument
Internal consistency
Concurrent/ discriminant validity
Factor analysis
Description/Aim
Inter-raterreliability
References
StructuredClinical Inter-view for MoodSpectrum(SCI-MOODS)
Internal consistency for theseven domains ranged be-tween 0.72 and 0.
Designed to evaluate the life-time presence/absence of theDSM-IV core symptoms ofdepression and mania, atypicalsymptoms, subthreshold mani-festations and behavioural traitsthat arise as a mean of copingwith mood symptoms
Coping in-ventory forprodromes ofmania (CIPM)
Alpha:Stimulation reduc-tion = 0.77Problem-directed cop-ing = 0.85Seeking professionalhelp = 0.53Denial or blame = 0.
4 factors:Stimulation re-ductionProblem-direct-ed copingSeeking profes-sional helpDenial or blame
Instrument aimed at assessinghow manic depressive sufferersdealt with their prodromes ofmania
Temperamentevaluationof Memphis,Pisa, Paris andSan Diego(TEMPS)
Alpha for the four scales:Depressive 0.85Hyperthymic 0.86Cyclothymic 0.94Irritable 0.
Four factors:depressivehyperthymiccyclothymicirritable
Clinician-AdministeredRating Scalefor Mania(CARS-M)
Alpha = 0.
Manic Rating Scale(r = 0.94).The sensitivity ofthe scale is veryhigh, differentiatingbetween diagnosticgroups (p < 0.001)
2 factors.Mania (10items).Psychoticism (5items)
Scale for the assessment andquantification of Mania; con-tains 15 items rated on a Likertscale from 1 to 5, except forone which goes from 1 to 4It is a symptomatic scale alsoincluding information culled byother members of the hospitalunit or family members
ManchesterNurse RatingScale for Ma-nia (MNRS-M)
All the individual items ofthe MNRS-M were signifi-cantly correlated with thetotal mania score
Correlation withShopsin GlobalMania Rating was0.65Correlation withYMRS was 0.
The scale, administered fromthe nursing staff, was designedfor the daily rating of manicward behaviours
The product-moment correlationcoefficients (
r ) ob-
tained ranged from0.813 to 0.993(p < 0.05)
HypomanicPersonalityScale
Test-retest reliabil-ity (15 weeks): 0.
A 48-item true–false scale mea-suring hyperactive, ambitious,and exhibitionistic behavioursas well as feelings of euphoriaand flights of thoughts
(Table I follows)
A review of self-report and interview-based instruments to assess mania and hypomania symptoms
Bech-Rafa-elsen’s maniascale
Clinician interview assessingthe current manic symptoms;comprises 11 items definedagainst a five-point scale
inter-rater reliabilityis high (r = 0.80-0.95 for four raters)
Young ManiaRating Scale(YMRS)Clinical inter-view
The total scores onthe YMRS correlat-ed highly with theglobal rating (0.88)and the PettersonScale (0.89). Thecorrelation withthe Beige scale,although of a lowermagnitude (0.71),was acceptable
The Young Mania Rating Scaleconsists of eleven items, eachwith five explicitly definedgrades of severity. The choiceof items was made on the basisof published descriptions of thecore symptoms of the manicphase of bipolar affective disor-der and includes those abnor-malities which were felt to existover the entire range of illnessfrom mild to severe
The correlationbetween the ratingsof two physicianswas 0.93 for thetotal YMRS scoreand ranged from0.66 for item 9, dis-ruptive-aggressivebehaviour, to 0.95for item 4, sleep.All correlationswere significant atthe 0.001 level
ADMINISTRATION: OTHER
The Interac-tive ComputerInterview forMania (ICI-M)Computer-administeredinterview
Alpha = 0.
Computer-administered inter-view that both presents probesdesigned to elicit informationabout the presence and severityof symptoms and utilizes a scor-ing algorithm to select follow-up questions and rate subjectresponses in accordance withrating scale anchor pointsThe goal of the ICI is to providea standard comparator that canbe used to enhance the sensitiv-ity and consistency of humanraters by providing on-goingfeedback on the concordance oftheir ratings with the ICI ratingsand identify those in need ofspecific remediation during thecourse of study operations
The intraclass cor-relation coefficientswas 0.91 betweenthe ICI-M and anexpert consensusrating
Observer-Rated Scalefor Mania(ORSM)
Alpha = 0.89Test-retest reliability.r = 0.76-0.
Correlations withDSM-IV were highwith a Pearson’scorrelation coef-ficient rangingfrom of .74 and .70(p < .01). Similarly,Pearson’s correla-tion coefficient forthe YMRS rangesfrom .75 and .76(p < .01) and forthe MSS ranges from.65 and .62 (p < .05)
The three-factorsolution ac-counted for70.5% of thevariance.Euphoric maniaInstable maniaPsychotic ma-nia
A mania rating scale that can beused by individuals who are inclose contact with the patientin order to assess mania and todetermine its severity
(continues)
A review of self-report and interview-based instruments to assess mania and hypomania symptoms
Five of these instruments are designed to assess the manic
pole of the bipolar disorder (Clinician-Administered Rat-
ing Scale for Mania (CARS-M), Observer-Rated Scale
for Mania (ORSM), Interactive Computer Interview for
Mania (ICI-M), Young Mania Rating Scale (YMRS) and
Bech-Rafaelsen Mania Scale (BRMES)) and four to assess
both poles (Bipolar Inventory of Symptoms Scale (BISS),
Brief Bipolar Disorder Symptom Scale (BDSS), Manches-
ter Nurse Rating Scale for Mania (MNRS-M) and the
Structured Clinical Interview for Mood Spectrum (SCI-
MOODS). Moreover, in Table I two instruments assess-
ing temperament, character and manic personality (the
Temperament evaluation of Memphis, Pisa, Paris and San
Diego [TEMPS] and the Hypomanic Personality Scale), a
rating scale assessing multiple psychiatric disorders (Con-
cise Associated Symptoms Tracking Scale; CAST-C), an
instrument designed to assess biological rhythms in the
clinical setting (Biological Rhythms Interview of Assess-
ment in Neuropsychiatry; BRIAN) and an instrument that
examines the coping strategies used by manic depressive
patients during the prodromal phase of their manic epi-
sodes (Coping Inventory for Prodromes of Mania [CIPM])
are presented.
Below we list the characteristics of the two most widely
used scales in clinical trials.
The Young Mania Rating Scale (YMRS)
This scale, developed by Young in 1978 39 , includes 11
items and is used to assess disease severity in patients
already diagnosed with mania. It is intended to be ad-
ministered by a trained clinician who assigns a severity
rating on a Likert scale for each item based on a personal
interview. The total score ranges from 0 to 56. The scale
is based on the patient’s subjective report of his/her clini-
cal condition over the previous 48 hours that typically
takes 15-30 minutes to administer. Items can be rated by
querying the patients or from direct observation, and en-
compass elevated mood, increased motor activity, sexual
interest, sleep, irritability, speech, language/thought dis-
order, content, disruptive/aggressive behaviour, appear-
ance and insight. It is the most used outcome measure-
ment in clinical trials and longitudinal naturalistic stud-
ies. A cut-off on the total YMRS score < 4 was suggested
by Berk 40 to denote complete remission. Gonzalez-Pin-
to 41 used a cut-off > 20 for acute mania and Benvenuti et
al. 42 used a cut-off of ≥ 10 to define a manic/hypomanic
switch in patients with unipolar depression.
The Bech-Rafaelsen mania scale (BRMAS)
The BRMAS 43 44^ is used to assess current manic symptoms
and takes 15-30 minutes to administer. The 11 items are
rated on a 5-point scale and each rating has very specific
anchor points that facilitate the rating. The items explore
TABLE II.
MOODS-SR items discriminating unipolar from bipolar patients. Item del MOODS-SR che discriminano tra pazienti bipolari e unipolari.
PSYCHOMOTOR ACTIVATION
- Urge to communicate
- Desire to reconnect with people
- Talkative
- Noisy
- Racing thoughts
- Too many thoughts at once
- Shifting interests
- Assertive
- Vigorous
- Very impatient
- Constantly active
- Irresponsible
- More energetic with less sleep
- Not tired even without sleeping
MIXED INSTABILITY
- Frequently changing: job, residence, friends, hobbies
- Risk taking
- Irritable or elevated mood when you were abusing alco- hol
- Irritable or elevated mood when you increased your use alcohol
- Made important decisions very rapidly
- Tended to ignore everyday rules and social etiquette
- More interested in sex
- Changed sexual partners
EUPHORIA
- Persistently good or high
- High sense of humor and irony
- Even the smallest thing could you very enthusiastic
- Liked to make puns or plays on words
- Making a lot of jokes
SUICIDALITY
- Life is not worth living
- Wishing not to wake up in the morning
- Want to die or hurt yourself
- Specific plan to hurt or kill yourself
- Suicide attempt
- Suicide attempt requiring medical attention
P. Rucci et al.
agnosing bipolar disorders are at high risk of missing the
correct diagnosis in approximately one-third of patients.
On the other hand, the positive predictive value of such
instruments is often inadequate, raising the possibility of
an over-diagnosis of bipolar disorder, if no more valid
and comprehensive diagnostic assessment tools are sub-
sequently provided.
In developing a broad-based screening measure for
multiple psychiatric disorders, Zimmermann and Mat-
tia 52 recommended that a cut-off resulting in diagnostic
sensitivity of 90% and a correspondingly high negative
predictive value be chosen when using an instrument in
clinical practice. With high negative predictive value,
the clinician can reliably assume that when the test in-
dicates that the disorder is not present, inquiring about
the disorder’s symptoms is pointless. Our review of self-
report instruments indicates that this sensitivity level is
not achieved by the MDQ, the HCL-32 or the BDRS and,
if it is achieved, this happens at the cost of very high false
positive rates. In general, the trade-off between sensitivity
and specificity depends on the disease and the specific
purpose of the screening. In the case of bipolar disorder,
early identification of patients suffering from this condi-
tion is as important as excluding this diagnosis to develop
a suitable treatment strategy.
The psychometric properties of the instruments reviewed
suggest that the MDQ might be useful for screening pa-
tients presenting with recurrent depression or anxiety to
rule out the presence of bipolar disorder in psychiatric
clinical settings and primary care. The HCL-32, which is
more sensitive than the MDQ, might be used to screen
potential cases to be further investigated with a diagnos-
tic interview. On this note, it should be emphasized that
other elements such as family history, age of onset of
symptoms, course of symptoms and previous response to
medication play a key role in the diagnostic process.
Considering the MOODS-SR, the instrument is relatively
long, which makes it more suitable for research purposes
than for routine clinical use. Still, the 33 items exploring
the key features discriminating bipolar disorder from uni-
polar depression seem to be promising as a stand-alone
screening instrument to detect the presence of manic/hy-
pomanic features lasting at least 3-5 days in the lifetime.
However, to date no study has provided evidence of the
psychometric properties of this subset of items.
The 5-item Altman Mania Rating Scale appears to be use-
ful for monitoring the longitudinal course of mania/hypo-
mania symptoms for research and clinical purposes and
generates results similar to those of other longitudinal
studies of bipolar disorder that use traditional retrospec-
tive, clinician-gathered mood data 21.
Regarding the interview-based instruments, the YMRS
and the BRMAS have a similar coverage, although the
motor activity, verbal activity, flight of thoughts, voice/
noise level, hostility/destructiveness, feelings of well
being, self-esteem, contact with others, sleep changes,
sexual interests, and work activities, similarly to YMRS,
but do not assess insight and appearance. This scale has
been frequently used as an outcome measure in clini-
cal trials for more than 30 years. Studies of the internal
validity of the BRMAS have demonstrated that the simple
sum of the 11 items of the scale is a sufficient statistic for
the assessment of the severity of manic states. Both factor
analysis and latent structure analysis (the Rasch analysis)
have been used to demonstrate that the scale is unidi-
mensional. The total score of the BRMAS has been stand-
ardized so that scores between 15 and 20 indicate mild
hypomania, scores between 20 and 27 indicate moderate
mania, and scores ≥ 28 indicate severe mania. The inter-
rater reliability has been found to be high in a number of
studies conducted in various countries 45.
Discussion
Traditionally, observer-rated scales have been used to
measure manic states and self-rating scales have been
developed only more recently. The latter have the advan-
tage of being able to assess the patient’s internal states
and avoiding possible misinterpretation of clinicians, al-
though some authors argued that their subjective nature
makes them at risk of exaggeration or understatement of
symptoms and non-standard interpretations of the mean-
ing of the questions 46.
In the experimental research context, self-report and
interview-based instruments are commonly utilized for
preselected patients with mood disorders who have well-
established diagnoses to assess treatment outcomes in
terms of response/remission 30 47-49^. In contrast, in routine
clinical practice no one would argue that rating scales
eliminate the need for a competent psychiatric evalua-
tion, considering that there are no ‘special questions’ on
the most widely used scales that are unfamiliar to a com-
petent clinician 50. Nonetheless, rating scales may be very
useful in clinical practice when it comes to making sure
that specific and standardized questions (e.g. suicidal
ideation) are consistently asked and recorded. Moreover,
evidence that the administration of rating scales might
improve the efficiency of diagnostic evaluation outside
clinical trials (characterized by well-defined inclusion/
exclusion criteria) is still controversial 30 28 51. In partic-
ular, two potential negative consequences have been
commonly reported with the systematic assessment pro-
vided by self-rating scales for mania in clinical settings.
On the one hand, the sensitivity of several instruments
is around 60-65%, and clinicians who rely on screening
scales that use the first stage in a two-stage process for di-
P. Rucci et al.
nia with corresponding DSM-III syndromes. Acta Psychiatr Scand Suppl 1986;326:1-37. (^45) Bech P. The Bech-Rafaelsen Melancholia Scale (MES) in clinical trials of therapies in depressive disorders: a 20-year review of its use as outcome measure. Acta Psychiatr Scand 2002;106:252-64. (^46) Shugar G, Schertzer S, Di Gasbarro J. Development, use and factor analysis of a self-report inventory for mania. Compr Psychiatry 1992;33:325-31. (^47) Weber Rouget B, Gervasoni N, Dubuis V, et al. Screening for bipolar disorders using a French version of the Mood Disor- der Questionnaire (MDQ). J Affect Disord 2005;88:103-8. (^48) Twiss J, Jones S, Anderson I. Validation of the Mood Disor- der Questionnaire for screening for bipolar disorder in a UK sample. J Affect Disord 2008;110:180-4. (^49) Zimmerman M. Misuse of the Mood Disorders Question- naire as a case-finding measure and a critique of the con- cept of using a screening scale for bipolar disorder in psychi- atric practice. Bipolar Disord 2012;14:127-34. (^50) Parker G, Fletcher K, Barrett M, et al. Screening for bipolar disorder: the utility and comparative properties of the MSS and MDQ measures. J Affect Disord 2008;109:83-9. (^51) Zimmerman M, Mattia JI. A self-report scale to help make psychiatric diagnoses: the Psychiatric Diagnostic Screening Questionnaire (PDSQ). Arch Gen Psychiatry 2001;58:787-94. (^52) Harding JK, Rush AJ, Arbuckle M, et al. Measurement-based care in psychiatric practice: a policy framework for imple- mentation. J Clin Psychiatry 2011;72:1136-43. (^53) Rucci P, Piazza A, Menchetti M, et al. Integration between Primary Care and Mental Health Services in Italy: determi- nants of referral and stepped care. Int J Family Med 2012, Article ID 507464. doi:10.1155/2012/507464. (^54) Trivedi MH, Wisniewski SR, Morris DW, et al. Concise As- sociated Symptoms Tracking scale: a brief self-report and clinician rating of symptoms associated with suicidality. J Clin Psychiatry 2011;72:765-74. (^55) Gaynes BN, DeVeaugh-Geiss J, Weir S, et al. Feasibility and Di- agnostic Validity of the M-3 Checklist: A Brief, Self-Rated Screen for Depressive, Bipolar, Anxiety, and Post-Traumatic Stress Dis- orders in Primary Care. Ann Farm Med 2010;8:160-9. (^56) Light KJ, Joyce PR, Frampton CM. Description and valida- tion of the Affective Temperament Questionnaire. Compr Psychiatry 2009;50:477-84. (^57) Adler M, Liberg B, Andersson S, et al. Development and validation of a self rating scale for manic, depressive and mixed affective states. Nord J Psychiatry 2008;62:130. (^58) Henry C, M’Bailara K, Mathieu F, et al. Construction and validation of a dimensional scale exploring mood disorders: MAThyS (Multidimensional Assessment of Thymic States). BMC Psychiatry 2008;19:82. (^59) Dodd AL, Mansell W, Sadhnani V, et al. Principal com- ponents analysis of the Hypomanic Attitudes and Positive Predictions Inventory and associations with measures of
the screening of bipolar disorders and comparison with the Mood Disorder Questionnaire (MDQ) in a clinical sample. Clin Pract Epidemiol Ment Health 2006;8:2. (^30) Ghaemi SN, Miller CJ, Berv DA, et al. Sensitivity and speci-
ficity of a new bipolar spectrum diagnostic scale. J Affect Disord 2005;84:273-7. (^31) Zimmerman M, Galione JN, Chelminski I, et al. Perfor-
mance of the Bipolar Spectrum Diagnostic Scale in psychi- atric outpatients. Bipolar Disord 2010;12:528-38. (^32) Poon Y, Chung KF, Tso KC, et al. The use of Mood Disorder
Questionnaire, Hypomania Checklist-32 and clinical predic- tors for screening previously unrecognised bipolar disorder in a general psychiatric setting. Psychiatry Res 2012;195:111-7. (^33) Vieta E, Sánchez-Moreno J, Bulbena A, et al. Cross valida-
tion with the mood disorder questionnaire (MDQ) of an instrument for the detection of hypomania in Spanish: the 32 item hypomania symptom check list (HCL-32). J Affect Disord 2007;101:43-55. (^34) Rybakowski JK, Dudek D, Pawlowski T, et al. Use of the
Hypomania Checklist-32 and the Mood Disorder Question- naire for detecting bipolarity in 1,051 patients with major depressive disorder. Eur Psychiatry 2012;27:577-81. (^35) Smith DJ, Griffiths E, Kelly M, et al. Unrecognized bipolar
disorder in primary care patients with depression. Br J Psy- chiatry 2011;199:49-56. (^36) Fagiolini A, Dell’Osso L, Pini S, et al. Validity and reliability
of the new instrument for assessing mood symptomatology: the Structured Clinical Interview for Mood Spectrum (SCI- MOODS). Int J Meth Psychiatr Res 1999;8:75-86. (^37) Dell’Osso L, Armani A, Rucci P, et al. Measuring mood
spectrum: comparison of interview (SCI-MOODS) and self-report (MOODS-SR) instruments. Compr. Psychiatry 2002;43:69-73. (^38) Cassano GB, Rucci P, Benvenuti A, et al. The role of psy-
chomotor activation in discriminating unipolar from bipo- lar disorders: a classification-tree analysis. J Clin Psychiatry 2012;73:22-8. (^39) Young RC, Biggs JT, Ziegler VE, et al. A rating scale for
mania: reliability, validity and sensitivity. Br J Psychiatry 1978;133:429-35. (^40) Berk M, Ng F, Wang WV, et al. The empirical redefinition of
the psychometric criteria for remission in bipolar disorder. J Affect Disord 2008;106:153-8. (^41) González-Pinto A, Galán J, Martín-Carrasco M, et al. Anxi-
ety as a marker of severity in acute mania. Acta Psychiatr Scand 2012;126:351-5. (^42) Benvenuti A, Rucci P, Miniati M, et al. Treatment-emergent
mania/hypomania in unipolar patients. Bipolar Disord 2008;10:726-32. (^43) Bech P, Bolwig TG, Kramp P, et al. The Bech-Rafaelsen Ma-
nia Scale and the Hamilton Depression Scale. Acta Psychiatr Scand 1979;59:420-30. (^44) Bech P, Kastrup M, Rafaelsen OJ. Mini-compendium of rat-
ing scales for states of anxiety depression mania schizophre-
A review of self-report and interview-based instruments to assess mania and hypomania symptoms
the bipolar inventory of symptoms scale. Acta Psychiatr Scand 2007;116:189-94. (^68) Dennehy EB, Suppes T, Crismon ML, et al. Development of the Brief Bipolar Disorder Symptom Scale for patients with bipolar disorder. Psychiatry Res 2004;127:137-45. (^69) Wong G, Lam D. The development and validation of the coping inventory for prodromes of mania. J Affect Disord 1999;53:57-65. (^70) Placidi GF, Signoretta S, Liguori A, et al. The semi-structured affective temperament interview (TEMPS-I). Reliability and psychometric properties in 1010 14-26-year old students. J Affect Disord 1998;47:1-10. (^71) Altman EG, Hedeker DR, Janicak PG, et al. The Clinician-Ad- ministered Rating Scale for Mania (CARS-M): development, reliability, and validity. Biol Psychiatry 1994;36:124-34. (^72) Brierley CE, Szabadi E, Rix KJ, et al. The Manchester Nurse Rat- ing Scales for the daily simultaneous assessment of depressive and manic ward behaviours. J Affect Disord 1988;15:45-54. (^73) Eckblad M, Chapman LJ. Development and validation of a scale for hypomanic personality. J Abnorm Psychol 1986;95:214-22. (^74) Reilly-Harrington NA, DeBonis D, Leon AC, et al. The in- teractive computer interview for mania. Bipolar Disord 2010;12:521-7. (^75) Krüger S, Quilty L, Bagby M, et al. The Observer-Rated Scale for Mania (ORSM): development, psychometric prop- erties and utility. J Affect Disord 2010;122:179-83.
personality, cognitive style and analogue symptoms in a stu- dent sample. Behav Cogn Psychother 2010;38:15-33. (^60) Mansell W. The Hypomanic Attitudes and Positive Pre-
dictions Inventory (HAPPI): A pilot study to select cogni- tions that are elevated in individuals with bipolar disorder compared to non-clinical controls. Behav Cogn Psychother 2006;34:467-76. (^61) Akiskal HS, Akiskal KK, Haykal RF, et al. TEMPS-A: progress
towards validation of a self-rated clinical version of the Tem- perament Evaluation of the Memphis, Pisa, Paris, and San Diego Autoquestionnaire. J Affect Disord 2005;85:3-16. (^62) Thalbourne MA, Bassett DL. The Manic Depressiveness
Scale: a preliminary effort at replication and extension. Psy- chol Rep 1998;83:75-80. (^63) Joseph S, Lewis CA. The Depression-Happiness Scale: reli-
ability and validity of a bipolar self-report scale. J Clin Psy- chol 1998;54:537-44. (^64) Bauer MS, Critis-Christoph P, Ball WA, et al. Independent
assessment of manic and depressive symptoms by self-rat- ing. Arch Gen Psychiatry 1991;48:807-12. (^65) Folstein MF, Luria R. Reliability, validity, and clinical ap-
plication of the Visual Analogue Mood Scale. Psychol Med 1973;3:479-86. (^66) Giglio LM, Magalhães PV, Andreazza AC, et al. Develop-
ment and use of a biological rhythm interview. J Affect Dis- ord 2009;118:161-5. (^67) Bowden CL, Singh V, Thompson P, et al. Development of
