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A spectrum approach to diagnosis.
In the recent series on crowdstudying ourselves, I queried readers about their estimates of bipolar prevalence in the community and in their practice, and their approach to bipolar diagnosis (categorical, per DSM, or a spectrum-based approach). The early results are very interesting-and will be more interesting if we have your input, if you have not already participated! I’ll summarize those results next month.
The diagnosis questionnaire led to a disturbing conclusion: if you’re trying to assess all the variables relevant to determining “How bipolar is this patient?” as recommended by heads of the NIMH, DSM-5, and STEP-BD, you need to ask 20 separate questions in your initial evaluation. Yikes! Our initial evaluations include many other time-consuming inquiries, as well as attention to building trust and rapport, laying the groundwork for mutually agreed-upon treatment goals and plans. I suggest that a questionnaire approach to the 20 questions can dramatically improve the efficiency of your initial interview.
This questionnaire, dubbed “MoodCheck,” has been in use in our clinic for over 5 years, which demonstrates its feasibility and value. It consists of 3 validated components: the Bipolar Spectrum Diagnostic Scale (BSDS), a family history screener, and elements of the Bipolarity Index.
Parts A and B: The Bipolar Spectrum Diagnostic Scale
The BSDS has multiple validation studies showing that it performs comparably to the better-known Mood Disorders Questionnaire (MDQ).1 As you can see in the pdf, Part A of the BSDS invites patients to consider 19 statements about mood and endorse those that describe their experience. Part B is just an amplifier: if these statements are characteristic of the patient’s experience, additional points are assigned. The BSDS was selected for this instrument because of potentially greater sensitivity in bipolar II2; because it characterizes bipolarity in spectrum terms; and because unlike the copyrighted MDQ, it is a public-sector document with no fees or strings attached (courtesy of its author, Dr. Ron Pies, Editor in Chief Emeritus of Psychiatric Times).
Part C: Family history screener
As you can see in the pdf, Part C is simply a table of checkboxes. When completed by parents, this table improved detection of pediatric bipolar disorder relative to the MDQ alone. It is easily completed by patients and provides a rapid visual representation of important family experience of psychiatric disorders. Interestingly, in that pediatric validation study, “No subset of family risk items performed better than the total”: ie, a large number of checks was as significant as checks in “bipolar disorder” boxes.3 This finding has not been replicated so far. Nevertheless, you’ll quickly discover that a large number of checked boxes is meaningful-associated with severity of psychopathology at minimum.
Two additional questions about prior diagnosis of bipolar disorder and previous suicide attempts complete Part C (because space was available on the page and they provide important information for primary care providers, for whom this instrument was originally designed). Because MoodCheck is a public-sector document, you can alter these questions if you wish (download a Word version).
Part D: Elements of the Bipolarity Index
As described in my last essay, just as family history is well known to be important in a thorough diagnostic assessment, so too are 9 other variables in the course of illness and response to treatment. Recall that the STEP-BD research team gave 80% of the diagnostic weight to these non-manic bipolar markers in their Bipolarity Index. If it makes sense to take a family history, then it makes sense to gather these other data as well. Part D does so efficiently, and you can “score it” with a quick glance. For primary care providers, I’ve shaded the boxes that carry the greatest statistical weight; you can remove the shading once you are familiar with the instrument.
Interpreting MoodCheck results
For primary care providers, I have provided 2 paragraphs on interpreting the results of this questionnaire. Psychiatric providers: you can remove these or replace them with your own guidelines.
For patients with suggestive but strongly positive results, I have directed them to my website, which explains “mood swings but not manic,” viz, bipolar II and mid-spectrum mood disorders. Some such psychoeducation is important to help patients understand the meaning of the MoodCheck questionnaire, which-by definition, a spectrum approach to diagnosis-does not provide a yes or no answer to the question “Do I have bipolar disorder?” Rather, as indicated in 2005 by Gary Sachs, head of the STEP-BD research program, the right question is “How bipolar are you?” MoodCheck will help you provide an estimate (the best we can do in the absence of a biological test) efficiently.
In next month’s essay, I’ll summarize and interpret the results from the survey questions on prevalence and diagnostic approach. Please click on those links and participate if you’ve not done so already. There are no right answers, only yours. Thanks!
1. Carvalho AF, Takwoingi Y, Sales PM, et al. Screening for bipolar spectrum disorders: a comprehensive meta-analysis of accuracy studies. J Affect Disord. 2015;172:337-346.
2. Zaratiegui RM, VÃ¡zquez GH, Lorenzo LS, et al. Sensitivity and specificity of the mood disorder questionnaire and the bipolar spectrum diagnostic scale in Argentinean patients with mood disorders. J Affect Disord. 2011;132:445-449.
3. Algorta GP, Youngstrom EA, Phelps J, et al. An inexpensive family index of risk for mood issues improves identification of pediatric bipolar disorder. Psychol Assess. 2013;25:12-22.