Screening Test for Bipolar Disorder Created

By Arline Kaplan © 2000 (All Rights Reserved)

"There are no bipolar patients in my practice, they just don’t come to see me," the primary care physician told psychiatrist Robert Hirschfeld, M.D.

"Oh yes they do," Hirschfeld responded, "but they don’t announce themselves as bipolars."

Hirschfeld, Titus H. Harris Distinguished Professor and chair of the department of psychiatry and behavioral sciences at the University of Texas Medical Branch in Galveston, described this conversation to emphasize how often bipolar patients go unrecognized.

"They don’t come in …with a DSM-IV [Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition] and say I’m bipolar," he told seminar participants at a U.S. Psychiatric and Mental Health Congress. Instead, patients come into health care settings with symptoms: anxiety, mood swings, insomnia, irritability, low energy/fatigue, inability to focus, substance abuse, excessive drinking, impulse control problems, depression, legal troubles or relationship issues.

"As a consequence of all this, they get misdiagnosed," he said.

To support his point, Hirschfeld shared data from the National Depressive and Manic-Depressive Association’s (National DMDA) Survey of its members with bipolar disorder (Lish et al., 1994) and a Stanley Foundation study (Suppes et. al, in press). In the National DMDA survey, 48% of the respondents consulted three or more professionals before receiving a correct diagnosis and 10% consulted seven or more professionals.

"About one-third of them waited 10 or more years to get a diagnosis, and that’s really 10 horrible years," Hirschfeld said. Many patients confided to him how they missed their adolescence and their 20s and "only began to get stabilized and to live something of a reasonable life after that."

He pointed out that the findings were similar in the study for the Stanley Foundation Bipolar Treatment Outcome Network conducted by Trisha Suppes, M.D., Ph.D., and colleagues at the University of Texas Southwestern Medical Center in Dallas.

"The number of years from the first symptoms to the first hospitalization were 11 for women and eight for men, so almost the same as in the NDMDA survey," he said. "People are not getting diagnosed; bipolar disorder is being overlooked."

"What are the consequences of this?" Hirschfeld asked. "Many of these people end up in jail. If they are in a primary care clinic, and they are given an antidepressant without coverage by a mood stabilizer, you may have a huge mess on your hands."

One way to increase recognition of bipolar disorder is to screen for it, Hirschfeld said.

Hirschfeld served as chair of the Bipolar Diagnostic Aid Advisory Committee that, operating on the belief that no screening test for bipolar disorder exists, came together to create one (Hirschfeld et al., 2000). The committee included experts in bipolar disorder—Hirschfeld; Paul Keck Jr., M.D., University of Cincinnati; Robert Post, M.D., National Institute of Mental Health; Gary Sachs, M.D., Harvard University; John Zajecka, M.D., Rush Presbyterian St. Luke’s Medical Center—as well experts on the design of screening instruments—Robert Spitzer, M.D., and Janet Williams, D.S.W., both of Columbia University. Representing consumer advocacy groups were Laurie Flynn of the National Alliance for the Mentally Ill and Lydia Lewis of the National Depressive and Manic-Depressive Association. The process was funded through a grant from Abbott Laboratories.

"Our purpose is to screen for bipolar spectrum disorders, which include bipolar I, bipolar II, cyclothymia and atypical bipolar disorder," Hirschfeld said in an interview. "We put together questions which are highly relevant to bipolar disorder, using DSM-IV criteria and also our clinical knowledge and background."

The first version of the Mood Disorder Questionnaire (MDQ) contained nine questions from the PRIME-MD (Primary Care Evaluation of Mental Disorders), a tool for identifying mental disorders in primary care patients; 13 questions on mania; and a few follow-up questions. It was validated through a psychiatric clinic sample.

"A number of us with outpatient mood disorders clinics volunteered 100 of our patients to participate in the first trial of this [screening test]," Hirschfeld said. "Essentially, someone would come into the clinic for treatment. They might have been ongoing patients or new patients. A research assistant approached them and asked if they would be willing to participate in this study by filling out the questionnaire. Those agreeing were informed that they might be …called back to have a research interview by telephone within the next several days….The research interview was the SCID [Structured Clinical Interview for DSM-IV] and was done by an experienced, well-trained person from Columbia University….She was blind to the clinical diagnosis and to the ratings that the people gave," Hirschfeld said.

"We got 524 completed MDQs from four or five different sites. And the top 20% in terms of scoring, got an interview using the SCID, because we wanted to have an enriched sample of bipolar patients. Then, we randomly selected another 100 from the remaining 80%. So of the 524 completing the MDQ, nearly 200 patients were interviewed. Of these 200, 109 turned out by research diagnosis to have bipolar disorder," Hirschfeld said.

In the follow-up interview, Hirschfeld said that the depression questions from the PRIME-MD are not included in the final version of the MDQ.

"We only have questions on the manic-type behavior, because that is all that you really need for a diagnosis of bipolar disorder," according to Hirschfeld. Comprising questions that can be answered with a yes or no, the questionnaire takes about five minutes to answer. It includes the following questions:

   o Has there ever been a period of time when you were not your usual self and you felt so good or so hyper that other people thought you were not your normal self or you were so hyper that you got into trouble?
   o Has there ever been a period of time when you were not you usual self and you were much more talkative or spoke much faster than usual?
   o Has there ever been a period of time when you were not your usual self and you did things that were unusual for you or that other people might have thought were excessive, foolish or risky?
   o Has there ever been a period of time when you were not your usual self and you got much less sleep than usual and found you didn’t really miss it?

In Hirschfeld’s own practice, he finds that the sleep question is highly diagnostic, but somewhat confusing.

"Everybody has had a period of insomnia and gotten much less sleep because they drank too much, or because they are working too hard…that’s not the same thing," he said. "But if you ask, could you get along for a week or two and need only two, three or even four hours less sleep per night, that to me is a very helpful question."

Beyond the 13 questions on mania, Hirschfeld said the MDQ asks whether the different symptoms and behaviors occurred together in a cluster and whether they caused impairment.

"What we found is if you check eight or more of the questions positively, then you really should get a full evaluation for bipolar disorder," he added.

Hirschfeld said he hopes to test the MDQ in other nonpsychiatric settings and go forward with programs to disseminate it.

"We want to see it used in community mental health centers, on the web, in magazines and perhaps in National Depression Screening Day," Hirschfeld said. "We want to make it as widely available as possible, so that people will have the opportunity to say, ‘Oh, my goodness, that’s me,’ or …‘that’s my husband, son, daughter.’"

References
Hirschfeld RM, Williams JB, Spitzer RL et al. (2000), Development and validation of a screening instrument for bipolar spectrum disorder: the mood disorder questionnaire. Am J Psychiatry 157(11):1873-1875.

Lish JD, Dime-Meenan S, Whybrow PC et al. (1994), The National Depressive and Manic-Depressive Association (DMDA) survey of bipolar members. J Affect Disord 31(4):281-294.

Suppes T, Leverich GS, Keck PE et al. (2001), The Stanley Foundation Bipolar Treatment Outcome Network II. Demographics and illness characteristics of the first 261 patients. J Affect Disord 67(1-3):45-59.