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Evidence-based assessment/Bipolar disorder in adults (assessment portfolio)/extended version

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What is a "portfolio"?

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  • For background information on what assessment portfolios are, click the link in the heading above.
  • Does all of this feel like TMI? Click here to go to a condensed version.

Preparation phase

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Diagnostic criteria for bipolar disorder in adults

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Bipolar Disorder (BP) is characterized by extreme fluctuations in mood (or emotional dysregulation that ranges from mania (as shown by displays or feelings of extreme happiness, unrealistic overachievement and anger), to depression (as shown by displays or feelings of sadness, changes in appetite or weight and irritability.[1] It has a lifetime risk of about 1%, with heritability estimated at up to 80%.[2] It is important to note that these moods exceed normal responses to life events, represent a change from the individual's normal functioning, and cause problems in daily activities.


ICD-11 Diagnostic Criteria

  • Bipolar Type I Disorder
    • Bipolar type I disorder is an episodic mood disorder defined by the occurrence of one or more manic or mixed episodes. A manic episode is an extreme mood state lasting at least one week unless shortened by a treatment intervention characterized by euphoria, irritability, or expansiveness, and by increased activity or a subjective experience of increased energy, accompanied by other characteristic symptoms such as rapid or pressured speech, flight of ideas, increased self-esteem or grandiosity, decreased need for sleep, distractibility, impulsive or reckless behavior, and rapid changes among different mood states (i.e., mood lability). A mixed episode is characterized by either a mixture or very rapid alternation between prominent manic and depressive symptoms on most days during a period of at least 2 weeks. Although the diagnosis can be made based on evidence of a single manic or mixed episode, typically manic or mixed episodes alternate with depressive episodes over the course of the disorder.
      • Note: The ICD-11 lists 18 additional subcategories of Bipolar type I disorder. They can be found here.
  • Bipolar Type II Disorder
    • Bipolar type II disorder is an episodic mood disorder defined by the occurrence of one or more hypomanic episodes and at least one depressive episode. A hypomanic episode is a persistent mood state characterized by euphoria, irritability, or expansiveness, and excessive psychomotor activation or increased energy, accompanied by other characteristic symptoms such as grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, and impulsive or reckless behavior lasting for at least several days. The symptoms represent a change from the individual’s typical behavior and are not severe enough to cause marked impairment in functioning. A depressive episode is characterized by a period of almost daily depressed mood or diminished interest in activities lasting at least 2 weeks accompanied by other symptoms such as changes in appetite or sleep, psychomotor agitation or retardation, fatigue, feelings of worthless or excessive or inappropriate guilt, feelings or hopelessness, difficulty concentrating, and suicidality. There is no history of manic or mixed Episodes.
      • Note: The ICD-11 lists 13 additional subcategories of Bipolar type II disorder. They can be found here.

Changes in DSM-5

  • The diagnostic criteria for Bipolar Disorder changed slightly from DSM-IV to DSM-5. Summaries are available here and here.


Base rates of BD in different clinical settings and populations

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This section describes the demographic setting of the population(s) sampled, base rates of diagnosis, country/region sampled, and the diagnostic method that was used. Using this information, clinicians will be able to anchor the rate of adolescent depression that they are likely to see in their clinical practice.

  • To see prevalence rates across multiple disorders, click here.
Demography Setting Base Rate Diagnostic Method Best Recommended For
United States, Canada, Puerto Rico, Germany, Taiwan, Korea, New Zealand Community Epidemiological Samples[3] 0.3 - 1.5% Structured and semi-structured diagnostic interviews
United States Community Epidemiological Samples[4] BPI - 1%; BPII - 1.1%; Subthreshold BP - 2.4% World Health Organisation Composite International Diagnostic Interview
United States Community samples (older adolescents)[5] 1% K-SADS Semi-Structured Interview
United States US National Epidemiological Catchment Area (ECA) database[6] 0.8 - 5.1% (manic and subthreshold mania) Diagnostic Interview Schedule (DIS)
United States US National Comorbidity Survey (NCS)[7] 0-4% (small community sample; reappraisal study) World Health Organisation Composite International Diagnostic Interview
United States and other countries Community sample[8] BPI - 0.6%; BPII-  1.8%;  Cyclothymia - 0.4-1% Unspecified
United States, Europe, Asia Community Samples[9] BPI - 0.6%; BPII - 0.4%; Subthreshold BP - 1.4%; Bipolar Spectrum Disorder - 2.4% World Health Organisation Composite International Diagnostic Interview
United States National Epidemiologic Survey on Alcohol and Related Conditions (NESARC)[10] BPI - 3.3% The Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV (AUDADIS-IV)
United States Outpatient Clinic Sample[11] 9.8% Review of medical records, questionnaire data
United States Outpatient Clinic Sample[12] 21.3% MDQ, SCID

Prediction phase

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Psychometric properties of screening instruments for adult bipolar disorder

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The following section contains a list of screening and diagnostic instruments for adult bipolar disorder. The section includes administration information, psychometric data, and PDFs or links to the screenings.

  • Screenings are used as part of the prediction phase of assessment; for more information on interpretation of this data, or how screenings fit in to the assessment process, click here.
  • For a list of more broadly reaching screening instruments, click here.
Measure Format (Reporter) Age Range Administration/

Completion Time

Inter-rater reliability Test-retest reliability Construct validity Content validity Highly recommended Free and Accessible PDFs
HCL-32 (Hypomania Checklist)[13][14] Self-report Adult 10-15 minutes Not applicable G G  Y
BSDS (Bipolar Spectrum Diagnostic Scale)[13] Self-report Adult 15 minutes Not applicable G G
GBI (General Behavior Inventory) Self-report Adult 15-20 minutes Not applicable A G A
MDQ (Mood Disorder Questionnaire)[13] Self-report Adult 5 minutes Not applicable A A A

Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

Likelihood ratios and AUCs of screening measures for bipolar disorder in adults

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  • For a list of the likelihood ratios for more broadly reaching screening instruments, click here.
Screening Measure (Primary Reference) Area Under Curve (AUC) and sample size DiLR+ (score) DiLR- (score) Population Clinical Generalizability
BSDS (Bipolar Spectrum Diagnostic Scale) [13] 0.81 (13) [13] 0.36 (4.93) Clinical
HCL-32 (Hypomania Checklist)[13] 0.80 (14)[13] 0.28 (2.45) Clinical
MDQ (Mood Disorder Questionnaire)[13] 0.78 (7)[13] 0.22 (5.4) Clinical

Note: Area Under Curve (AUC, or AUROC) is equal to the probability that a classifier will rank a randomly chosen positive diagnosis of Bipolar Disorder higher than a randomly chosen negative diagnosis of Bipolar Disorder[15].

More on high preforming bipolar screening measures

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Expand for more information

7 Up 7 Down Inventory (7U7D)

  • The 7 Up 7 Down Inventory is a recently developed and validated questionnaire with 14 items of manic and depressive tendencies carved from the General Behavior Inventory, a well-validated but cumbersome interview. For both mania and depression factors, 7 items produced a psychometrically adequate measure applicable across both aggregate samples. Internal reliability of the Mania scale was .81 (youth) and .83 (adult) and for Depression was .93 (youth) and .95 (adult)[15].The 7 Up 7 Down Inventory, along with the accompanying research article can be found here

Bipolar Spectrum Diagnostic Scale (BSDS)

  • The Bipolar Spectrum Diagnostic Scale (BSDS) is a diagnostic tools that can assess for bipolar disorder in those who have Bipolar Disorder I, Bipolar Disorder II and Bipolar Disorder NOS. It was designed to help detect milder versions of bipolar disorder[1]. It is a self-report measure, and it has been shown to be generally effective in detecting bipolar disorder, though this effectiveness is not shown in individuals who have low insight.[16] The sensitivity of the BSDS is due to its focus on energy and drive rather than the mood symptoms present during hypomanic symptoms[16]. The threshold for a positive diagnosis is 13 points. The BSDS effectively screened out unipolar patients, maintained good sensitivity across the bipolar spectrum and low rate of false positives.[16].

Mood Disorder Questionnaire (MDQ)

  • The Mood Disorder Questionnaire (MDQ) is a self-report scale for bipolar disorder which focuses more on mood symptoms.[17] It is very effective in detecting bipolar I disorder but less sensitive at detecting bipolar II disorder and Not Otherwise Specified (NOS).[18]

Interpreting adult bipolar disorder screening measure scores

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Prescription phase

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Gold standard diagnostic interviews

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  • For a list of broad reaching diagnostic interviews sortable by disorder with PDFs (if applicable), click here.
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Diagnostic instruments for BPSD
Measure Format (Reporter) Age Range Administration/

Completion Time

Interrater Reliability Test-Retest Reliability Construct Validity Content Validity Highly Recommended Free and Accessible Measures

Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

Severity interviews for bipolar disorder

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Measure Format (Reporter) Age Range Administration/

Completion Time

Interrater Reliability Test-Retest Reliability Construct Validity Content Validity Highly Recommended Free and Accessible Measures

Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

Process phase

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The following section contains a list of process and outcome measures for bipolar disorder in adults. The section includes benchmarks based on published norms and on mood samples for several outcome and severity measures, as well as information about commonly used process measures. Process and outcome measures are used as part of the process phase of assessment. For more information of differences between process and outcome measures, see the page on the process phase of assessment.

Process measures

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There are many processes that may be considered important when evaluating an adult with Bipolar Disorder; however, due to the diversity of the population and symptom expression, there are too many to narrow down. Clinical judgment is recommended when deciding what additional measures should be included (e.g. executive functioning, sensory processing, cognitive flexibility). The measure provided below are commonly used to assess and provide important information regarding levels of daily functioning of individuals with Bipolar Disorder.

More information on process measure coming soon.

Outcome and severity measures

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This table includes clinically significant benchmarks for adult bipolar disorder specific outcome measures

  • Information on how to interpret this table can be found here.
  • Additionally, these vignettes might be helpful resources for understanding appropriate adaptation of outcome measures in practice.
  • For clinically significant change benchmarks for the CBCL, YSR, and TRF total, externalizing, internalizing, and attention benchmarks, see here.
Clinically significant change benchmarks with common instruments for bipolar disorder
Benchmarks Based on Published Norms
Measure Subscale Cut-off scores Critical Change
(unstandardized scores)
A B C 95% 90% SEdifference
CBCL T-scores
(2001 Norms) 		Total 49 70 58 5 4 2.4

Treatment

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t

This user tweets on Twitter as REACTTOOLKIT.

External resources

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  1. ICD-10 diagnostic criteria
  2. Find-a-Therapist (a curated list of find-a-therapist websites where you can find a provider)
  3. OMIM (Online Mendelian Inheritance in Man)
    1. 125480
    2. 611536
    3. 309200,
    4. 611535
    5. 603663
  4. eMedicine information
  5. Effective Child Therapy information on Bipolar Disorder
    • Effective Child Therapy is website sponsored by Division 53 of the American Psychological Association (APA), or The Society of Clinical Child and Adolescent Psychology(SCCAP), in collaboration with the Association for Behavioral and Cognitive Therapies (ABCT). Use for information on symptoms and available treatments.
  6. The Psych Show with Dr. Ali Mattu videos (geared towards public; might send to client)
    1. How to Cope with Bipolar Disorder
    2. Top 10 Bipolar Myths

References

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Click here for references
  1. ↑ 1.0 1.1 Zimmerman, M., Galione, J. N., Chelminski, I., Young, D. and Ruggero, C. J. (2010), Performance of the Bipolar Spectrum Diagnostic Scale in psychiatric outpatients. Bipolar Disorders, 12: 528–538. doi:10.1111/j.1399-5618.2010.00840.x
  2. ↑ Purcell, Shaun M.; Wray, Naomi R.; Stone, Jennifer L.; Visscher, Peter M.; O'Donovan, Michael C.; Sullivan, Patrick F.; Sklar, Pamela; (Leader), Shaun M. Purcell et al. (2009/08). "Common polygenic variation contributes to risk of schizophrenia and bipolar disorder". Nature 460 (7256). doi:10.1038/nature08185. ISSN 1476-4687. http://www.nature.com/doifinder/10.1038/nature08185. 
  3. ↑ Weissman, Myrna M.; Bland, Roger C.; Canino, Glorisa J.; Faravelli, Carlo; Greenwald, Steven; Hwu, Hai-Gwo; Joyce, Peter R.; Karam, Eile G. et al. (1996-07-24). "Cross-National Epidemiology of Major Depression and Bipolar Disorder". JAMA 276 (4): 293–299. doi:10.1001/jama.1996.03540040037030. ISSN 0098-7484. https://jamanetwork.com/journals/jama/fullarticle/405806. 
  4. ↑ Merikangas, Kathleen R.; Akiskal, Hagop S.; Angst, Jules; Greenberg, Paul E.; Hirschfeld, Robert M. A.; Petukhova, Maria; Kessler, Ronald C. (2007-05-01). "Lifetime and 12-Month Prevalence of Bipolar Spectrum Disorder in the National Comorbidity Survey Replication". Archives of General Psychiatry 64 (5): 543–552. doi:10.1001/archpsyc.64.5.543. ISSN 0003-990X. https://jamanetwork.com/journals/jamapsychiatry/fullarticle/482285. 
  5. ↑ LEWINSOHN, PETER M.; KLEIN, DANIEL N.; SEELEY, JOHN R.. "Bipolar Disorders in a Community Sample of Older Adolescents: Prevalence, Phenomenology, Comorbidity, and Course". Journal of the American Academy of Child & Adolescent Psychiatry 34 (4): 454–463. doi:10.1097/00004583-199504000-00012. http://linkinghub.elsevier.com/retrieve/pii/S089085670963731X. 
  6. ↑ Judd, Lewis L.; Akiskal, Hagop S.. "The prevalence and disability of bipolar spectrum disorders in the US population: re-analysis of the ECA database taking into account subthreshold cases". Journal of Affective Disorders 73 (1-2): 123–131. doi:10.1016/s0165-0327(02)00332-4. https://doi.org/10.1016/S0165-0327(02)00332-4. 
  7. ↑ Kessler, R. C.; Rubinow, D. R.; Holmes, C.; Abelson, J. M.; Zhao, S. (1997/09). "The epidemiology of DSM-III-R bipolar I disorder in a general population survey". Psychological Medicine 27 (5): 1079–1089. ISSN 1469-8978. https://www.cambridge.org/core/journals/psychological-medicine/article/epidemiology-of-dsmiiir-bipolar-i-disorder-in-a-general-population-survey/950D518D15F64E2059F1033558615A9A. 
  8. ↑ Diagnostic and statistical manual of mental disorders : DSM-5. (5th ed.). Arlington, VA: American Psychiatric Association., American Psychiatric Association. DSM-5 Task Force.. 2013. ISBN 9780890425541. OCLC 830807378. https://www.worldcat.org/oclc/830807378. 
  9. ↑ Merikangas, Kathleen R.; Jin, Robert; He, Jian-Ping; Kessler, Ronald C.; Lee, Sing; Sampson, Nancy A.; Viana, Maria Carmen; Andrade, Laura Helena et al. (2011-03-07). "Prevalence and Correlates of Bipolar Spectrum Disorder in the World Mental Health Survey Initiative". Archives of General Psychiatry 68 (3). doi:10.1001/archgenpsychiatry.2011.12. ISSN 0003-990X. http://archpsyc.jamanetwork.com/article.aspx?doi=10.1001/archgenpsychiatry.2011.12. 
  10. ↑ Grant, Bridget F.; Stinson, Frederick S.; Hasin, Deborah S.; Dawson, Deborah A.; Chou, S. Patricia; Ruan, W. June; Huang, Boji (October 2005). "Prevalence, correlates, and comorbidity of bipolar I disorder and axis I and II disorders: results from the National Epidemiologic Survey on Alcohol and Related Conditions". The Journal of Clinical Psychiatry 66 (10): 1205–1215. ISSN 0160-6689. PMID 16259532. https://www.ncbi.nlm.nih.gov/pubmed/16259532. 
  11. ↑ Das, Amar K. (2005-02-23). "Screening for Bipolar Disorder in a Primary Care Practice". JAMA 293 (8). doi:10.1001/jama.293.8.956. ISSN 0098-7484. http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.293.8.956. 
  12. ↑ Hirschfeld, RM; Cass, AR; Holt, DC; Carlson, CA (2005). "Screening for bipolar disorder in patients treated for depression in a family medicine clinic.". The Journal of the American Board of Family Practice 18 (4): 233-9. PMID 15994469. 
  13. ↑ 13.0 13.1 13.2 13.3 13.4 13.5 13.6 13.7 13.8 Carvalho, André F.; Takwoingi, Yemisi; Sales, Paulo Marcelo G.; Soczynska, Joanna K.; Köhler, Cristiano A.; Freitas, Thiago H.; Quevedo, João; Hyphantis, Thomas N. et al. (February 2015). "Screening for bipolar spectrum disorders: A comprehensive meta-analysis of accuracy studies". Journal of Affective Disorders 172: 337–346. doi:https://doi.org/10.1016/j.jad.2014.10.024. 
  14. ↑ Feng, Yuan; Wang, Yuan-Yuan; Huang, Wei; Ungvari, Gabor S.; Ng, Chee H.; Wang, Gang; Yuan, Zhen; Xiang, Yu-Tao (2017-06-01). "Comparison of the 32-item Hypomania Checklist, the 33-item Hypomania Checklist, and the Mood Disorders Questionnaire for bipolar disorder". Psychiatry and Clinical Neurosciences 71 (6): 403–408. doi:10.1111/pcn.12506. ISSN 1440-1819. http://onlinelibrary.wiley.com/doi/10.1111/pcn.12506/abstract. 
  15. ↑ Youngstrom, Eric A.; Murray, Greg; Johnson, Sheri L.; Findling, Robert L. (2013-12). "The 7 Up 7 Down Inventory: A 14-item measure of manic and depressive tendencies carved from the General Behavior Inventory". Psychological assessment 25 (4): 1377–1383. doi:10.1037/a0033975. ISSN 1040-3590. PMID 23914960. PMC PMC3970320. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3970320/. 
  16. ↑ 16.0 16.1 16.2 Nassir Ghaemi, S.; Miller, Christopher J.; Berv, Douglas A.; Klugman, Jeffry; Rosenquist, Klara J.; Pies, Ronald W. (February 2005). "Sensitivity and specificity of a new bipolar spectrum diagnostic scale". Journal of Affective Disorders 84 (2-3): 273–277. doi:10.1016/S0165-0327(03)00196-4. ISSN 0165-0327. PMID 15708426. https://www.ncbi.nlm.nih.gov/pubmed/15708426. 
  17. ↑ Hirschfield, R., Williams, J., Spitzer R., Calabrese, J., Flynn L., Keck, P., Lewis L., McElroy S., Post, R., Rapport, D., Russel, J., Sachs, G., Zajecka, J., 2000. Development and validation of a screening instrument for bipolar spectrum disorder: the mood disorder questionnaire. Am. J. Psychiatry 157, 1873-1875.
  18. ↑ Miller, C., Ghaemi, S.N., Klugman, J., Berv, D.A., Pies, R.W., 2002. Utility of mood disorder questionnaire and bipolar spectrum diagnostic scale (Abstract). American Psychological Association Annual Meeting, Philadelphia, PA.
  19. ↑ Lobban, A. F., Robinson, H. A., Appelbe, D., Barraclough, J., Bedson, E., Collinge, E., Dodd, S., Flowers, S., Honary, M., Johnson, S., Caixeiro Mateus, M. D. C., Mezes, B., Minns, V., Murray, E., Walker, A. J., Williamson, P., Wintermeyer, C., & Jones, S. H. (2017). Protocol for an online randomised controlled trial to evaluate the clinical and cost-effectiveness of a peer-supported self-management intervention for relatives of people with psychosis or bipolar disorder: Relatives Education And Coping Toolkit (REACT). BMJ Open, 7, [016965]. https://doi.org/10.1136/bmjopen-2017-016965
  20. ↑ Lobban, F., Akers, N., Appelbe, D., Chapman, L., Collinge, L., Dodd, S., Flowers, S., Hollingsworth, B., Johnson, S., Jones, S. H., Mateus, C., Mezes, B., Murray, E., Panagaki, K., Rainford, N., Robinson, H., Rosala-Hallas, A., Sellwood, W., Walker, A., & Williamson, P. (2020). Clinical effectiveness of a web-based peer-supported self-management intervention for relatives of people with psychosis or bipolar (REACT): online, observer-blind, randomised controlled superiority trial. BMC Psychiatry, 20(1), [160]. https://doi.org/10.1186/s12888-020-02545-9
  21. ↑ F, Lobban; N, Akers; D, Appelbe; R, Iraci Capuccinello; L, Chapman; L, Collinge; S, Dodd; S, Flowers et al. (2020-07-01). "A web-based, peer-supported self-management intervention to reduce distress in relatives of people with psychosis or bipolar disorder: the REACT RCT". Health Technology Assessment 24 (32). doi:10.3310/hta24320. ISSN 2046-4924. PMID 32608353. PMC PMC7355407. https://www.journalslibrary.nihr.ac.uk/hta/hta24320. 
  22. ↑ Lobban, Fiona; Appelbe, Duncan; Appleton, Victoria; Billsborough, Julie; Fisher, Naomi Ruth; Foster, Sheena; Gill, Bethany; Glentworth, David et al. (2020-03-17). "IMPlementation of An online Relatives’ Toolkit for psychosis or bipolar (IMPART study): iterative multiple case study to identify key factors impacting on staff uptake and use". BMC Health Services Research 20 (1): 219. doi:10.1186/s12913-020-5002-4. ISSN 1472-6963. PMID 32183787. PMC PMC7077000. https://doi.org/10.1186/s12913-020-5002-4. 
  23. ↑ Beck, A. K., Baker, A., Jones, S. H., Lobban, A. F., Kay-Lambkin, F., Attia, J., & Banfield, M. (2018). Exploring the feasibility and acceptability of a recovery-focused group therapy intervention for adults with bipolar disorder: trial protocol. BMJ Open, 8, [e019203]. https://doi.org/10.1136/bmjopen-2017-019203
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