Evidence-based assessment/Instruments/General Behavior Inventory

The General Behavior Inventory (GBI) is a questionnaire designed by Richard Depue and colleagues to measure manic and depressive symptoms in adults, as well as to assess for cyclothymic disorder. It is one of the most widely used psychometric tests for measuring the severity of bipolar disorder in research, and it also can track the fluctuation of symptoms over time. The GBI was first designed for use with adults; however, it has been adapted into versions that allow parents to rate their children. Multiple short versions are available that are often more convenient to use. Current versions include the original full length GBI (self-report), the Parent GBI (P-GBI), the Parent GBI-10-item Mania Scale (P-GBI-10M) and two Parent GBI-10-item Depression Scales (Form A & B), and the 7 Up-7 Down Inventory, as well as a Sleep scale. A version was tested as a teacher-report version, but it proved not to be practical for general use.

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Wikipedia has more about this subject: General Behavior Inventory

Attribution: User Eyoungstrom has contributed a lot to this resource and would really appreciate involvement in future editing.

A research volunteer rebuilding a data table from a scatterplot in one of the first publications using the GBI

Access and Use

The General Behavior Inventory is free to use in both research and clinical work. Some of the short forms have been formally CC-BY-SA licensed. The original author, Richard Depue, asks that you contact him to let him know about the project (rad5@cornell.edu). The GBI has been translated into several languages (in short forms as well as full length, and parent as well as self-report); see the External Links section for a link to an extensive repository.

Suggested citations are:

Self report, full length version

Depue, R. A., Slater, J. F., Wolfstetter-Kausch, H., Klein, D. N., Goplerud, E., & Farr, D. A. (1981). A behavioral paradigm for identifying persons at risk for bipolar depressive disorder: A conceptual framework and five validation studies. Journal of Abnormal Psychology, 90, 381-437. https://doi.org/10.1037/0021-843X.90.5.381

and if using specifically in teens:

Danielson, C. K., Youngstrom, E. A., Findling, R. L., & Calabrese, J. R. (2003). Discriminative validity of the General Behavior Inventory using youth report. Journal of Abnormal Child Psychology, 31, 29-39.

Parent report about youth symptoms (full length version):

Youngstrom, E. A., Findling, R. L., Danielson, C. K., & Calabrese, J. R. (2001). Discriminative validity of parent report of hypomanic and depressive symptoms on the General Behavior Inventory. Psychological Assessment, 13, 267-276.

Teacher report (not recommended for clinical use):

Youngstrom, E. A., Joseph, M. F., & Greene, J. (2008). Comparing the psychometric properties of multiple teacher report instruments as predictors of bipolar disorder in children and adolescents. Journal of Clinical Psychology, 64, 382-401. http://dx.doi.org/10.1002/jclp.20462

Sleep scale

Meyers, O. I., & Youngstrom, E. A. (2008). A Parent General Behavior Inventory subscale to measure sleep disturbance in pediatric bipolar disorder. Journal of Clinical Psychiatry, 69, 840-843. https://doi.org/ej07m03594

10 Item Mania and Depression forms

Parent report

Youngstrom, E. A., Van Meter, A. R., Frazier, T. W., Youngstrom, J. K., & Findling, R. L. (2018). Developing and validating short forms of the Parent General Behavior Inventory Mania and Depression Scales for rating youth mood symptoms. Journal of Clinical Child & Adolescent Psychology. https://doi.org/https://doi.org/10.1080/15374416.2018.1491006

Self report

Youngstrom, E. A., Perez Algorta, G., Youngstrom, J. K., Frazier, T. W., & Findling, R. L. (2020). Evaluating and Validating GBI Mania and Depression Short Forms for Self-Report of Mood Symptoms. Journal of Clinical Child & Adolescent Psychology, 1-17.

7 Up-7 Down

Youngstrom, E. A., Murray, G., Johnson, S. L., & Findling, R. L. (2013). The 7 Up 7 Down Inventory: A 14-item measure of manic and depressive tendencies carved from the General Behavior Inventory. Psychological Assessment, 25, 1377-1383. https://doi.org/10.1037/a0033975

Note that the 7 Up has less content coverage, and small but significant differences in reliability and validity compared to the 10 item mania scale. Another practical (and sometimes ethical) consideration is that the 7 Down includes the suicidal ideation item, whereas the 10 item depression short forms do not ask about suicidal ideation.

Other short forms have not been extensively published or replicated.

Scoring and interpretation

GBI scoring

The current GBI questionnaire includes 73 Likert-type items which reflect symptoms of different moods, and six additional validity items at the end. The original version of the GBI used "case scoring" where items were coded as "threshold" or "not at threshold." Symptoms that were rated as 1 or 2 were considered to be absent and symptoms rated as 3 or 4 were considered to be present. However, Likert scaling would be a better scoring option. The items on the GBI are now scaled from 0-3 rated as 0 (never or hardly ever present), 1 (sometimes present), 2 (often present), and 3 (very often or almost constantly present). All versions that we are circulating now use the 0 to 3 anchors. The scoring for the self-report and parent report versions are the same for the full length, sleep, and 10 and 7 item short forms.

The Depression Scale consists of the sum of items:

01, 03, 05, 06, 09, 10, 12, 13, 14, 16, 18, 20, 21, 23, 25,

26, 28, 29, 32, 33, 34, 36, 37, 39, 41, 44, 45, 47, 49, 50, 52,

55, 56, 58, 59, 60, 62, 63, 65, 67, 68, 69, 70, 71, 72, 73.

The Hypomanic/Biphasic scale sums these items:

02, 04, 07, 08, 11, 15, 17, 19, 22, 24, 27, 30, 31, 35, 38, 40, 42, 43, 44, 46, 48, 51, 53, 54, 57, 61, 64, 66. (Note that Depue's scoring includes item 44 on both the depression and the hypomanic/biphasic scale).

To compare scores to data offered by Youngstrom et al. (any publication), just add the items (if scored 0 to 3), or add the items and subtract the number of items on the scale (if scored 1 to 4). To compare scores to college student and adult data (published by Depue, Klein, and others), check carefully whether to use the 0/1 case scoring method versus a form of Likert scoring, as appropriate.

GBI Short Forms

The 7 Up-7 Down has relatively narrow content coverage

There are several short forms that have been carved from the GBI. These include the 10-item mania and depression scales, as well as the 7-item versions (the 7 Up-7 Down scale), and a sleep scale.

For all of these, the score is simply the sum of the items. If these are given as standalone scales, the the 10 item scales are the sum of the ten items.

If the 73-item version is given, then these are the items to extract for each short form:

• Sleep (7 items): 5, 15, 18, 25, 31, 37, 52.
  • 5 and 18 load on a lassitude factor, and 52 crossloads
  • 15, 25, 31, 37 and 52's main loading are on the larger insomnia factor
• 10 item Mania: 53, 54, 4, 11, 22, 40, 27, 19, 64, 31.
• 10 item Depression Form A: 3, 45, 68, 16, 56, 13, 5, 20, 50, 59.
• 10 item Depression Form B: 34, 14, 63, 72, 62, 9, 23, 6, 32, 18).
• 7 Down: 23, 34, 63, 47, 56, 62, 73.
• 7 Up: 22, 31, 30, 64, 43, 46, 38.

The 10 item short forms cover more facets of mood symptoms

• Hypomania (Depue's scoring): 4, 7, 8, 11, 15, 17, 22, 27, 30, 31, 38, 42, 43, 44, 46, 51, 54, 57, 61, 64, 66.
• Mixed (Depue's scoring): 2, 19, 24, 35, 40, 48, 53).

Note that researchers have used other sets of items as short forms.

A sortable table below shows the overlap between items across the different forms, along with the item content:

Additional research versions:

• LAMS 12 Item self report: 52, 40, 44, 59, 19, 29 (factor 1); 11, 7, 31, 38, 22, 4 (factor 2).
• Lewinsohn used a 12 item version in the Oregon epidemiological study: 4, 8, 11, 15, 30, 44, 51, 64 (all from Depue's hypomanic set); 2, 19, 24, 48 (from Depue's mixed set). Boldfaced items overlap with the 10M scale and could be used in a calibration study.
• Jensen et al. rationally derived a 7 item impulsive aggression scale: 27, 42, 44, 51, 14, 39, 53, 54.

Item #	Variable	Depue 2 scale	Depue 3 scale	7Up-7D	Sleep	10 item Forms	LAMS 12	Impulsive Aggression	Parcel	Parcel Label	Content
22	agbi22	HB	hyp	u		M	F2		4	elated mood	Has your child had periods of extreme happiness and intense energy lasting several days or more when he/she also felt much more anxious or tense (jittery, nervous, uptight) than usual (other than related to the menstrual cycle)?
31	agbi31	HB	hyp	u	sleep	M	F2		4	elated mood	Has your child had periods of extreme happiness and intense energy (clearly more than his/her usual self) when, for several days or more, it took him/her over an hour to get to sleep at night?
64	agbi64	HB	hyp	u		M			7	racing thoughts, cog disturb (up)	Has your child had times when his/her thoughts and ideas came so fast that he/she couldn’t get them all out, or they came so quickly others complained that they couldn’t keep up with your child ideas?
4	agbi04	HB	hyp			M	F2		3	Increased energy	Has your child experienced periods of several days or more when, although he/she was feeling unusually happy and intensely energetic (clearly more than your child’s usual self), he/she was also physically restless, unable to set still, and had to keep moving or jumping from one activity to another?
11	agbi11	HB	hyp			M	F2		5	high drive	Have there been periods of several days or more when your child’s friends or other family members told you that your child seemed unusually happy or high – clearly different from his/her usual self or from a typical good mood?
19	agbi19	HB	mix			M	F1		2	Mood never in middle	Has your child’s mood or energy shifted rapidly back and forth from happy to sad or high to low?
27	agbi27	HB	hyp			M		ImpAgg	6	rage, manic irritability	Have there been times of several days or more when, although your child was feeling unusually happy and intensely energetic (clearly more than his/her usual self), he/she also had to struggle very hard to control inner feelings of rage or an urge to smash or destroy things?
40	agbi40	HB	mix			M	F1		2	Mood never in middle	Have you found that your child’s feelings or energy are generally up or down, but rarely in the middle?
53	agbi53	HB	mix			M		ImpAgg	2	Mood never in middle	Has your child had periods lasting several days or more when he/she felt depressed or irritable, and then other periods of several days or more when he/she felt extremely high, elated, and overflowing with energy?
54	agbi54	HB	hyp			M		ImpAgg	6	rage, manic irritability	Have there been periods when, although your child was feeling unusually happy and intensely energetic, almost everything got on his/her nerves and make him/her irritable or angry (other than related to the menstrual cycle?
23	agbi23	dep	dep	d		Db			9	feels sad	Have there been times of several days or more when your child was so sad that it was quite painful for him/her, or he/she felt that he/she couldn’t stand it?
34	agbi34	dep	dep	d		Db			18	rumination(?)	Over the past year, have there been long periods in your child’s life when he/she felt sad, depressed, or irritable most of the time?
62	agbi62	dep	dep	d		Db			10	hopeless, low self-esteem	Has your child had periods when it seemed that the future was hopeless and things could not improve?
63	agbi63	dep	dep	d		Db			9	feels sad	Have there been periods lasting several days or more when your child was so down in the dumps that he/she thought he/she might never snap out of it?
6	agbi06	dep	dep			Db			20	tearful, sad appearance	Have people said that your child looked sad or lonely?
9	agbi09	dep	dep			Db			11	loss of interest	Have there been periods lasting several days or more when your child lost almost all interest in people close to him/her and spent long times by himself/herself?
14	agbi14	dep	dep			Db		ImpAgg	15	dep irritable mood	Has your child had periods of sadness and depression when almost everything gets on his/her nerves and makes him/her irritable or angry (other than related to the menstrual cycle)?
18	agbi18	dep	dep		sleep	Db			19	atypical dep features	Have there been times of several days or more when your child was so tired and worn out that it was very difficult or even impossible to do his/her normal everyday activities (not including times of intense exercise, physical illness, or heavy work schedules)?
32	agbi32	dep	dep			Db			18	rumination	Over the past year, have there been times when your child looked back over his/her life and could see only failures or hardships?
72	agbi72	dep	dep			Db			18	rumination	Have there been periods of time when your child felt a persistent sense of gloom?
56	agbi56	dep	dep	d		Da			10	hopeless, low self-esteem	Have there been times of several days or more when your child really got down on himself/herself and felt worthless?
3	agbi03	dep	dep			Da			9	feels sad	Has your child become sad, depressed, or irritable for several days or more without really understanding why?
5	agbi05	dep	dep		sleep	Da			14	sleep disturb (dep)	Have there been periods of several days or more when your child felt he/she needed more sleep, even though he/she slept longer at night or napped more during the day (not including times of exercise, physical illness, or heavy work schedules)?
13	agbi13	dep	dep			Da			11	loss of interest	Have there been times when your child lost almost all interest in the things that he/she usually likes to do (such as hobbies, school, work, entertainment)?
16	agbi16	dep	dep			Da			17	somatic sx (appetite & sleep)	Has your child had long periods in which he/she felt that he/she couldn’t enjoy life as easily as other people?
20	agbi20	dep	dep			Da			18	rumination	Have there been periods lasting several days or more when your child spent much of his/her time brooding about unpleasant things that have happened?
45	agbi45	dep	dep			Da			9	feels sad	Over the past year, have there been times of several days or more when your child was so down that nothing (not even friends or good news) could cheer him/her up?
50	agbi50	dep	dep			Da			16	excess guilt & paranoia	Has your child had sad and depressed periods lasting several days or more when he/she also felt much more anxious or tense (jittery, nervous, uptight) than usual (other than related to the menstrual cycle)?
59	agbi59	dep	dep			Da	F1		12	low energy/anhedonia	Have there been periods of several days or more when your child was slowed down and couldn’t move as quickly as usual?
68	agbi68	dep	dep			Da			19	atypical dep features	Has your child had long periods when he/she was down and depressed, interrupted by brief periods when his/her mood was normal or slightly happy?
30	agbi30	HB	hyp	u					4	elated mood	Have there been times lasting several days or more when your child felt he/she must have lots of excitement, and he/she actually did a lot of new or different things?
38	agbi38	HB	hyp	u			F2		8	grandiosity	Has your child had periods of extreme happiness and high energy lasting several days or more when what your child saw, heard, smelled, tasted, or touched seemed vivid or intense?
43	agbi43	HB	hyp	u					8	grandiosity	Have there been periods of several days or more when your child’s thinking was so clear and quick that it was much better than most other people’s?
46	agbi46	HB	hyp	u					8	grandiosity	Have there been times of several days or more when your child felt that he/she was a very important person or that his/her abilities or talents were better than most other people’s?
47	agbi47	dep	dep	d					10	hopeless, low self-esteem	Have there been times when your child hated himself/herself or felt that he/she was stupid, ugly, unlovable, or useless?
73	agbi73	dep	dep	d					10	hopeless, low self-esteem	Have there been times when your child felt that he/she would be better off dead?
1	agbi01	dep	dep						13	cog disturb (dep)	Have there been periods in your child’s life over the past year when it was almost impossible to make small decisions even though this may not be generally true of him/her?
2	agbi02	HB	mix						1	Extremes  of Mood & Energy	Have you found your child’s enjoyment in being with people changes -- from times when he/she enjoys them immensely and wants to be with them all the time, to times when he/she does not want to see them at all?
7	agbi07	HB	hyp				F2		3	Increased energy	Have there been periods of several days or more when your child was almost constantly active such that others told you they couldn’t keep up with him/her or that he/she wore them out?
8	agbi08	HB	hyp						7	racing thoughts, cog disturb (up)	Have there been periods of several days or more when your child could not keep his/her attention on any one thing for more than a few seconds, and his/her mind jumped rapidly from one thought to another or to things around him/her?
10	agbi10	dep	dep						11	loss of interest	Has your child had periods of several days or more when food seemed rather flavorless and he/she didn’t enjoy eating at all?
12	agbi12	dep	dep						13	cog disturb (dep)	Have there been times when your child’s memory or concentration seemed especially poor and he/she found it difficult, for example, to read or follow a TV program, even though he/she tried?
15	agbi15	HB	hyp		sleep				3	Increased energy	Have there been times of several days or more when your child did not feel the need for sleep and was able to stay awake and alert for much longer than usual because he/she was full of energy?
17	agbi17	HB	hyp						5	high drive	Has your child had periods of several days or more when he/she wanted to be with people so much of the time that they asked your child to leave them alone for awhile?
21	agbi21	dep	dep						12	low energy/anhedonia	Have there been times when your child felt that he/she was physically cut off from other people or from himself/herself, or felt as if he/she was in a dream, or felt that the world looked different or had changed in some way?
24	agbi24	HB	mix						1	Extremes  of Mood & Energy	Have you found that your child’s enjoyment in eating changes – from periods of two or more days when food tastes exceptionally good, clearly better than usual, to other periods of several days or more when food seems rather flavorless and perhaps your child doesn’t enjoy eating at all?
25	agbi25	dep	dep		sleep				14	sleep disturb (dep)	Have there been times of several days or more when your child wakes up much too early in the morning and has problems getting back to sleep?
26	agbi26	dep	dep						19	atypical dep features	Has your child had periods when he/she was so down that he/she found it hard to start talking or that talking took too much energy?
28	agbi28	dep	dep						20	tearful, sad appearance	Have there been periods other than when your child was physically ill that he/she had more than one of the following:
29	agbi29	dep	dep				F1*		16	excess guilt & paranoia	Has your child experienced periods of several days or more when he/she was feeling down and depressed, and he/she also was physically restless, unable to sit still, and had to keep moving or jumping from one activity to another?
33	agbi33	dep	dep						12	low energy/anhedonia	Has your child experienced times of several days or more when he/she felt as if he/she was moving in slow motion?
35	agbi35	HB	mix						1	Extremes  of Mood & Energy	Has it seemed that your child experiences both pleasurable and painful emotions more intensely than other people?
36	agbi36	dep	dep						16	excess guilt & paranoia	Have there been periods of several days or more when your child felt guilty and thought he/she deserved to be punished for something he/she had or had not done?
37	agbi37	dep	dep		sleep				14	sleep disturb (dep)	Has your child had times of several days or more when he/she woke up frequently or had trouble staying asleep during the middle of the night?
39	agbi39	dep	dep					ImpAgg	15	dep irritable mood	Have there been times when your child was feeling low and depressed, and he/she also had to struggle very hard to control inner feelings of rage or an urge to smash or destroy things?
41	agbi41	dep	dep						13	cog disturb (dep)	Has your child had periods of several days or more when it was difficult or almost impossible to think and his/her mind felt sluggish, stagnant, or “dead”?
42	agbi42	HB	hyp					ImpAgg	5	high drive	Have there been times when your child had a strong urge to do something mischievous, destructive, risky, or shocking?
44	agbi44	dep	dep				F1	ImpAgg	6	rage, manic irritability	Have there been times when your child exploded at others and afterwards felt bad about himself/herself?
48	agbi48	HB	mix						1	Extremes  of Mood & Energy	Have you found that your child’s thinking changes greatly – that there are periods of several days or more when he/she thinks better than most people, and other periods when his/her mind doesn’t work well at all?
49	agbi49	dep	dep						12	low energy/anhedonia	Have there been times of a day or more when your child had no feelings or emotions and seemed cut off from other people?
51	agbi51	HB	hyp						5	high drive	Have there been times when your child has done things – like perhaps driving recklessly, taking a trip on the spur of the moment, creating a public disturbance, being more sexually active than usual, getting into fights, destroying property, or getting into trouble with the law – which he/she later thought showed poor judgment?
52	agbi52	dep	dep		sleep		F1		14	sleep disturb (dep)	Has your child had periods of sadness and depression when, for several days or more, it took him/her over an hour to get to sleep at night, even though he/she was very tired?
55	agbi55	dep	dep						15	dep irritable mood	Have there been times when upsetting or bad thoughts kept going through your child’s mind and he/she couldn’t stop them?
57	agbi57	HB	hyp						7	racing thoughts, cog disturb (up)	Have there been times when your child had blank spells in which his/her activities were interrupted, and he/she did not know what was going on around him/her?
58	agbi58	dep	dep						19	atypical dep features	Has your child had sad and depressed periods of several days or more, interrupted by periods lasting between an hour to a day when he/she felt extremely happy and intensely energetic?
60	agbi60	dep	dep						17	somatic sx (appetite & sleep)	Has your child experienced weight changes (increases, decreases, or both) of five (5) pounds or more in short periods of time (three weeks or less), not including changes due to physical illness, menstruation, exercise, or dieting?
61	agbi61	HB	hyp						8	grandiosity	Have there been periods of a couple days or more when your child’s sexual feelings and thoughts were almost constant, and he/she couldn’t think about anything else?
65	agbi65	dep	dep						17	somatic sx (appetite & sleep)	Have there been times of several days or more when your child felt very down and depressed during the early part of the day, but then less so during the evening?
66	agbi66	HB	hyp						4	elated mood	Have then been times when your child began many new activities with lots of enthusiasm and then found himself/herself quickly losing interest in them?
67	agbi67	dep	dep						17	somatic sx (appetite & sleep)	Have you found that your child’s mood consistently follows the seasons, where he/she has long periods of depression during the winter but mostly happy periods during the summer?
69	agbi69	dep	dep						20	tearful, sad appearance	Have there been times of several days or more when your child has struggled to control an urge to cry, has had frequent crying spells, or found himself/herself crying without really understanding why (other than related to the menstrual cycle)?
70	agbi70	dep	dep						11	loss of interest	Have there been times of several days or more when almost all sexual interest was lost?
71	agbi71	dep	dep						16	excess guilt & paranoia	Has your child found himself/herself at times feeling fearful or suspicious or his/her environment or people around him/her?

Reliability

For all versions of the GBI, the full length scales have exceptionally high internal consistency reliability. This is due to a combination of the scale length (28 or 46 items) and the items asking about related symptoms, often in blends. The length of the scales and the high reading level make them less useful in many clinical settings. Item Response Theory (IRT) provides a different way of estimating the reliability of test scores that is not tied to the length of the scale. The IRT approach also has the advantage of seeing how reliable scores are across the range of the underlying trait. For the GBI, IRT would show whether the reliability stays at acceptable levels even at low levels of depression or manic symptoms (as would often be seen if using the scale in a general community setting or screening), as well as at the high end of mood symptom severity (as might be encountered in a hospital).

These figures compare the reliability for several of the short forms based on self report (i.e., teenagers using the GBI to describe themselves).

Item Response Theory (IRT) estimates of reliability for self-report on the GBI

10 Item Short Forms	7 Item Short Forms

The GBI or P-GBI for assessing the probability of mood disorders

The diagnostic accuracy of the test depends on the base rate of disorders for your sample. The positive and negative predictive value are directly influenced by base rate. However, the sensitivity and specificity of a test also can vary from sample to sample (Kraemer, 1992). For this reason, the cut scores published in any article cannot be assumed to be equally valid in new contexts. Please refer to the GBI Manual (available from Depue) and the monograph published in the Journal of Abnormal Psychology, for additional information about the measure. Two meta-analyses have included the GBI, one in youths under age 18, and the other as a self-report measure in adults. The GBI was in the top tier of measures in terms of diagnostic accuracy in both meta-analyses. However, the short forms have not had their diagnostic accuracy published in adult samples (i.e., all published work used the 73 item version).

Bipolar disorder is rare in most clinical settings (e.g., prevalence of less than 10% in outpatient and private practices, and 2-4% in the general population). Because of the low “base rate,” most people scoring high on any screening test are likely to not have the condition. Put another way, the “false positives” will outnumber the “true positives” in most situations unless bipolar disorder is fairly common where one is using the test.

Nomogram for combining likelihood ratios and probabilities

The preferred method for using these tools would be to focus on the change in likelihood of a bipolar diagnosis based on high and low scores. Low scores on a good test decrease the odds that a given youth has a bipolar disorder, just as high scores should increase the odds. It is possible to formally combine (1) the change in odds associated with a test score and (2) the prior probability that the youth had a bipolar diagnosis to obtain a new estimate of the probability that the child has bipolar disorder. This can be done visually (using a “nomogram”), mathematically, by use of a table containing the posterior probabilities for a fixed prevalence, or using an online calculator. There are several excellent sources for clinicians who are interested in learning more about using changes in odds as a way of refining diagnosis, including the Prediction section in the materials about Evidence Based Assessment on Wikiversity.

The changes in odds (or diagnostic likelihood ratios) associated with scores on six different tests (the P-GBI, the P-YMRS, the Achenbach CBCL, TRF, and YSR, and the self-report GBI) based on a large sample of outpatients, and an update based a more recent review is available. We also are including a table here that is based on these likelihood ratios, estimating the probability that a child has bipolar disorder assuming a base rate of 5% in combination with a test score in the particular range. We chose the 5% base rate estimate for three reasons: (1) because other colleagues are estimating that 5% of the youths evaluated at outpatient academic research centers meet criteria for a bipolar spectrum disorder (e.g., 6-7% of outpatient cases evaluated in the TEAM multi-site NIMH grant; Geller et al., 2002); (2) because 5% is low enough to serve as a reminder that bipolar disorder is likely to be rare in community mental health, outpatient, and private practice settings, yet high enough to act as a reminder that the disorder can occur and should be assessed; (3) because a 5% base rate will be reduced to negligible probabilities by low or moderate scores on good tests, and raised to intermediate probabilities (30% to 50% range) by high scores on the same tests.

If bipolar disorder is substantially more rare or more common at your site than 5%, we strongly recommend using a rate compared to benchmarks from similar settings as the starting point.

Teenager or young adult filling out a version of GBI about themselves

Target Diagnosis:	Bipolar	Bipolar	Bipolar	Any Mood
Scale	MDQ	GBI-10M	7 Up	GBI-10Da
Shortest	12	10	7	10
Reading Levela	7.3	11.1	11.1	11.1
Languages	13+	25+	4+	25+
Projected d	.40	.43	.36
Projected AUC (95% CI)	.61 (.54 to .67)	.62 (.58 to .67)	.60 (.56 to .65)	.66 (.62 to .70)
Sensitivity at Specificity=.9	.20	.22	.20	.23
DiLR+	2.0 raw 9+	2.2 raw 19+	2.0 raw 11+	2.3 raw 16+
Time Frame	Lifetime	Past year	Past year	Past year

^aFlesch-Kincaid estimate of grade level.

Parent or primary caregiver using GBI to describe their youth's mood symptoms

Target Diagnosis:	Bipolar	Bipolar	Bipolar	Any Mood
Scale	PGBI-10M	CMRS	FIRM	PGBI-10Da
Length (items)	10*	10*	1/2 page	10*
Reading Levela	11.1	6.5	7.6	11.1
Languages	25+	5	2	25+
Projected d	1.30	.87	.47	1.30
Projected AUC (95% CI)	.82 (.80 to .84)	.73 (.66 to .80)	.63 (.54 to .72)	.82 (.80 to .84)
Sensitivity at Specificity=.9	.47	.21	.28	.52
DiLR+	4.7 raw 15.5+	2.1 raw 12+	2.8 raw 8+	5.2 raw 10+
Time Frame	Past year	Lifetime	Lifetime (family history)	Past year

Using the GBI to measure treatment response

The GBI has been used in several treatment studies, and it shows good sensitivity to treatment effects. The 10 item versions in particular are brief enough to be repeated during the course of treatment, but show similar effect sizes to interview-based ratings in research studies. The 7 Up-7 Down scales have not been tested in an extracted, standalone format in treatment studies yet.

Here are benchmarks for evaluating change during treatment:

	Benchmarks*			Critical Change (Raw Scores)			Minimal Important Difference
Measure	Away	Back	Closer	95%	90%	SEdifference	(MID) d ~.5
PGBI-10Ma	1	9	6	6	5	3.2	3
PGBI-10Daa	--	7	4	6	5	3.0	3
PGBI-10Dba	--	7	4	6	5	2.9	3
AGBI-10Mc	--	14	7	6	5	3.1	3
AGBI-10Dac	--	18	7	6	5	3.2	3
AGBI-10Dbc	--	16	7	6	5	2.9	4
7 Upc	--	8	4	4	4	2.2	3
7 Downc	--	12	5	5	4	2.3	3

*The benchmarks are based on clinical and nonclinical norms, following the "clinically significant change" model by Jacobson and colleagues.

Interpretive example for measuring treatment progress and outcome

Juan's mother fills out a PGI-10M and PGBI-10Da as part of an evaluation. Both of these have raw scores that range from 0 to 30. Juan initially scores a 21, which is in a high risk range for potential bipolar disorder. After the feedback and first therapy session, the score comes down to a 17 (4 point drop). This is larger than the "Minimally Important Difference" (MID) of 3, suggesting that this is large enough for the person to believe that treatment might be helping some.

However, the amount of change needed to be be confident that treatment is actually contributing to reliable change would need to be larger: The 95% confidence in change target is 6 points for this measure (equating to a reliable change index > 1.96 in Jacobson's approach).

After several months of treatment, Juan's score according to his mother's report is down to a 7. This is enough to be confident that treatment is helping. The 14 point reduction (21-7 = 14 point difference) not only exceeds the targets for MID and reliable change, but it also is lower than the "Back" into the normal range threshold of 9. The Back threshold is the 95th percentile for a reference group without bipolar disorder (in this case often with other mild or moderate clinical issues, as there is no nonclinical standardization sample for the PGBI, like most clinical symptom assessments). Scores this high are likely to still be noticeable and may be concerning to others, but they are also within the range of what could also occur for other reasons besides having a bipolar disorder, including problems in daily living as a youth or adult. The Back threshold is the most liberal of the "clinically significant change" definitions proposed by Jacobson and colleagues.

Reducing the score to a 6 or lower would satisfy Jacobson's "Closer" definition -- reliable change combined with a score more typical of the nonbipolar than bipolar reference groups (operationally defined as the weighted mean of the two groups). Again, scores of 5-6 may be noticeable and sometimes irritating, but they also are a marked improvement compared to where Juan started. This would be an even more impressive example of clinically significant change.

If treatment continued and succeeded in getting his score down to a 0 or 1, that would not only show near complete elimination of the symptoms, but it also would satisfy Jacobson's most stringent definition of clinically significant change -- getting the score Away from the clinical reference group (e.g., below the 2.5th percentile of the clinical reference group). This is an exceptionally stringent definition, and impossible to achieve with many outcome measures, where two SDs below average would require negative raw scores.

Evidence Base

Peer Reviewed Research

The first paper published on the GBI was in 1981, and research has appeared steadily since then. The GBI consistently has exceptional evidence of reliability, due to its combination of length and well-written (but complex) items. It has showed excellent evidence of discriminative validity in two meta-analyses, one focused on self-report in adults and the other looking at performance with children and teenagers. Miller et al. (2009) noted, in their review of assessment instruments for adult bipolar spectrum disorders:

As a diagnostic screening tool, the scale with the best support is the GBI, as it has consistently demonstrated sensitivity of approximately .75 and specificity above .97. Readers should be cautious, however, because multiple versions of the scale exist, and cutoffs for a positive screen have not been firmly established.

PubMed Search: Click here for a current search on PubMed, a free database that covers medicine (so some articles published in psychology journals might be missing). The entries will usually include abstracts, and sometimes will include a version of full text (especially if the project was grant funded). The search is designed to be highly specific (i.e., not including lots of irrelevant articles), but it might miss some articles.

Languages Available

The GBI has been translated into multiple languages. Some of the different languages available are linked here.

There is a repository that includes many of these here. An older version of this subset is hosted on Trello here. If you are looking here, note that there are separate columns for the 7 Up-7 Down, General Behavior Inventory (self-report), and parent report versions.

Research Resources

Scoring syntax to make all of the above scales is available in SPSS in the OTOPS project. We are working on making a version available in R as well.

The code will work with any informant or language, provided that the variable names are the same. Because there are different versions of the GBI available on the Internet, please be careful to check that the content and order of the items is the same in the version you are using as in the 73 (+6 validity items) version that we used as the basis for the code. A second caveat is to check whether item level scores are typed in as 0 to 3 (the newer format) versus 1 to 4 (the original format).

If your institution has a Qualtrics license, you can import these .QSF files and have the survey read to launch out of the box, or you can customize it for your project.

Set of QSF files here. (*** upload to OSF and drop link to here).

Supplemental Materials

Two papers that tested several short forms when used as parent report and as adolescent self report included supplemental materials that provided more detail about methods and results. These supplemental materials are published here so that they are freely accessible and archived (rather than having them only behind a publisher's paywall).

Factor Structure of the Short Forms

Tables

Rationale for the Ranking of Expected Criterion Correlations

Both papers had two samples, an academic clinic and a community mental health center, along with a large set of variables that could be used to examine the criterion validity of the short forms compared to the full length GBI scales.

Here is the detailed description of how the authors ranked the criterion correlations from what they expected to be largest to smallest:

The GBI scales were expected to show the highest correlation with the cognate rating scale on the Youth Self Report (YSR) because they were converging measures of the same trait, they were completed by the same informant (i.e., they shared method variance)(Podsakoff, MacKenzie, & Podsakoff, 2012), and they were continuous scales (not categorical variables, which would shrink the size of the observed correlation even when measuring the same construct) (Cohen, 1988).

The YSR Internalizing score was expected to show the highest correlation because of the shared method variance: both it and the GBI were completed by the same person. They would be expected to correlate r ~.3 to .4 even if they measured different constructs, due to response set, mood congruent biases, and other factors unrelated to the trait (Podsakoff et al., 2012). Further, Internalizing and Externalizing correlate r ~.6 in the standardization sample (Achenbach & Rescorla, 2001) and also in our samples. Finally, the 28-item and 10-item GBI versions included some “mixed” items, and so they had depression content embedded in them. The 7 Up, in contrast, was “purer” and showed lower correlations with Internalizing in both samples (though still > .4).

The YSR Externalizing score was the best available converging measure for the mania scales in the two samples, but it was not expected to show quite as high criterion correlations as the depression-Internalizing coefficients. A meta-analysis (Youngstrom, Genzlinger, Egerton, & Van Meter, 2015) of diagnostic accuracy shows that Externalizing is not as strongly associated with bipolar disorder as the GBI is: The effect size was r ~.45 for parent ratings on measures like the GBI, versus r ~.34 for measures such as the CBCL Externalizing; r ~.26 for GBI versus r ~ .13 for YSR correlations with diagnoses. The Externalizing score does not include items asking about grandiosity, inflated self-esteem, elevated or expansive mood, or decreased need for sleep without fatigue – the “handle” symptoms that are more specific to hypomania and mania (Craney & Geller, 2003; Youngstrom, Birmaher, & Findling, 2008). Put simply, Externalizing is not as good a measure of the mania construct as the GBI scales are, so the criterion correlation with it is not going to be stellar.

Next, the youth and parent correlations use different sources, eliminating the shared method variance component. Meta-analyses find that parent-youth agreement about the same trait in the youth hovers in the r ~.2 to .3 range (Achenbach, McConaughy, & Howell, 1987; De Los Reyes et al., 2015), exactly what we see in the Academic sample and similar to the estimates in the Community sample.

For the correlations with the diagnoses and interview-based severity ratings: Meta-analyses have established that parent report is significantly more strongly related to youth diagnoses than youth self-report is (Stockings et al., 2015; Youngstrom et al., 2015). Converting the effect sizes from Youngstrom et al. 2015 into correlations yields an estimate of r ~ .45 for parent ratings and corresponding youth diagnoses, versus .26 for youth ratings and their own diagnoses. The same pattern will hold for the YMRS and CDRS-R as the diagnoses – they were based on the same interview as the KSADS diagnoses, and so they correlate with the diagnosis r > .9. Because of attenuation artifacts when using a categorical variable (i.e., diagnosis) instead of a continuous one (i.e., severity on the YMRS or CDRS-R), we would expect the correlations with diagnosis to be about 80% of the size of the correlation with the severity rating (Cohen, 1988).

Depression scores were expected to show a small to moderate correlation with age as well as with female sex based on normative data (e.g., patterns in Internalizing scores in the standardization sample for the ASEBA; Achenbach & Rescorla, 2001). Anxiety diagnoses were expected to show a small to moderate correlation with depression scales due to overlapping symptoms (e.g., the tripartite model of depression and anxiety) (Chorpita & Daleiden, 2002; Watson, Clark, et al., 1995; Watson, Weber, et al., 1995).

Last in the rankings were some demographic variables (e.g., race) and unrelated diagnoses that were expected to have near-zero correlation coefficients.

External Links

• The Open Translations Project (TOpTraP) -- an effort to gather the translated versions of the best free measures in one place. The GBI 10 item mania and depression scales are available in more than two dozen languages; the full length version is available in several.
• EffectiveChildTherapy.Org information on Bipolar Disorder -- a website built for families to learn more about ways to improve social, emotional, and academic life for youths
• Society of Clinical Child and Adolescent Psychology -- the professional society for psychologists focusing on helping youths and families dealing with emotional and behavioral challenges

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