Screening for Bipolar Disorder Flavio Guzmán, MD

Outline Why is it important? Why do we miss the diagnosis of BD? Three critical aspects to include in any bipolarity evaluation The DIGFAST mnemonic Screening instruments: MDQ and BSDS

Why is an accurate diagnosis important? Delayed diagnosis Progression of comorbidities Substance abuse Less effective treatments Pharmacological Psychosocial Vieta, E. (2013). Managing bipolar disorder in clinical practice. London: Springer Healthcare.

Why do we miss the diagnosis of bipolar disorder? Not asking about manic and hypomanic symptoms Not including a family member in evaluation Clinician factors Depressive episodes last longer than hypomanic episodes Illness factors Lack of insight about mania and hypomania Patient factors Goodwin, F., Jamison, K. & Ghaemi, S. (2007). Manic-depressive illness : bipolar disorders and recurrent depression. Oxford University Press.

Some interviewing challenges False positives Normal mood variations Ask about other people’s perceptions Diagnostic criteria at different points Keep referring to defined period of time Carlat, D. (2012). The psychiatric interview : a practical guide. Philadelphia, PA: Lippincott Williams & Wilkins.

Three aspects to consider in a screening History of hospitalization Interview with relatives and friends Family history of bipolar disorder Goodwin, F., Jamison, K. & Ghaemi, S. (2007). Manic-depressive illness : bipolar disorders and recurrent depression. Oxford University Press.

Use the mnemonic “DIGFAST” Distractibility Indiscretion Grandiosity Flight of ideas Activity increase Sleep deficit Talkativeness Carlat, D. (2012). The psychiatric interview : a practical guide. Philadelphia, PA: Lippincott Williams & Wilkins.

Screening Instruments

Screening instruments Types of scales Screening instruments Symptom rating scales Helpful for efficient screening of patients with depression If positive, perform more comprehensive evaluation Monitor mood status over time Response to treatment MDQ BSDS Depression: HAM-D, MADRS Mania: Young Mania Rating Scale (YMRS) Bech Rafaelsen Mania Rating Scale (MAS) Yildiz, A. (n.d.). (2015).The bipolar book: History, neurobiology, and treatment. (1st ed.). New York, N.Y.: Oxford University Press.

Screening instruments Types of scales Screening instruments Symptom rating scales Helpful for efficient screening of patients with depression If positive, perform more comprehensive evaluation Monitor mood status over time Response to treatment MDQ BSDS Depression: HAM-D, MADRS Mania: Young Mania Rating Scale (YMRS) Bech Rafaelsen Mania Rating Scale (MAS) Yildiz, A. (n.d.). (2015).The bipolar book: History, neurobiology, and treatment. (1st ed.). New York, N.Y.: Oxford University Press.

Mood Disorder Questionnaire Self-rated screening instrument 13 questions about manic and hypomanic symptoms Yes/No format 5 minutes Miller, C. J, et al  (2009). Assessment tools for adult bipolar disorder. Clinical Psychology: Science and Practice, 16(2), 188-201.

Mood Disorder Questionnaire Self-rated screening instrument 13 questions about manic and hypomanic symptoms Yes/No format 5 minutes More than 7 items Positive screen Bipolar disorder assessment Miller, C. J, et al  (2009). Assessment tools for adult bipolar disorder. Clinical Psychology: Science and Practice, 16(2), 188-201.

Mood disorder questionnaire (MDQ) Sensitivity Specificity 0.7 0.9 10 patients with BD 7 correctly diagnosed 3 would be missed 10 patients without BD 9 successfully ruled out 1 false positive Miller, C. J, et al  (2009). Assessment tools for adult bipolar disorder. Clinical Psychology: Science and Practice, 16(2), 188-201.

Better performance in inpatient settings than in community Limitations of the MDQ Better performance in inpatient settings than in community MDQ may capture common experiences Less commonly endorsed in inpatient settings Miller, C. J, et al  (2009). Assessment tools for adult bipolar disorder. Clinical Psychology: Science and Practice, 16(2), 188-201.

Bipolar Spectrum Diagnostic Scale (BSDS) Originally designed to improve detection of BD II Written in story format 19 sentences that describe symptoms 10 minutes to complete Ghaemi, S. N.,et al (2005). Sensitivity and specificity of a new bipolar spectrum diagnostic scale. Journal of affective disorders, 84(2), 273-277

General instructions for the BSDS Read the 19 sentences in the passage First scoring How much the entire passage describes you: very well, fairly well, to some degree but not most or not at all Go back and put a check after each sentence that describes you Second scoring: 1 point per sentence Ghaemi, S. N.,et al (2005). Sensitivity and specificity of a new bipolar spectrum diagnostic scale. Journal of affective disorders, 84(2), 273-277

General instructions for the BSDS Read the 19 sentences in the passage First scoring How much the entire passage describes you: very well, fairly well, to some degree but not most or not at all Go back and put a check after each sentence that describes you Second scoring: 1 point per sentence Ghaemi, S. N.,et al (2005). Sensitivity and specificity of a new bipolar spectrum diagnostic scale. Journal of affective disorders, 84(2), 273-277

The BSDS informs about the likelihood of BD Range Likelihood of bipolar disorder 20-25 Highly likely 13-19 Moderate probability 7-12 Low probability 0-6 Highly unlikely Ghaemi, S. N.,et al (2005). Sensitivity and specificity of a new bipolar spectrum diagnostic scale. Journal of affective disorders, 84(2), 273-277

BSDS sensitivity and specificity 0.76 (BD I and BD II) 0.85 0.75 BDI 0.79 BDII Ghaemi, S. N.,et al (2005). Sensitivity and specificity of a new bipolar spectrum diagnostic scale. Journal of affective disorders, 84(2), 273-277

Key points Importance of: Consider using a screening instrument Hospitalization history Positive family history Interviewing a relative or close friend Consider using a screening instrument MDQ or BSDS BSDS Captures subtle bipolar symptoms Informs about the likelihood of bipolar disorder