What are the recommended screening questions and tools for diagnosing bipolar disorder?

Recommended Screening Questions and Tools for Bipolar Disorder

Psychiatric assessments should include specific screening questions for bipolar disorder that focus on distinct, spontaneous periods of mood changes associated with sleep disturbances and psychomotor activation. 1

Key Screening Questions

Effective bipolar disorder screening should focus on identifying the cardinal features of manic or hypomanic episodes:

1. Questions about mood changes:

   • Have you experienced distinct periods of elevated, expansive, or irritable mood?
   • Have these mood changes been clearly different from your normal self?
   • How long did these periods last? (Hours, days, weeks)

2. Questions about associated symptoms during these periods:

   • Did you experience decreased need for sleep without feeling tired?
   • Did you feel more talkative than usual or pressure to keep talking?
   • Did you have racing thoughts or feel your thoughts were speeding up?
   • Were you more distractible than usual?
   • Did you engage in activities with potential painful consequences (spending sprees, sexual indiscretions, foolish business investments)?
   • Did you feel increased energy or goal-directed activity?
   • Did you feel unusually self-confident or have grandiose ideas?

3. Questions about impact:

   • Did these symptoms cause problems in your relationships, work, or other important areas?
   • Did these symptoms lead to hospitalization?
   • Did these symptoms include psychotic features (delusions or hallucinations)?

Validated Screening Tools

Several validated screening instruments can be used to supplement clinical questioning:

1. Mood Disorder Questionnaire (MDQ):

   • Most widely studied screening instrument for bipolar disorder 2
   • Better at detecting bipolar I than bipolar II disorder (sensitivity 66.3% vs 38.6%) 2
   • Optimal cutoff is co-occurrence of four symptoms with omission of the impairment criterion 3
   • When used for screening purposes, a lower threshold (score of 5) may be more appropriate to achieve adequate sensitivity 4

2. Hypomania Checklist-32 (HCL-32):

   • Shows better psychometric performance and discriminatory capacity than the MDQ 3
   • Optimal cutoff is 11 affirmative responses 3
   • Higher internal consistency and better test-retest reliability than MDQ 3

3. Mood Swings Questionnaire (MSQ):

   • Demonstrates superior sensitivity and specificity compared to MDQ 5
   • Available in both 46-item and 27-item versions

Clinical Risk Factors to Assess

Important clinical factors that should prompt more thorough screening:

1. Family history:

   • Family history of bipolar disorder is strongly associated with increased risk (odds ratio=4.93) 3
   • Combined use of HCL-32 and family history assessment provides the best approach for detecting previously unrecognized bipolar disorder 3

2. Previous depressive episodes:

   • Patients with history of depression should be screened for bipolar disorder
   • Up to 50% of patients with bipolar disorder are initially misdiagnosed 2

3. Age of onset:

   • Early-onset depression (adolescence/early adulthood) has higher likelihood of bipolar disorder

4. Response to antidepressants:

   • Poor response or manic/hypomanic switch with antidepressants

Diagnostic Considerations

After positive screening, follow these diagnostic principles:

1. Follow DSM criteria including duration:

   • Manic episode: ≥7 days (or any duration if hospitalization required)
   • Hypomanic episode: ≥4 days
   • Use Bipolar Disorder NOS for symptoms lasting hours to less than 4 days 1

2. Assess for differential diagnoses:

   • Manic-like symptoms can occur in disruptive behavior disorders, PTSD, and developmental disorders 1
   • Distinguish between situational reactions and true mood episodes
   • Rule out substance-induced mood disorders

3. Evaluate for comorbidities:

   • Assess for substance abuse, anxiety disorders, ADHD, and other psychiatric conditions 1
   • Screen for suicidality, especially in adolescents with mood disorders 1

Pitfalls and Caveats

1. Overdiagnosis concerns:

   • Low positive predictive value of screening tools (22.1% at MDQ cutoff of 5) means most positive screens are false positives 4
   • Screening tools should not replace thorough clinical assessment

2. Underdetection issues:

   • Bipolar II disorder is particularly difficult to detect with screening tools 2
   • Patients may not recognize hypomanic episodes as pathological

3. Age considerations:

   • In children and adolescents, irritability rather than euphoria may be the predominant mood presentation 1
   • Adolescents with bipolar disorder have high rates of suicide attempts 1

4. Clinical implementation:

   • Screening should be followed by comprehensive diagnostic assessment
   • Systems must be in place to ensure positive screens lead to appropriate follow-up and treatment

The most effective approach combines the use of structured screening tools (preferably the HCL-32) with assessment of family history and careful clinical evaluation of mood episode patterns, focusing on identifying distinct periods of mood elevation with associated symptoms rather than just irritability or increased energy.