Improving the diagnosis of bipolar disorder: Predictive value of screening tests

Emory University, Atlanta, Georgia, United States
Journal of Affective Disorders (Impact Factor: 3.38). 07/2006; 92(2-3):141-8. DOI: 10.1016/j.jad.2006.01.029
Source: PubMed


To examine the impact of assumptions about prevalence or prior clinical probability of bipolar disorder on the clinical performance (predictive values) of diagnostic screening tests.
Sensitivity and specificity data from four reports on two bipolar screening instruments (the Mood Disorders Questionnaire and the Bipolar Spectrum Diagnostic Scale) were used to calculate positive and negative predictive values at varying prevalence levels. Bayesian statistical concepts were employed.
At low prevalence or low prior clinical probability, the sensitivity and specificity of the test have little impact on negative predictive value; the tests perform well, with low risk of false negatives. Similarly, at low prevalence or low prior clinical probability, positive predictive values are low regardless of which sensitivity and specificity data are used: the risk of false positives is substantial.
At lower prevalence or prior probabilities, as in the community or primary care setting, these screening tests can rule out bipolarity (when patients have insight into their symptoms), but do not effectively rule it in. Clinicians' estimates of prior probability have as much, or in many cases more, impact on the clinical performance of the bipolar screening tools than the tests' sensitivity and specificity. To improve the performance of screening tools, the primary emphasis needs to be placed on improving clinicians' skill at recognizing clinical and historical features of bipolar diagnosis.

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    • "The bipolar disorder research community has embraced the use of self-administered screening questionnaires. More than a half-dozen such scales have been developed (Angst and Cassano, 2005; Bowden et al., 2007; Depue et al., 1989; Hirschfeld et al., 2000; Parker et al., 2008, 2012; Phelps and Ghaemi, 2006), and articles calling for improved recognition have recommended their use (Angst et al., 2005; Dunner, 2003; Hirschfeld and Vornik, 2004). In fact, recent review articles of bipolar disorder by prominent researchers in prestigious medical journals such as the New England Journal of Medicine and the British Medical Journal have advocated the use of these measures (Anderson et al., 2012; Frye, 2011). "
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    ABSTRACT: Compared with bipolar disorder, borderline personality disorder (BPD) is as frequent (if not more frequent), as impairing (if not more impairing), and as lethal (if not more lethal). Yet, BPD has received less than one-tenth the funding from the National Institutes of Health than has bipolar disorder. More than other reviewers of the literature on the interface between bipolar disorder and BPD, Paris and Black (Paris J and Black DW (2015) Borderline Personality Disorder and Bipolar Disorder: What is the Difference and Why Does it Matter? J Nerv Ment Dis 203:3-7) emphasize the clinical importance of correctly diagnosing BPD and not overdiagnosing bipolar disorder, with a focus on the clinical feature of affective instability and how the failure to recognize the distinction between sustained and transient mood perturbations can result in misdiagnosing patients with BPD as having bipolar disorder. The review by Paris and Black, then, is more of an advocacy for BPD than other reviews in this area have been. In the present article, the author will illustrate how the bipolar disorder research community has done a superior job of advocating for and "marketing" their disorder compared with researchers of BPD. Specifically, researchers of bipolar disorder have conducted multiple studies highlighting the problem with underdiagnosis, written commentaries about the problem with underdiagnosis, developed and promoted several screening scales to improve diagnostic recognition, published numerous studies of the operating characteristics of these screening measures, attempted to broaden the definition of bipolar disorder by advancing the concept of the bipolar spectrum, and repeatedly demonstrated the economic costs and public health significance of bipolar disorder. In contrast, researchers of BPD have almost completely ignored each of these issues and thus have been less successful in highlighting the public health significance of the disorder.
    No preview · Article · Jan 2015 · The Journal of nervous and mental disease
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    • "However, the SCID has been found to have limitations for diagnosing BD, especially BD II (Benazzi and Akiskal, 2009). The main screening tools used in epidemiological studies are the Mood Disorder Questionnaire (MDQ) (Hirschfeld et al., 2005), the Hypomania Checklist (HCL-32) (Angst, 2005) and the Bipolar Spectrum Diagnostic Scale (BSDS) (Phelps and Ghaemi, 2006). The MDQ has been translated into several languages and validated in various countries (Miller et al., 2004). "
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    ABSTRACT: There are no validated screening tools for Bipolar Disorder (BD) in Russia. To validate the Russian version of the HCL-32 for the detection of Bipolar II disorder (BD II) in patients with Recurrent Depressive Disorder (RDD). 409 patients with a current diagnosis of RDD were recruited. The diagnosis was confirmed by the validated Russian version of the Mini International Neuropsychiatric Interview (MINI). Another investigator interviewed the patients using the НСL-32 questions. The total HCL-32 score in patients with BD II was significantly higher than in patients with RDD: 18.2 (4.22) versus 10.85 (5.81) (p<0.001, d=1447). At the cut-off 14 points the sensitivity was 83.7%, specificity 71.9% (p<0.001). The Cronbach's alpha was 0.887 that means good internal consistency. The best discrimination was achieved with 8 items: decreased need for sleep, less shyness or inhibition, talkativeness, more jokes and puns, jumping thoughts distractibility, exhausting or irritating others and high and more optimistic mood. We proposed the reduced variant of the scale, that includes only these 8 variables, with sensitivity 90.5%, specificity 69.8% (AUC=0.88). The Russian version of the HCL-32 displayed a good ratio of sensitivity to specificity and can be recommended as a validated screening instrument. An 8-item version of HCL needs further research. Limitations include the specific nature of the sample, the HCL-32 assessment carried out by a psychiatrist, no comparison with other BD screening scales. The results of the 8-item version may be sample and culture dependent.
    Full-text · Article · Oct 2013 · Journal of Affective Disorders
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    • "The treatment and clinical implications of the failure to recognize bipolar disorder in depressed patients are significant, and include the underprescription of mood-stabilizing medications, an increased risk of rapid cycling, and increased costs of care.4,14-16 As a result of the potential morbidity associated with a delay in diagnosis, experts have called for improved recognition of bipolar disorder,1,6 and screening scales have been developed and recommended to facilitate the identification of bipolar disorder.17-19 "
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    ABSTRACT: It is clinically important to recognize both bipolar disorder and borderline personality disorder (BPD) in patients seeking treatment for depression, and it is important to distinguish between the two. Research considering whether BPD should be considered part of a bipolar spectrum reaches differing conclusions. We reviewed the most studied question on the relationship between BPD and bipolar disorder: their diagnostic concordance. Across studies, approximately 10% of patients with BPD had bipolar I disorder and another 10% had bipolar II disorder. Likewise, approximately 20% of bipolar II patients were diagnosed with BPD, though only 10% of bipolar I patients were diagnosed with BPD. While the comorbidity rates are substantial, each disorder is nontheless diagnosed in the absence of the other in the vast majority of cases (80% to 90%). In studies examining personality disorders broadly, other personality disorders were more commonly diagnosed in bipolar patients than was BPD. Likewise, the converse is also true: other axis I disorders such as major depression, substance abuse, and post-traumatic stress disorder are also more commonly diagnosed in patients with BPD than is bipolar disorder. These findings challenge the notion that BPD is part of the bipolar spectrum.
    Full-text · Article · Jun 2013
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