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Clinical Correlates of False Positive Assignment in Bipolar Screening Measures Across Psychiatric Diagnoses Among Patients Without Bipolar Disorder

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Clinical Correlates of False Positive Assignment in Bipolar Screening Measures Across Psychiatric Diagnoses Among Patients Without Bipolar Disorder ORIGINAL ARTICLE Print ISSN 1738-3684 / On-line ISSN 1976-3026 https://doi.org/10.30773/pi.2020.0246 OPEN ACCESS Clinical Correlates of False Positive Assignment in Bipolar Screening Measures Across Psychiatric Diagnoses among Patients without Bipolar Disorder Ji Hyun Baek1, Ji Sun Kim2, Andrew A. Nierenberg3, Hong Jin Jeon1, and Kyung Sue Hong1 1Department of Psychiatry, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea 2Department of Psychiatry, Sooncheonhyang University Cheonan Hospital, Cheonan, Republic of Korea 3Bipolar Clinical and Research Program, Massachusetts General Hospital, Boston, MA, USA Objective In this study, we aimed to determine clinical correlates of false positive assignment (FPA) on commonly used bipolar screen- ing questionnaires. Methods A retrospective chart review was conducted to a total of 3885 psychiatric outpatients. After excluding patients who have bipo- lar spectrum illnesses, patients who were assigned as having hypomania on the mood disorder questionnaire (MDQ) or the hypomania checklist-32 (HCL-32) were identified as patients who had FPA. Psychiatric diagnoses and severity of emotional symptoms were com- pared between patients with and without FPA. Results Patients with FPA on the MDQ showed significant associations with presence of major depressive disorder, generalized anxiety disorder, and alcohol-use disorder, while patients with FPA on the HCL-32 showed associations with presence of panic disorder and ag- oraphobia. FPA on the MDQ was also associated with greater emotional symptoms and lifetime history of suicide attempts. Logistic re- gression analysis showed that male sex, younger age, presence of alcohol-use disorder, and severity of depression and obsessive-compul- sive symptoms were significantly associated with FPA on the MDQ. Conclusion The FPA for the MDQ was associated with clinical factors linked to trait impulsivity, and the FPA for both the MDQ and the HCL-32 could be related to increased anxiety. Psychiatry Investig 2020;17(11):1118-1125 Key Words Hypomania, Self-report questionnaire, False positive assignment, MDQ, HCL-32. INTRODUCTION pomania through retrospective examination. To facilitate ear- ly recognition of bipolar disorder, several self-reported screening Bipolar disorder (BD) is considered an under-recognized questionnaires have been widely applied in clinical settings. disease. Under-diagnosis can lead to delayed diagnosis and The Mood Disorder Questionnaire (MDQ)1 and the Hypo- mistreatment, which eventually results in a worse clinical mania Symptom Checklist-32 (HCL-32)2 are two of the most course and poorer treatment outcome. However, it is still dif- commonly used questionnaires. Their abilities to detect bi- ficult to differentiate BD from unipolar depressive disorder polarity initially appear comparable,3 but several studies in clinical settings. showed that the HCL-32 may be better at detecting hypoma- Diagnosis of BD depends on a patient’s history of hypoman- nia than the MDQ.4 ic/manic episodes, indicating the importance of capturing hy- Although the MDQ and the HCL-32 are designed to be used for patients with major depression to detect (hypo)ma- Received: June 26, 2020 Revised: August 26, 2020 nia, they both are commonly used to define so-called bipolar- Accepted: September 5, 2020 Correspondence: Kyung Sue Hong, MD, PhD ity in diverse populations, both in clinical and research set- Department of Psychiatry, Samsung Medical Center, Sungkyunkwan University tings.5-9 But this can lead to different problems related to over- School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Republic of Korea Tel: +82-2-3410-3589, Fax: +82-2-3410-0050, E-mail: [email protected] screening. These screening measures generally have low positive cc This is an Open Access article distributed under the terms of the Creative Commons predictive values, so additional interviews with trained profes- Attribution Non-Commercial License (https://creativecommons.org/licenses/by- sionals are necessary to confirm the presence of mania/hypo- nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduc- tion in any medium, provided the original work is properly cited. mania.10 To use these questionnaires properly, we need to iden- 1118 Copyright © 2020 Korean Neuropsychiatric Association JH Baek et al. tify the clinical correlates of false positive assignment (FPA) mania Symptom Checklist-32 (HCL-32)2 were used to evalu- from these questionnaires in patients whose clinical diagno- ate subthreshold hypomania. The MDQ evaluates experienc- ses are not bipolar disorders. es of (hypo)manic episodes using 13 questions derived from A few studies have reported on the clinical correlates of FPA items of DSM-IV manic episode. The HCL-32 asks an indi- for bipolar screening questionnaires. Two studies11,12 report- vidual their experiences when they were in a ‘high’ mood. ed that FPA from the MDQ was associated with elevated rates Each question asks specific behavior, thoughts and emotions of anxiety, impulse control, substance use, and attention-deficit that can be experienced during (hypo)manic state. Further- disorder. However, clinical correlates of FPA from the HCL-32 more, the HCL-32 evaluates whether the episode impact on have not been studied. their daily living. Widely used cut-off scores showed relative- This study aimed to identify the clinical correlates of FPA ly low specificity for BD,10 so we adopted cut-off scores previ- for the MDQ and the HCL-32 in Korean psychiatric outpa- ously shown to have >80% specificity in Korean populations: tients with diverse mood and anxiety disorders. Among pa- the cut-off score for the MDQ was 9,13 and the cut-off score for tients who were diagnosed with non-bipolar mood and anxi- the HCL-32 was 20.9 We defined the MDQ (+) group as pa- ety disorders via standard psychiatric interviews, we explored tients with an MDQ score ≥9 and the HCL (+) group as pa- clinical features associated with false positive assignment on the tients with HCL-32 score ≥20. two most commonly used bipolar screening questionnaires. The psychological assessment METHODS Subject diagnoses were evaluated using the Korean version of the Mini International Neuropsychiatric Interviews (MINI).14 Study populations If patients have dual diagnoses based on the MINI, they were Data were obtained from a retrospective chart review of pa- counted twice in comparing frequencies of psychiatric diag- tients who visited the Depression Center of the Department noses. Of the MINI modules, the suicide module was used to of Psychiatry, Samsung Medical Center, between January 2011 evaluate suicide risk. Suicidality was measured using the MINI and December 2017. After an initial interview with a board- suicide-item modules and the HAMD suicide-item scores. The certified psychiatrist, patients between 18 and 65 years old MINI suicide module is a six-question, yes-or-no, interview- who were suspected to have mood and anxiety problems were er-administered questionnaire used to evaluate suicidality and referred to a psychologist for a comprehensive psychological current risk of suicide. The MINI suicide module asks about evaluation. The psychologist who conducted the evaluation experiences of recurrent thoughts of death, idea of self-harm, had more than two years of clinical experience. The psycho- presence of suicide ideation, plans and (current and past) sui- logical evaluation was part of routine care and designed to con- cide attempts. A single score is generated after summing the firm subject clinical diagnosis based on the DSM-IV-TR and weighted scores. Suicide risk scores are categorized as low risk to evaluate symptom severity. After the psychologist finalized (<6), medium risk (6–9), or high risk (≥10) for a future sui- patients’ psychiatric diagnoses, the result was reviewed and cide attempt.15 confirmed by a psychiatrist who order the test. Patients sus- The Hamilton Depression Rating Scale (HAM-D) (Hamil- pected of psychosis, intellectual disability, cognitive impair- ton, 1967) and the Beck Depression Inventory II (BDI-II) were ment, organic brain disease or who had difficulty in understand- used to evaluate current depressive symptoms. The Beck’s ing overall evaluation process were excluded. Additionally, hopelessness scale (BHS)16 was used to evaluate severity of those who required an emergency admission were not referred pessimism. The Hamilton Anxiety Rating Scale (HAM-A)17 for evaluation. This study used test results from comprehen- and the Beck Anxiety Inventory (BAI)18 were used to evaluate sive psychological evaluations. anxiety symptoms. The Anxiety Sensitivity Index-3 (ASI-3)19 The study protocol was approved by the Institutional Re- was used to evaluate anxiety sensitivity. The Albany Panic and view Board of Samsung Medical Center (IRB no. 2018-11-019). Phobia Questionnaire (APPQ)20 was used to assess fear of sit- All identifying data were removed from the clinical database uations and activities that are commonly avoided by individ- prior to analyses. Because this study was a retrospective chart uals with agoraphobia and social anxiety disorder. The Penn review, no consent was needed from participants. State Worry Questionnaire (PSWQ)21 was used to evaluate se- verity of worry. The Liebowitz social anxiety scale22 was used Applied measures to measure severity of social anxiety. The Obsessive Compul- sive Inventory-Revised (OCI-R)23 was applied to obsessive Evaluation of FPA on the bipolar screening measures compulsive symptoms. The Mood Disorder Questionnaire (MDQ)1 and the Hypo- www.psychiatryinvestigation.org 1119 Clinical Correlates of False Positive Assignment on Bipolar Screening Questionnaires Statistical analyses 1.13–1.59), generalized anxiety disorder (aOR=1.73, 95% CI: Chi-square tests were used to compare rates of sex and in- 1.38–2.18), and alcohol-use disorder (aOR=2.00, 95% CI: dependent Student’s t-test was used to compare age between 1.47–2.73). The HCL (+) group showed significant associa- the MDQ (+) and (-) groups, and the same analyses were tions with panic disorder (aOR=1.45, 95% CI: 1.12–1.88) and conducted between the HCL-32 (+) and (-) groups.
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