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Systematic Review of Symptom Assessment Measures for Use in Measurement-Based Care of Bipolar Disorders

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Systematic Review of Symptom Assessment Measures for Use in Measurement-Based Care of Bipolar Disorders REVIEWS AND OVERVIEWS Systematic Review of Symptom Assessment Measures for Use in Measurement-Based Care of Bipolar Disorders Joseph M. Cerimele, M.D., M.P.H., Simon B. Goldberg, Ph.D., Christopher J. Miller, Ph.D., Stephen W. Gabrielson, M.S.L.I.S., John C. Fortney, Ph.D. Objective: Utilization of measurement-based care (MBC) for depressive symptoms, and six patient-reported and four bipolar disorders is limited, in part because of uncertainty clinician-observed measures of both symptom types. regarding the utility of available measures. The aim of this Patient-reported measures with the highest clinical utility study was to synthesize the literature on patient-reported included the Altman Self-Rating Mania Scale for assessment and clinician-observed measures of symptoms of bipolar of manic symptoms, the Quick Inventory of Depressive disorder and the potential use of these measures in MBC. Symptomatology–Self Report (QIDS-SR) (depressive symp- toms), and the Internal State Scale (both types). Highly rated Methods: A systematic review of multiple databases clinician (C)-observed scales were the Bech-Rafaelsen Ma- (PubMed, Embase, PsycINFO, Cochrane Library, and other nia Rating Scale (mania), the QIDS-C (depressive symptoms), gray literature) was conducted in June 2017 to identify val- and the Bipolar Inventory of Symptoms Scale (both types). idated measures. Data on the psychometric properties of each measure were extracted and used to assess the mea- Conclusions: Suitable choices are available for MBC of bi- sure’s clinical utility on the basis of established guidelines. polar disorders. The choice of a measure could be informed by clinical utility score and may also depend on how clini- Results: Twenty-eight unique measures were identified in cians or practices weigh each category of the clinical utility 39 studies, including four patient-reported and six clinician- scale and on the clinical setting and presenting problem. observed measures assessing manic symptoms, three patient-reported and five clinician-observed measures of Psychiatric Services 2019; 70:396–408; doi: 10.1176/appi.ps.201800383 Even while engaging in treatment, many individuals with a In the past decade, several organizations have recom- bipolar disorder experience symptoms of mania and de- mended the adoption of MBC specifically for the treatment pression that fluctuate or occur concurrently (1–7). Failure of bipolar disorder. In 2009, the International Society to systematically assess symptoms and compare them with prior clinical status can lead to inaccurate detection of HIGHLIGHTS nonresponse and uncertainty about when to make treatment changes (8). Likewise, the presence of residual depressive or • This systematic review assessed the clinical utility of hypomanic symptoms is associated with poor outcomes, symptom measures for use when treating individuals with including recurrence of a mood episode (7)—highlighting bipolar disorder. • the need for ongoing symptom assessment and treatment Of 28 measures evaluated: 10 assess manic symptoms, to target (i.e., remission). eight assess depressive symptoms, and 10 assess both manic and depressive symptoms. Measurement-based care (MBC) is a clinical strategy • Clinical utility scores were based on each measure’s re- involving regular measurement of symptom frequency and liability, validity, and ease of use. severity, side effects, and treatment adherence and use of • fi – Measures with high clinical utility included the Altman those ndings to inform clinical decision making (9 11). Self-Rating Mania Scale, the Bech-Rafaelsen Mania Rat- Existing literature demonstrates that MBC is effective for ing Scale, the Quick Inventory of Depressive Symp- treating patients with most psychiatric disorders and that tomatology, the Internal State Scale, and the Bipolar adoption of MBC has been recommended in the treatment Inventory of Symptoms Scale. of individuals with a range of psychiatric illnesses (9). 396 ps.psychiatryonline.org Psychiatric Services 70:5, May 2019 CERIMELE ET AL. for Bipolar Disorders (12) recommended using symptom reviews (15, 16), were hand-searched to identify additional measures at baseline and at follow-up clinical visits to aid scales, including those described in articles published clinicians in determining clinical response and remission for before 1990. individuals with bipolar disorder. The report also noted that symptom measurement can provide additional clinical in- Eligibility and Exclusion sights, such as determining the predominant polarity of a Article titles found in the search were screened for relevance mixed episode (12). Guidelines published by the U.S. De- to the topic by the first author. Selected abstracts were then partment of Veterans Affairs (VA) and the Department of screened. Articles were eligible if they described symptom Defense (DoD) also recommend using symptom measures to measures for adults with a bipolar disorder, were published monitor treatment of bipolar disorder, but unlike VA/DoD in English, and addressed measurement psychometrics guidelines for depression (13), they do not provide specific (e.g., validity or reliability). instructions about which measures to use, how to interpret Studies that did not report on individuals with a bipolar results of any specific measure, or frequency of measure- disorder, did not include adult populations, did not measure ment (14). The absence of clear guidance in MBC of bipo- bipolar disorder symptoms, or did not include primary data lar disorder—as well as limited clinician understanding (e.g., review articles) were excluded. We also excluded re- of available measures that could be used as options—may ports on instruments that would not be appropriate for use have contributed to low adoption of MBC for this clinical in MBC, such as screening measures used for case identifi- population. cation and instruments assessing only one symptom (e.g., Prior reviews of bipolar disorder measures, published in suicidal ideation). 2009 (15) and 2013 (16), included measures of bipolar dis- order symptoms and screening tools and other instruments Data Abstraction that are not used for serial symptom assessment. Neither We developed a data abstraction tool. Abstracted infor- review used a comprehensive systematic review methodol- mation included study author and year; study population ogy that included searching multiple databases, assessed a and clinical setting; and other details about the measure, full range of psychometric properties, or evaluated clinical including the number of items, time frame assessed, and utility. We sought to extend prior reports by conducting a scoring of items. One author (JMC) reviewed eligible studies systematic review of instruments that could be used for to complete the data abstraction tool. All eligible studies MBC of bipolar disorder. In particular, we sought to answer were reviewed by two additional authors (SBG and JCF) to the following questions, What patient-reported and clinician- assess information required for computing the clinical util- observed measures of bipolar disorder symptoms exist? ity scores described below. Disagreements were resolved What are the psychometric properties and clinical utility of through discussion among authors and through consultation the existing measures? with a multidisciplinary group of researchers within the Department of Psychiatry and Behavioral Sciences at the METHODS University of Washington School of Medicine. Corre- sponding authors were contacted for missing data. We followed the Preferred Reporting Items for Systematic To quantify the clinical utility of the included measures, Reviews and Meta-Analyses (PRISMA) method to conduct we adapted a method developed by Zimmerman et al. and report the results of this review (17). to describe the clinical utility of symptom measures (18). Clinical utility was assessed based on 11 items related to Search Strategy content, use, or psychometrics of the measure for individuals Search strategies were developed to capture articles about with bipolar disorder, including three items of validity and bipolar disorders, symptom measures, and measurement two items of reliability. Items (with cutoff criteria when psychometrics. (Complete search strategies are available in applicable) included whether the instrument was brief (#18 the online supplement). Searches were constructed by using items); assessed suicidal thoughts; was easy to score (total a combination of keywords and standardized terms in score computed by adding individual item responses); was PubMed, Embase, PsycINFO, and the Cochrane Register publicly available (determined by author report or identified of Controlled Trials. Gray literature sources were also through Internet search); reported a remission indicator in searched, including ClinicalTrials.gov, ProQuest Disserta- included study (a score suggesting clinical remission); and tions and Theses, and the World Health Organization’s In- was adequate in internal consistency (Cronbach’s a $.7), ternational Clinical Trials Registry Platform. Results were test-retest reliability (Pearson correlation coefficient $.6), filtered for English articles, adults, and years 1990 to the content validity (proportion of assessed DSM-5 symptoms present. Searches were conducted in June 2017. Citations of depression and mania), concurrent validity (Pearson or were managed in EndNote, including removal of duplicates, Spearman’s correlation coefficient $.6), construct validity and the excluded and included citations were organized by (either
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