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Psychometric Properties of the Hypomania Checklist-32 in Korean Patients with Mood Disorders

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Psychometric Properties of the Hypomania Checklist-32 in Korean Patients with Mood Disorders Original Article https://doi.org/10.9758/cpn.2017.15.4.352 pISSN 1738-1088 / eISSN 2093-4327 Clinical Psychopharmacology and Neuroscience 2017;15(4):352-360 Copyrightⓒ 2017, Korean College of Neuropsychopharmacology Psychometric Properties of the Hypomania Checklist-32 in Korean Patients with Mood Disorders Bo-Hyun Yoon1, Jules Angst2, Won-Myong Bahk3, Hee Ryung Wang3, Seung-Oh Bae4, Moon-Doo Kim5, Young-Eun Jung5, Kyung Joon Min6, Hwang-Bin Lee7, Seunghee Won8, Jeongwan Hong9, Myong Su Choi10, Duk-In Jon11, Young Sup Woo3 1Department of Psychiatry, Naju National Hospital, Naju, Korea, 2Department of Psychiatry, Psychotherapy and Psychosomatics, Psychiatric Hospital, University of Zurich, Zurich, Switzerland, 3Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, 4Hangang Mental Clinic, Gimpo, 5Department of Psychiatry, Jeju National University Hospital, Jeju, 6Department of Psychiatry, Chung-Ang University College of Medicine, Seoul, 7Department of Psychiatry, National Center for Mental Health, Seoul, 8Department of Psychiatry, Kyungpook National University School of Medicine, Daegu, 9Department of Psychiatry, Iksan Hospital, Iksan, 10Choimyongsu Psychiatric Clinic, Jeonju, 11Department of Psychiatry, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea Objective: The aim of this study was to examine the validity of the Korean version of the Hypomania Checklist-32, second revision (HCL-32-R2) in mood disorder patients. Methods: A total of 454 patients who diagnosed as mood disorder according to Structured Clinical Interview for DSM-IV Axis I Disorders, clinician version (SCID-CV) (bipolar disorder [BD] I, n=190; BD-II, n=72; and major depressive disorder [MDD], n=192) completed the Korean module of the HCL-32-R2 (KHCL-32-R2). Results: The KHCL-32-R2 showed a three-factorial structure (eigenvalue ＞2) that accounted for 43.26% of the total variance. Factor 1 was labeled “active/elated” and included 16 items; factor 2, “irritable/distractible” and included 9 items; and factor 3 was labeled “risk-taking/indulging” and included 9 items. A score of 16 or more on the KHCL-32-R2 total scale score dis- tinguished between BD and MDD, which yielded a sensitivity of 70% and a specificity of 70%. MDD and BD-II also could be differentiated at a cut-off of 15 with maximized sensitivity (0.67) and specificity (0.66). Cronbach’s alpha of KHCL-32-R2 and its subsets (factors 1, 2, and 3) were 0.91, 0.89, 0.81 and 0.79, respectively. Correlations between KHCL-32-R2 and Montgomery- Asberg Depression Rating Scale, Young Mania Rating Scale and Korean version of Mood Disorder Questionnaire were −0.66 (p=0.41), −0.14 (p=0.9), and 0.61 (p＜0.001), respectively. Conclusion: The KHCL-32-R2 may be a useful tool in distinguishing between bipolar and depressive patients in clinical settings. KEY WORDS: HCL-32-R2; Validation; Sensitivity; Specificity; Bipolar disorder; Major depression. INTRODUCTION practice.3) Hypomania as an element of BD-II is often not experienced or not recognized by the patient and their Bipolar disorder (BD) is a major psychiatric disorder families as pathological; therefore, it is usually not re- with a highly recurrent and chronic nature.1) It is often un- ported to doctors and remains under-diagnosed in 25 to der- or misdiagnosed, thus delaying the administration of 50% of MDD patients.4) Furthermore, clinicians tend not effective treatment, with one- to two-thirds of patients to investigate hypomania if patients present with a depres- with BD not receiving appropriate treatment due to sive episode.4) All of these factors contribute to failure to misdiagnosis.2) BD, particularly BD-II, is frequently mis- accurately diagnose BD in clinical practice. Recommen- diagnosed as major depressive disorder (MDD) in clinical dations for improving the diagnostic accuracy of BD in- clude establishing a comprehensive history of hypo- Received: January 10, 2017 / Revised: February 7, 2017 mania/mania, and supplementing it with the administra- 5,6) Accepted: February 16, 2017 tion of screening tools. Diagnostic error has also often Address for correspondence: Won-Myong Bahk, MD, PhD stemmed from the misinterpretation of hypomania as the Department of Psychiatry, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 10 63-ro, Yeongdeungpo-gu, result of antidepressant treatment (“drug induced switch Seoul 07345, Korea to hypomania”); it is now agreed that patients who switch Tel: +82-2-3779-1250, Fax: +82-2-780-6577 are true cases of BD-II, now also recognized in Diagnostic E-mail: [email protected] This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 352 Psychometric Properties of KHCL-32-R2 353 and Statistical Manual of Mental Disorders 5th edition or severe clinical status, those who could not cooperate (DSM-5).7) Of course, such over-diagnosis of MDD de- with the study procedures, patients who received ele- creases the specificity of screening instruments for troconvulsive therapy or modified eletroconvulsive ther- hypomania. apy during the previous four weeks, and individuals who Standardized structured diagnostic interviews such as were illiterate or suffered from mental retardation, de- the Mini International Neuropsychiatric Interview (MINI)8) mentia or intellectual impairment. The study was ap- and the Structural Clinical Interview for DSM-IV (SCID)9) proved by the relevant ethics committees or institutional are often used in research and even clinical practice, but review boards. applying these tools is time-consuming and requires A total of 454 patients were enrolled; the total number well-trained raters. Recently, several self-report screening of enrolled BD-I, BD-II and MDD patients was 190 tools have been developed to overcome these difficulties (41.9%), 72 (15.9%) and 192 (42.3%), respectively. Two and to aid in the detection of BD. Based on DSM-IV diag- hundred seventy-six patients (60.8%) were female and nostic criteria, the 32-item Hypomania Checklist (HCL- 324 (71.4%) were outpatients. 32),4) Mood Disorder Questionnaire (MDQ),10) and Bipolar Spectrum Diagnostic Scale11) are instruments intended for Instruments and Assessment Procedure widespread screening of bipolarity in patient with mood Patients with mood disorders were referred to the re- disorders. search team at each recruitment site to be screened for Initially developed as a 32-question instrument (HCL- eligibility. All inpatients and patients who visited out- 32-R1), in its recently modified version, the HCL-32 in- patient clinic and fulfilled the study criteria were invited to cludes an additional 2 questions (HCL-32-R2).12) Trans- participate in the study. cultural analysis of the BRIDGE Study (Bipolar Disor- The Montgomery-Asberg Depression Rating Scale ders: Improving Diagnosis, Guidance and Education), (MADRS)16,17) was used to measure the severity of de- which administered the HCL-32-R2, showed that it had pressive symptoms within the past week. The Young good stability across five geographical regions (Iberia, Mania Rating Scale (YMRS) was also applied to all Central Europe, Eastern Europe, North Africa/the Near patients.18,19) The MDQ, a self-report questionnaire used East, and the Far East including Korea).13) to screen mania/hypomania, was administered.10) It con- Although the Korean version of the HCL-32-R1 has sisted of 13 yes/no questions, reflecting DSM-IV in- been validated,14,15) the study of the psychometric proper- clusion criteria, followed by a single yes/no question ties of the HCL-32-R2 has not yet been tested in Korea. about whether the symptoms clustered simultaneously Therefore, the aim of this study was to exam the validity of and another question about the causality of the symptoms. the Korean adaptation of the HCL-32-R2 (KHCL-32-R2). The Korean version of MDQ was used in this study.20) The HCL-32-R2 is a slightly extended version of the METHODS original 32-item HCL-32 scale (R1).4,21) Compared to the HCL-32-R1,4) the HCL-32-R2 includes two additional Subjects items (“I gamble more” and “I eat more”), yielding a total This study was carried out from September 1, 2013 to of 34 items. The HCL-32-R2 used in this study was adopt- March 31, 2015 via 10 universities or psychiatric hospitals ed from the Korean HCL-32-R2 module included in in Korea. BRIDGE study12) with the author’s permission. The Korean Mood disorders patients who were diagnosed with BDs version of the HCL-32-R1 has been validated,14,15) but the (BD-I, BD-II, or BD-not otherwise specified [NOS]) or extended version has not yet been validated. unipolar disorders (MDD, depressive disorder NOS The diagnostic assessment of BD and MDD was con- [DEP-NOS], or dysthymic disorder [DD]) via the SCID ducted at the time of inclusion with the SCID clinical ver- were recruited. Their ages ranged between 18 and 60 years sion (SCID-CV) to establish DSM-IV diagnoses by clini- and all had a minimum of six years of education. One main cians who were blind to the diagnosis and the HCL-32-R2 eligibility criteria for participation in this study was the scores of each subject.9) ability to provide independent written informed consent, After providing written informed consent, patients regardless of their symptom severity. Exclusion criteria were invited to complete the HCL-32-R2, MDQ, and the included mood disorders secondary to general medical or additional clinical assessments including MADRS and neurological conditions, patients diagnosed with unstable YMRS. Sociodemographic information was collected 354 B.H. Yoon, et al. from medical records and patients’ families.
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