Screening
Multiple methods may be used to screen for bipolar disorder. No screening methodology can compare to a comprehensive current and past history by a clinician, corroborated by medical records and family interview.[90] Given the high rates of misdiagnosis of bipolar disorder, it is important to screen for symptoms of bipolar disorder in all patients presenting with depressive symptomatology, typically in primary care.[29] Screen for undiagnosed bipolar disorder prior to the prescription of antidepressant therapy, given the potential for iatrogenic worsening of symptoms with antidepressants in the presence of undiagnosed bipolar disorder.
Asking about current and past symptoms of mania/hypomania in line with Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) criteria, while taking into account the impact of the symptoms on a patient's life and the pattern of mood episodes over the lifetime course, improves diagnostic detection beyond the use of a simple screening instrument.[91] A slightly different approach recommended by UK-based guidance from the National Institute for Health and Care Excellence (NICE) is for clinicians to ask all adults presenting in primary care with depression whether they have experienced periods of overactivity or disinhibited behaviour. If the overactivity or disinhibited behaviour lasted for 4 days or more, NICE recommends considering referral for a specialist mental health assessment.[29]
One way to assess this may be to ask the following questions:[101]
Have you experienced a mood that was higher than normal, or have you felt much more irritable than usual, and that others have noticed?
At the same time, have you had an increase in your energy levels so that you are much more active or don’t need as much sleep?
If the answer to either of these is 'yes', clinicians can find out more by asking ‘What did you do?’, and to ask about other symptoms of mania/hypomania.
NICE recommends against the use of questionnaires in primary care to identify bipolar disorder, given that they are not sufficiently sensitive or specific to be diagnostic.[29] However in practice some clinicians may find that screening tools can aid clinical assessment, as an adjunct to comprehensive history taking.
Recommendations on screening for specific patient groups
Perinatal women
The American College of Obstetricians and Gynecologists (ACOG) highlights the high prevalence of bipolar disorder in the perinatal population, and the associated significant negative outcomes that increase both maternal and infant mortality risk. ACOG recommends that everyone receiving antenatal and postnatal care be screened for bipolar disorder using a standardised, validated instrument, for example, Mood Disorder Questionnaire (MDQ).[85] Screening with each pregnancy is recommended.[85]
Screening tools
Depression screening options include the Primary Care Evaluation of Mental Disorders (PRIME-MD) and Patient Health Questionnaire (PHQ-9) for adults.[92][93] Mania/hypomania screening options include the Rapid Mood Screener (RMS), Mood Disorder Questionnaire (MDQ), Bipolarity Index and Young Mania Rating Scale (YMRS).[95][96][97][98] The US Preventive Services Task Force recommends that primary care practices screening adults should have systems in place to ensure that positive screening results are followed by accurate diagnosis, effective treatment, and careful follow-up.[102]
PRIME-MD
A tool for identifying mental disorders in primary care practice and research.
PHQ-9
Self-administered
Can be used as a diagnostic and disease management tool and has been validated for use in primary care settings to screen for depression[93]
9-item questionnaire that reflects the DSM-IV-TR criteria. It classifies current symptoms based on duration on a scale of 0 (no symptoms) to 4 (daily symptoms)
This questionnaire is still being used in clinical practice, despite the release of DSM-5-TR
PHQ-2
A briefer version of PHQ-9,, with only the 2 following screening questions, has been validated:[94]
'Over the past 2 weeks have you felt down, depressed, hopeless?'
'Over the past 2 weeks have you felt little interest or pleasure in doing things?'
A positive response to either question warrants a thorough review of bipolar diagnostic criteria or use of an equivalent tool.
RMS
The RMS is a rapid (6-question) tool developed to screen for manic symptoms/bipolar I disorder features in patients presenting with a depressive episode, for example, in primary care.[95]
If patient answers ‘yes’ to at least 4 questions this is viewed as a positive screening result, and further assessment to determine a potential diagnosis of bipolar disorder is required.
A positive screening result is associated with a sensitivity of 88%, and a specificity of 80%.[95]
MDQ Mood Disorder Questionnaire (MDQ) Opens in new window
A screening instrument for bipolar disorder that has been validated in a variety of populations. This self-assessment instrument includes 13 questions that ask about symptoms of mania/hypomania based on DSM-IV-TR criteria. A score of 7 or more positive responses to the 13 questions, as well as endorsing the clustering of the symptoms into an episode that caused at least moderate distress or negative consequences, is a positive MDQ screen and has been correlated with a diagnosis of bipolar disorder.[96]
This questionnaire is still being used in clinical practice, despite the release of DSM-5-TR.
Bipolarity Index Bipolarity Index Opens in new window
This recently described system of evaluating bipolar disorder risk considers 5 dimensions of bipolarity: episode characteristics (mania or hypomania); age at onset; illness course; response to medications; family history. Each dimension is scored up to a maximum of 20 points for a maximum total score of 100. A cutoff score of ≥50 on the Bipolarity Index corresponds to a sensitivity of 0.91 and specificity of 0.90 for distinguishing bipolar from non-bipolar disorders.[97]
YMRS Young Mania Rating Scale Opens in new window
A validated symptom severity scale with point-score ranges generally associated with degrees of severity. Contains 11 items scored on the basis of subjective reporting of symptoms in the previous 48 hours and clinical observations during the course of an interview.
Commonly used to measure changes in manic symptoms in response to treatment.[98]
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