Janine N. Galione

Screening for Bipolar Disorder and Finding Borderline Personality Disorder

OBJECTIVE Bipolar disorder and borderline personality disorder share some clinical features and have similar correlates. It is, therefore, not surprising that differential diagnosis is sometimes difficult. The Mood Disorder Questionnaire (MDQ) is the most widely used screening scale for bipolar disorder. Prior studies found a high false-positive rate on the MDQ in a heterogeneous sample of psychiatric patients and primary care patients with a history of trauma. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we examined whether psychiatric outpatients without bipolar disorder who screened positive on the MDQ would be significantly more often diagnosed with borderline personality disorder than patients who did not screen positive. METHOD The study was conducted from September 2005 to November 2008. Five hundred thirty-four psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV and Structured Interview for DSM-IV Personality Disorders and asked to complete the MDQ. Missing data on the MDQ reduced the sample size to 480. Approximately 10% of the study sample were diagnosed with a lifetime history of bipolar disorder (n = 52) and excluded from the initial analyses. RESULTS Borderline personality disorder was 4 times more frequently diagnosed in the MDQ positive group than the MDQ negative group (21.5% vs 4.1%, P < .001). The results were essentially the same when the analysis was restricted to patients with a current diagnosis of major depressive disorder (27.6% vs 6.9%, P = .001). Of the 98 patients who screened positive on the MDQ in the entire sample of patients, including those diagnosed with bipolar disorder, 23.5% (n = 23) were diagnosed with bipolar disorder, and 27.6% (n = 27) were diagnosed with borderline personality disorder. CONCLUSIONS Positive results on the MDQ were as likely to indicate that a patient has borderline personality disorder as bipolar disorder. The clinical utility of the MDQ in routine clinical practice is uncertain.

Screening for Bipolar Disorder with the Mood Disorders Questionnaire: A Review

Background: Several research reports have suggested that bipolar disorder is underrecognized. Recommendations for improving the detection of bipolar disorder include the use of screening questionnaires. The Mood Disorders Questionnaire (MDQ) has been the most widely studied screening instrument for bipolar disorder, with nearly two dozen published reports on its performance. We reviewed the literature on the MDQs performance to assess its utility as a screening instrument. Methods: We conducted a Medline search on the terms Mood Disorders Questionnaire, MDQ, screening AND bipolar disorder, and recognition AND bipolar disorder. Only studies of adults were included. Results: Across all studies the sensitivity of the MDQ was 61.3%; specificity, 87.5%; positive predictive value, 58.0%; and negative predictive value, 88.9%. Compared to the studies using the MDQ for psychiatric outpatients, studies using it in the general population found it to have much lower sensitivity and positive predictive value, and higher specificity and negative predictive value. The MDQs sensitivity was higher in detecting bipolar I disorder than bipolar II disorder (66.3% vs. 38.6%). Lowering the threshold to identify cases markedly improved the MDQs sensitivity, with only a modest reduction in specificity. Studies of the best symptom cutoff to identify cases have produced inconsistent findings. Conclusions: The MDQs performance depends upon the setting in which it is used, the threshold to identify caseness, and the subtype of bipolar disorder examined. Conceptual issues in the use of a bipolar disorder screening questionnaire are discussed, and questions are raised about the clinical value of a self‐report screening scale for bipolar disorder. Based on current available evidence, routine clinical use of the MDQ cannot be recommended because of the absence of studies simultaneously examining both the potential benefits (e.g., improved detection) and costs (e.g., overdiagnosis) of screening.

Sustained unemployment in psychiatric outpatients with bipolar disorder: frequency and association with demographic variables and comorbid disorders

OBJECTIVES The negative impact of bipolar disorder on occupational functioning is well established. However, few studies have examined the persistence of unemployment, and no studies have examined the association between diagnostic comorbidity and sustained unemployment. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we described the amount of time unemployed in the five years before the evaluation in a large cohort of outpatients diagnosed with bipolar disorder, and determined the demographic and clinical correlates of sustained unemployment. METHODS A total of 206 patients diagnosed with DSM-IV bipolar I or bipolar II disorder were interviewed with semi-structured interviews assessing comorbid Axis I and Axis II disorders, demographic and clinical variables. The interview included an assessment of the amount of time missed from work due to psychiatric reasons during the past five years. Persistent unemployment was defined as missing up to two years or more from work. RESULTS Less than 20% of the patients reported not missing any time from work due to psychiatric reasons, and more than one-third missed up to two years or more from work. Prolonged unemployment was associated with increased rates of current panic disorder and a lifetime history of alcohol abuse or dependence. Patients with prolonged unemployment were older and experienced more episodes of depression. CONCLUSIONS Most patients presenting for the treatment of bipolar disorder have missed some time from work due to psychiatric reasons, and the persistence of employment problems is considerable. Comorbid psychiatric disorders are a potentially treatable risk factor for sustained unemployment. It is therefore of public health significance to determine if current treatments are effective in bipolar disorder patients with current panic disorder, and if not, to attempt to develop treatments that are effective.

A simpler definition of major depressive disorder

BACKGROUND The DSM-IV symptom criteria for major depressive disorder (MDD) are somewhat lengthy, with many studies showing that treatment providers have difficulty recalling all nine symptoms. Moreover, the criteria include somatic symptoms that are difficult to apply in patients with medical illnesses. In a previous report, we developed a briefer definition of MDD that was composed of the mood and cognitive symptoms of the DSM-IV criteria, and found high levels of agreement between the simplified and full DSM-IV definitions. The goal of the present study was to replicate these findings in another large sample of psychiatric out-patients and to extend the findings to other patient samples. METHOD We interviewed 1100 psychiatric out-patients and 210 pathological gamblers presenting for treatment and 1200 candidates for bariatric surgery. All patients were interviewed by a diagnostic rater who administered a semi-structured interview. We inquired about all symptoms of depression for all patients. RESULTS In all three samples high levels of agreement were found between the DSM-IV and the simpler definition of MDD. Summing across all 2510 patients, the level of agreement between the two definitions was 95.5% and the kappa coefficient was 0.87. CONCLUSIONS After eliminating the four somatic criteria from the DSM-IV definition of MDD, a high level of concordance was found between this simpler definition and the original DSM-IV classification. This new definition offers two advantages over the current DSM-IV definition--it is briefer and it is easier to apply with medically ill patients because it is free of somatic symptoms.

A comparison of depressed patients with and without borderline personality disorder: implications for interpreting studies of the validity of the bipolar spectrum

The nosological status of borderline personality disorder as it relates to the bipolar disorder spectrum has been controversial. Studies have supported, in part, the validity of the bipolar spectrum by demonstrating that these patients, compared to patients with nonbipolar depression, are characterized by earlier age of onset of depression, recurrent depressive episodes, comorbid anxiety and substance use disorders and increased suicidality. However, all of these factors have likewise been found to distinguish depressed patients with and without borderline personality disorder. A family history of bipolar disorder is one of the few disorder specific validators. In the present study from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compared the demographic and clinical characteristics of depressed patients with and without borderline personality disorder. We hypothesized that many of the factors used to validate the bipolar spectrum will also distinguish depressed patients with and without borderline personality disorder except, however, a family history of bipolar disorder. Two thousand nine hundred psychiatric outpatients at Rhode Island Hospital were evaluated with the Structured Clinical Interview for DSM-IV (SCID) and Structured Interview for DSM-IV Personality Disorders (SIDP-IV). Family history information regarding first-degree relatives was obtained from the patient using the Family History Research Diagnostic Criteria. One hundred and one patients with borderline personality disorder plus major depressive disorder were compared to 947 patients with major depressive disorder alone on the prevalence of bipolar disorder validators. Compared to depressed patients without borderline personality disorder, depressed patients with borderline personality disorder had a younger age of onset, more depressive episodes, a greater likelihood of experiencing atypical symptoms and had a higher prevalence of comorbid anxiety disorders, substance use disorders, and number of previous suicide attempts. The depressed patients with borderline personality disorder did not significantly differ from the patients without borderline personality disorder on morbid risk for bipolar disorder in first degree relatives. In addition, patients with a diagnosis of bipolar disorder had a significantly higher morbid risk of bipolar disorder in first degree relatives than the borderline personality disorder group. The findings indicate that many factors used to validate the bipolar spectrum are not disorder specific. These results raise questions about studies of the validity of the broad bipolar spectrum that do not assess borderline personality disorder. Our results do not support inclusion of borderline personality disorder as part of the bipolar spectrum.

Psychiatric diagnoses in patients who screen positive on the Mood Disorder Questionnaire: Implications for using the scale as a case-finding instrument for bipolar disorder

Bipolar disorder is prone to being overlooked because its diagnosis is more often based on retrospective report than cross-sectional assessment. Recommendations for improving the detection of bipolar disorder include the use of screening questionnaires. The Mood Disorder Questionnaire (MDQ) is the most widely studied self-report screening scale that has been developed to improve the detection of bipolar disorder. Although developed as a screening scale, the MDQ has also been used as a case-finding measure. However, studies of the MDQ in psychiatric patients have found high false positive rates, though no study has determined the psychiatric diagnoses associated with false positive results on the MDQ. The goal of the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project was to identify the psychiatric disorders associated with increased false positive rates on the MDQ. Four hundred eighty psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV (SCID) and completed the MDQ. After excluding the 52 patients diagnosed with a lifetime history of bipolar disorder we compared diagnostic frequencies in patients who did and did not screen positive on the MDQ. Based on the Hirschfeld et al. scoring guidelines of the MDQ, 15.2% (n=65) of the 428 nonbipolar patients screened positive on MDQ. Compared to patients who screened negative, the patients who screened positive were significantly more likely have a current and lifetime diagnosis of specific phobia, posttraumatic stress disorder, alcohol and drug use disorders, any eating disorder, any impulse control disorder, and attention deficit disorder. Results were similar using a less restrictive threshold to identify MDQ cases. That is, MDQ caseness was associated with significantly elevated rates of anxiety, impulse control, substance use, and attention deficit disorders. Studies using the MDQ as a stand-alone proxy for the diagnosis of bipolar disorder should consider whether the presence of these other forms of psychopathology could be responsible for differences between individuals who screen positive and negative on the scale.

Performance of the Bipolar Spectrum Diagnostic Scale in psychiatric outpatients

OBJECTIVES Recent research has suggested that bipolar disorder, when defined to include milder variants such as bipolar II disorder and bipolar disorder not otherwise specified (NOS), is more prevalent than had been previously reported and often underrecognized. Recommendations for improving the detection of bipolar disorder have included careful clinical evaluations inquiring about a history of mania and hypomania and the use of screening questionnaires. The Bipolar Spectrum Diagnostic Scale (BSDS) was designed to be particularly sensitive to the milder variants of bipolar disorder. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined the operating characteristics of the BSDS in a large sample of psychiatric outpatients presenting for treatment. METHODS A total of 1,100 psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV and asked to complete the BSDS. Missing data on the BSDS reduced the sample size to 961, approximately 10% (n = 90) of whom were diagnosed with bipolar disorder. RESULTS The sensitivity of the BSDS was similar for bipolar I disorder, bipolar II disorder, and bipolar disorder NOS/cyclothymia. A receiver operating curve (ROC) analysis indicated that cutoffs of 11 and 12 maximized the sum of sensitivity and specificity for the entire group of patients with bipolar disorder (area under curve = 0.80, p < 0.001). The cutoff point associated with 90% sensitivity for the entire sample of patients with bipolar disorder was 8. At this cutoff the specificity of the scale was 51.1% and positive predictive value was 16.0%. We compared the patients with and without bipolar disorder on each of the BSDS symptom items. The odds ratios were higher for the items assessing hypomanic/manic symptoms than items assessing depressive symptoms. We therefore examined the performance of a subscale composed only of the hypomania/mania items. The area under the curve in the ROC analysis was nearly identical to that of the entire scale (0.81, p < 0.001). CONCLUSIONS With its high negative predictive value, the BSDS was excellent at ruling out a diagnosis of bipolar disorder; however, the low positive predictive value indicates that it is not good at ruling in the diagnosis. These data raise questions about the use of the BSDS as a screening measure in routine clinical psychiatric practice.

Are screening scales for bipolar disorder good enough to be used in clinical practice

Bipolar disorder is often underdiagnosed. Recommendations for improving the detection of bipolar disorder include the use of screening questionnaires. The most widely studied screening scale is the Mood Disorders Questionnaire (MDQ). Studies of the performance of the MDQ in heterogeneous samples of psychiatric outpatients presenting for treatment have raised concerns about the adequacy of the MDQ as a screening measure because of its relatively low sensitivity. The sensitivity of a scale is not an inherent property of the instrument but depends on the threshold used to identify positive cases. Prior studies used the scoring recommendations of the developers of the MDQ to examine its performance; none examined the performance of the scale across the range of cutoff scores to determine whether a lower threshold would be more appropriate for the purposes of screening. The goal of the present study was to examine the operating characteristics of the MDQ at all cutoff scores to determine the cutoff point that would be appropriate for the purpose of screening. Seven hundred fifty-two psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV, and completed the MDQ. When MDQ caseness was based only on symptom score without regard to level of impairment, the cutoff score associated with at least 90% sensitivity was 5. At this cutoff the specificity of the MDQ was 60.7%, and its positive predictive value was 22.1%. These findings indicate that when the cutoff to identify cases on the MDQ was set to achieve a desired level of sensitivity as a screening instrument most cases screening positive on the scale did not have bipolar disorder. Low positive predictive value does not support the use of the MDQ or any bipolar disorder screening scale in psychiatric clinical practice.

Overdiagnosis of bipolar disorder and disability payments.

The diagnosis of bipolar disorder has received increasing attention during the past decade. Several research reports have suggested that bipolar disorder is under-recognized, and that many patients, particularly those with major depressive disorder, have, in fact, bipolar disorder. More recently, some reports have suggested that bipolar disorder is also overdiagnosed at times. There are several possible reasons for bipolar disorder overdiagnosis. In the present study, we examined whether secondary gain associated with receiving disability payments might be partially responsible for bipolar disorder overdiagnosis. A total of 82 psychiatric outpatients reported having been previously diagnosed with bipolar disorder, which was not confirmed when interviewed with the Structured Clinical Interview for DSM-IV. The percentage of patients receiving disability payments and the duration of disability payments were compared in these 82 patients and 528 patients who were not diagnosed with bipolar disorder. Compared with the patients who had never been diagnosed with bipolar disorder, the patients overdiagnosed with bipolar disorder were significantly more likely to have received disability payments at some point during the past 5 years, and were receiving disability payments for significantly more weeks. We conducted a regression analysis controlling for the number of lifetime diagnoses, and overdiagnosis of bipolar disorder was a significant predictor of disability status (OR = 3.8; 95% CI, 1.6–8.8). Thus, an unconfirmed diagnosis of bipolar disorder was significantly associated with receiving disability benefits.

Diagnosing social anxiety disorder in the presence of obesity: implications for a proposed change in DSM-5†

Background: The proposed draft of the DSM‐5 from the Anxiety Disorder Workgroup recommends allowing the diagnosis of social anxiety disorder (SAD) in individuals with medical conditions, if the anxiety is considered to be excessive. Although prior research has examined diagnosing SAD in individuals with stuttering, such research has not yet been conducted in obese individuals. Methods: This study compared demographic and clinical characteristics of obese individuals diagnosed with DSM‐IV SAD (n = 135), modified SAD (clinically significant social anxiety related to weight only; n = 40), and a group of obese individuals with no history of psychiatric disorders (n = 616). All participants were seeking psychiatric clearance for bariatric surgery and completed a comprehensive diagnostic interview. Results: The two social anxiety groups differed from the no disorder group on adolescent and past 5 years social functioning, and overall current functioning. Individuals with modified SAD had a later onset of their social anxiety, yet reported greater impairment in social life and distress about their social anxiety compared to the DSM‐IV SAD group. Conclusions: Although both of the social anxiety groups differed from the no disorder group on social and overall functioning, there were few differences between those with DSM‐IV SAD and modified SAD. This suggests that obese individuals with social anxiety related to weight only may experience comparable severity of anxiety to those with DSM‐IV SAD, and supports adoption of the DSM‐5 Workgroups recommendation to change criterion H. Depression and Anxiety, 2011.  © 2011 Wiley‐Liss, Inc.