The main results of the present study are that the Farsi version of the HCL-32 did correlate highly with an existing self-rating questionnaire for bipolar disorders (MDQ), that it discriminated between patients with MDD and BP, that mean scores did not substantially differ from those of samples drawn from other continents, and that contrary to previous findings, a four-factorial, rather than a two-factorial solution emerged.
Strong correlations between the established Farsi version of the MDQ and the present HCL-32 do suggest that the Farsi version of the HCL-32 measures the same psychological construct, hypomanic stages within bipolar disorders. Moreover, Cronbach's alphas reflected a consistently high internal consistency. Therefore, the Farsi version seems applicable for these disorders. Moreover, one needs only few minutes to complete the HCL-32; this implies that the present version is a quick and easy self-assessment tool. In this regard, the present data do also fit well within the broad range of findings which suggest a cross-cultural and generalized presence of bipolar disorders [1
Whereas the present questionnaire enables discrimination of patients with MDD and patients with BP, it does not allow a distinction between patients with BP I and BP II. The underlying reasons remain unclear, though one might speculate that in the current sample differences between patients with BP I and BP II were not present at the time of the survey. Another reason may be that the mood states, rather than being categorical entities, may be better viewed within a continuum ranging from one pole (depressive symptoms) to another (manic stage; cf. [7
]), and that within this continuum BP I and BP II stages are barely detectable by self-rating. In this view, it is also of note that previous research with the HCL-32 has not consistently allowed a distinction between BP I and BP II [1
] (but see also [3
In contrast to previous studies (cf. [28
]), a four-factor rather than a two-factor structure emerged. However, Holtmann et al. [8
], applying the HCL-32 with a sample of adolescents (mean age: 17.1 years), found a three-factor structure, with the first factor ''active-elated'' reflecting symptoms related to energy and activity. By contrast, the adult factor ''irritable-risk taking'' was better reflected by two separate factors (''disinhibited/stimulation-seeking'' and ''irritable-erratic''). Importantly, these factors were associated with externalizing problems. Also differing from earlier two-factorial solutions, Rybakowski et al. [29
] reported a three-factor solution for a sample of patients suffering from treatment-resistant depression. Factor 1 was related to elevated mood and increased activity, factor 2 was related to increased sexual activity, whereas factor 3 was related to irritability. In brief, it seems that the factorial structure of the HCL-32 is not conclusively limited to two factors, and that solutions may vary as a function of the sample concerned.
Despite the new findings, several issues warrant against generalization, and these data should be interpreted cautiously. First, the sample size is rather small and issues related to gender were not taken into account. However, we emphasized effect size calculations which are not sensitive to sample sizes. Second, comorbid substance use or dependence is relatively common in bipolar disorder, and to some degree also in depression. However, respondents with comorbid substance use were excluded from the sample. As a result, data may be biased and not entirely representative. Third, recall of hypomanic symptoms in the past as assessed by the HCL-32 and MDQ might have been biased by current clinical state. Fourth, results from comparisons with samples taken from Angst et al. [1
] should be interpreted cautiously because of the uneven distribution of patients suffering from MDD and BP. Fifth, only patients willing and able to participate and to complete the questionnaires were included in the study; therefore, again, results may be biased. Sixth, the cross-sectional design does not allow investigation of further implications related to the long-term development of the assessed mood changes. Seventh, compared to other findings (e.g., [10
]) the cut-off of 14.5 points to distinguish between patients suffering from MDD and BP might be rather high, though this cut-off point is comparable to other studies (cf. [5
]). Last, statistical comparisons between the present data and statistical information from other samples were not systematically controlled for gender and age.