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1.  Development and validation of a screening instrument for bipolar spectrum disorder: The Mood Disorder Questionnaire Thai version 
The Mood Disorder Questionnaire (MDQ) has been translated to many languages and has been used in many countries as a screening instrument for bipolar disorder. The main objective of this study was to evaluate validity of the Thai version of the MDQ as a screening instrument for bipolar disorder in a psychiatric outpatient sample, and to determine its optimum question #1 item threshold value for bipolar disorder.
The English language Mood Disorder Questionnaire (MDQ) was translated into Thai. The process involved back-translation, cross-cultural adaptation, field testing of the prefinal version, as well as final adjustments. Two hundred and fifty major depressive disorder outpatients were further assessed by the Thai version of the MDQ and the Thai version of the Mini International Neuropsychiatric Interview (MINI). During the assessment, reliability and validity analyses, and receiver operating characteristic curve (ROC) analysis were performed.
The Thai version of the MDQ screening had adequate internal consistency (Cronbach’s alpha =0.791, omega total =0.68, and omega hierarchical =0.69). The optimal question #1 item threshold value was at least five positive items, which yielded adequate sensitivity (76.5%), specificity (72.7%), positive predictive value (74.3%), and negative predictive value (75.0%). The ROC area under the curve (AUC) for this study was 0.82 (95% confidence interval: 0.70 to 0.90).
The Thai version of the MDQ had some useful psychometric properties for screening for bipolar disorder in a mood disorder clinic setting, with a recommended question #1 item threshold value of at least five positive items.
PMCID: PMC4144938  PMID: 25170269
Thai MDQ; screening test; reliability; predictive validity; cutoff point
2.  Evaluation of Mood Disorder Questionnaire (MDQ) in Patients with Mood Disorders: A Multicenter Trial across China 
PLoS ONE  2014;9(4):e91895.
The aim of this study was to test the ability of the Chinese version of the Mood Disorder Questionnaire (MDQ) to identify Bipolar Disorders (BD) in patients diagnosed with Major Depressive Disorder (MDD) or Unipolar Disorder (UD) in the clinical setting.
1,487 being treated for MDD or UD at 12 mental health centers across China, completed the MDQ and subsequently examined by the Mini International Neuropsychiatric Interview (MINI). Receiver Operating Characteristic(ROC) curves were used to determine the ability of the MDQ to differentiate between BD (BD, BD-I and BD-II) and MDD or UD and patients with BD-I from patients with BD-II.
Of the 1,487 patients, 309 (20.8%) satisfied the DSM-IV criteria for BD: 118 (7.9%) for BD-I and 191 (12.8%) for BD-II. When only part one of the MDQ was used, the best cutoff was 7 between BD and UD (sensitivity 0.66, specificity 0.88, positive predictive value 0.59, negative predictive value 0.91), 6 between BD-II and UD, and 10 between BD-I and BD-II. If all three parts of the MDQ were used, the MDQ could not distinguish between BD and UD at a cutoff of 7 (or 6), and the sensitivity was only 0.22 (or 0.24).
The Chinese version of the MDQ had good psychometric features in screening bipolar disorders from depressive patients with mood disorders when part two and part three of the MDQ were ignored.
PMCID: PMC3976254  PMID: 24705393
3.  Validation of the Chinese version of the "Mood Disorder Questionnaire" for screening bipolar disorder among patients with a current depressive episode 
BMC Psychiatry  2012;12:8.
The Mood Disorder Questionnaire (MDQ) is a well-recognized screening tool for bipolar disorder, but its Chinese version needs further validation. This study aims to measure the accuracy of the Chinese version of the MDQ as a screening instrument for bipolar disorder (BPD) in a group of patients with a current major depressive episode.
142 consecutive patients with an initial DSM-IV-TR diagnosis of a major depressive episode were screened for BPD using the Chinese translation of the MDQ and followed up for one year. The final diagnosis, determined by a special committee consisting of three trained senior psychiatrists, was used as a 'gold standard' and ROC was plotted to evaluate the performance of the MDQ. The optimal cut-off was chosen by maximizing the Younden's index.
Of the 142 patients, 122 (85.9%) finished the one year follow-up. On the basis of a semi-structured clinical interview 48.4% (59/122) received a diagnosis of unipolar depression (UPD), 36.9% (45/122) BPDII and 14.8% (18/122) BPDI. At the end of the one year follow-up,9 moved from UPD to BPD, 2 from BPDII to UPD, 1 from BPDII to BPDI, the overall rate of initial misdiagnosis was 16.4%. MDQ showed a good accuracy for BPD: the optimal cut-off was 4, with a sensitivity of 0.72 and a specificity of 0.73. When BPDII and BPDI were calculated independently, the optimal cut-off for BPDII was 4, with a sensitivity of 0.70 and a specificity of 0.73; while the optimal cut-off for BPDI was 5, with a sensitivity of 0.67 and a specificity of 0.86.
Our results show that the Chinese version of MDQ is a valid tool for screening BPD in a group of patients with current depressive episode on the Chinese mainland.
PMCID: PMC3299660  PMID: 22293033
4.  Screening for Bipolar Disorder Symptoms in Depressed Primary Care Attenders: Comparison between Mood Disorder Questionnaire and Hypomania Checklist (HCL-32) 
Psychiatry Journal  2013;2013:548349.
Objective. To describe the prevalence of patients who screen positive for bipolar disorder (BD) symptoms in primary care comparing two screening instruments: Mood Disorders Questionnaire (MDQ) and Hypomania Checklist (HCL-32). Participants. Adult patients presenting to their primary care practitioners for any cause and reporting current depression symptoms or a depressive episode in the last 6 months. Methods. Subjects completed MDQ and HCL-32, and clinical diagnosis was assessed by a psychiatrist following DSM-IV criteria. Depressive symptoms were evaluated in a subgroup with the Patient Health Questionnaire (PHQ-9). Results. A total of 94 patients were approached to participate and 93 completed the survey. Among these, 8.9% screened positive with MDQ and 43.0% with HCL-32. MDQ positive had more likely features associated with BD: panic disorder and smoking habit (P < .05). The best test accuracy was performed by cut-off 5 for MDQ (sensitivity = .91; specificity = .67) and 15 for HCL-32 (sensitivity = .64; specificity = .57). Higher total score of PHQ-9 was related to higher total scores at the screening tests (P < .001). Conclusion. There is a significant prevalence of bipolar symptoms in primary care depressed patients. MDQ seems to have better accuracy and feasibility than HCL-32, features that fit well in the busy setting of primary care.
PMCID: PMC3820078  PMID: 24236281
5.  Can the Loudness Dependence of Auditory Evoked Potentials and Suicidality Be Used to Differentiate between Depressive Patients with and without Bipolarity 
Psychiatry Investigation  2013;10(2):143-147.
This study aimed to test the hypothesis that the loudness dependence of auditory evoked potentials (LDAEP) can be used to predict the presence of bipolarity in patients with major depressive episodes.
A cohort of 61 patients who met the criteria for major depressive disorder (MDD) following diagnosis using Axis I of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders-text revision, and who had no history of hypomanic or manic episodes was included in this study. The patients were stratified into two subgroups based on whether or not they achieved a positive score for the Korean versions of the Mood Disorder Questionnaire (K-MDQ). The LDAEP was evaluated by measuring the auditory event-related potentials before beginning medication with serotonergic agents.
The Barratt Impulsiveness Scale (BIS) score was also higher for the positive screening group (81.24±11.87) than for the negative screening group (73.30±14.92; p=0.039, independent t-test). However, the LDAEP, Beck Depression Inventory, Hamilton Depression Rating Scale, Beck Hopelessness Scale (BHS), and Hamilton Anxiety Scale scores did not differ significantly between them. When binary logistic regression analysis was carried, the relationship between the positive or negative subgroups for K-MDQ and BIS or Beck Scale for Suicidal Ideation (BSS) score was also significant (respectively, p=0.017, p=0.038).
We found that LDAEP was not significantly different between depressive patients with and without bipolarity. However, our study has revealed the difference between two subgroups based on whether or not they achieved a positive score for the K-MDQ in BIS or BSS score.
PMCID: PMC3687048  PMID: 23798962
LDAEP; Major depressive disorder; Bipolarity; Bipolar spectrum disorder
6.  A cross-validation of the provisional diagnostic instrument (PDI-4) 
BMC Family Practice  2012;13:104.
The Provisional Diagnostic Instrument (PDI-4) is a brief, adult self-report instrument for 4 common psychiatric diagnoses in primary care patients: major depressive episode (MDE), generalized anxiety disorder (GAD), attention deficit hyperactivity disorder (ADHD), and bipolar I disorder based on past or present mania. Our objective was to assess validity of the PDI-4 in a population independent of the study population originally used to develop the scale.
An online version of the 17-item PDI-4 was administered to 1,047 adults in the US; respondents also completed the PHQ-9, HADS-A, CAARS-S, and MDQ within the online survey. Respondents self-reported diagnosis by a healthcare professional with the terms depression (n=221), anxiety (n=218), attention deficit disorder (n=206), bipolar or manic depressive disorder (n=195), or none of these (n=207). Statistical analyses examined convergent and discriminant validity, and operating characteristics of the PDI-4 relative to the individual, validated, self-rated scales PHQ-9, HADS-A, CAARS-S, and MDQ, for each PDI-4 diagnosis.
Convergent validity of the PDI-4 was supported by strong correlations with the corresponding individual scales (range of 0.63 [PDI-4 and MDQ] to 0.87 [PDI-4 and PHQ-9]). Operating characteristics of the PDI-4 were similar to results in the previous site-based study. The scale exhibited moderate sensitivities (0.52 [mania] to 0.70 [ADHD]) and strong specificities (0.86 [mania] to 0.92 [GAD]) using the individual scales as the gold standards. ANOVAs demonstrated that PDI-4 discriminated between subsets of patients defined by pre-specified severity level cutoff scores of the individual scales. However, overlapping symptoms and co-morbidities made differentiation between mental diagnoses much weaker than differentiation from the control group with none of the diagnoses.
The PDI-4 appears to be a suitable, brief, self-rated tool for provisional diagnoses of common mental disorders. However, the high level of symptom overlap between these diagnoses emphasizes that such brief scales are not a replacement for thorough diagnostic evaluation by trained medical providers.
PMCID: PMC3515462  PMID: 23067304
Cross validation; Diagnostic instrument; Anxiety; Depression; Hyperactivity; Mania
7.  Usefulness of the Spanish version of the mood disorder questionnaire for screening bipolar disorder in routine clinical practice in outpatients with major depression 
According to some studies, almost 40% of depressive patients – half of them previously undetected – are diagnosed of bipolar II disorder when systematically assessed for hypomania. Thus, instruments for bipolar disorder screening are needed. The Mood Disorder Questionnaire (MDQ) is a self-reported questionnaire validated in Spanish in stable patients with a previously known diagnosis. The purpose of this study is to evaluate in the daily clinical practice the usefulness of the Spanish version of the MDQ in depressive patients.
Patients (n = 87) meeting DSM-IV-TR criteria for a major depressive episode, not previously known as bipolar were included. The affective module of the Structured Clinical Interview (SCID) was used as gold standard.
MDQ screened 24.1% of depressive patients as bipolar, vs. 12.6% according to SCID. For a cut-off point score of 7 positive answers, sensitivity was 72.7% (95% CI = 63.3 – 82.1) and specificity 82.9% (95% CI = 74.9–90.9). Likelihood ratio of positive and negative tests were 4,252 y 0,329 respectively.
The small sample size reduced the power of the study to 62%.
Sensitivity and specificity of the MDQ were high for screening bipolar disorder in patients with major depression, and similar to the figures obtained in stable patients. This study confirms that MDQ is a useful instrument in the daily clinical assessment of depressive patients.
PMCID: PMC2426693  PMID: 18498637
8.  Validation of the Italian version of the "Mood Disorder Questionnaire" for the screening of bipolar disorders 
The study measured the accuracy of the Italian version of the Mood Disorder Questionnaire (MDQ) as a screening instrument for bipolar disorders in a psychiatric setting.
154 consecutive subjects attending the Division of Psychiatry of the University of Cagliari (Italy), were screened for bipolar disorders using the Italian translation of the MDQ, and diagnostically interviewed with the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID) by physicians.
On the basis of the SCID: 51 (33.1%) received a diagnosis of bipolar or schizoaffective bipolar type disorders, 63 (40.9%) were diagnosed as having at least one psychiatric disorder in Axis I (other than bipolar or schizoaffective bipolar type disorders), whilst 40 (25.9%) were unaffected by any type of psychiatric disorder. MDQ showed a good accuracy for bipolar or schizoaffective bipolar type disorders: the cut-off 4 had sensitivity 0.90 and specificity 0.58; the cut-off 5 had sensitivity 0.84 and specificity 0.70; and the cut-off 6 had sensitivity 0.76 and specificity 0.86. The accuracy for bipolar II disorders was sufficient but not excellent: the cut-off 4 had sensitivity 0.80 and specificity 0.45; the cut-off 5 had sensitivity 0.70 and specificity 0.55; and the cut-off 6 had sensitivity 0.55 and specificity 0.65.
Our results seem to indicate a good accuracy of MDQ, and confirm the results of recent surveys conducted in the USA. Moreover the instrument needs to be validated in other settings (e.g. in general practice).
PMCID: PMC1199611  PMID: 16042762
bipolar disorder; mood disorders; screening; mood disorder questionnaire
9.  Using the mood disorder questionnaire and bipolar spectrum diagnostic scale to detect bipolar disorder and borderline personality disorder among eating disorder patients 
BMC Psychiatry  2013;13:69.
Screening scales for bipolar disorder including the Mood Disorder Questionnaire (MDQ) and Bipolar Spectrum Diagnostic Scale (BSDS) have been plagued by high false positive rates confounded by presence of borderline personality disorder. This study examined the accuracy of these scales for detecting bipolar disorder among patients referred for eating disorders and explored the possibility of simultaneous assessment of co-morbid borderline personality disorder.
Participants were 78 consecutive female patients who were referred for evaluation of an eating disorder. All participants completed the mood and eating disorder sections of the SCID-I/P and the borderline personality disorder section of the SCID-II, in addition to the MDQ and BSDS. Predictive validity of the MDQ and BSDS was evaluated by Receiver Operating Characteristic analysis of the Area Under the Curve (AUC).
Fifteen (19%) and twelve (15%) patients fulfilled criteria for bipolar II disorder and borderline personality disorder, respectively. The AUCs for bipolar II disorder were 0.78 (MDQ) and 0.78 (BDSD), and the AUCs for borderline personality disorder were 0.75 (MDQ) and 0.79 (BSDS).
Among patients being evaluated for eating disorders, the MDQ and BSDS show promise as screening questionnaires for both bipolar disorder and borderline personality disorder.
PMCID: PMC3599106  PMID: 23443034
Bipolar disorder; Borderline personality disorder; Eating disorder; Comorbidity; Screening scale
10.  Relationship between Personality Disorder Functioning Styles and the Emotional States in Bipolar I and II Disorders 
PLoS ONE  2015;10(1):e0117353.
Bipolar disorder types I (BD I) and II (BD II) behave differently in clinical manifestations, normal personality traits, responses to pharmacotherapies, biochemical backgrounds and neuroimaging activations. How the varied emotional states of BD I and II are related to the comorbid personality disorders remains to be settled.
We therefore administered the Plutchick – van Praag Depression Inventory (PVP), the Mood Disorder Questionnaire (MDQ), the Hypomanic Checklist-32 (HCL-32), and the Parker Personality Measure (PERM) in 37 patients with BD I, 34 BD II, and in 76 healthy volunteers.
Compared to the healthy volunteers, patients with BD I and II scored higher on some PERM styles, PVP, MDQ and HCL-32 scales. In BD I, the PERM Borderline style predicted the PVP scale; and Antisocial predicted HCL-32. In BD II, Borderline, Dependant, Paranoid (-) and Schizoid (-) predicted PVP; Borderline predicted MDQ; Passive-Aggressive and Schizoid (-) predicted HCL-32. In controls, Borderline and Narcissistic (-) predicted PVP; Borderline and Dependant (-) predicted MDQ.
Besides confirming the different predictability of the 11 functioning styles of personality disorder to BD I and II, we found that the prediction was more common in BD II, which might underlie its higher risk of suicide and poorer treatment outcome.
PMCID: PMC4307975  PMID: 25625553
11.  The high frequency of manic symptoms in fibromyalgia does influence the choice of treatment? 
Mood disorders were found associated with fibromyalgia (FM) and clinical studies have revealed the efficacy of antidepressant drugs in the treatment of FM. However no specific instruments to identify manic symptoms were used.
To assess the frequency of anxiety and mood disorders (particularly bipolar disorders and manic symptoms) in a consecutive sample of women affected by FM using standardized diagnostic tools and to compare the prevalence of these disorders with that observed in a sample of healthy controls from the general population.
Cases: consecutive series of women (N = 37, mean age 50.1 ± 21.0) attending a Rheumatology outpatient Unit at the University of Cagliari. Controls: 148 women, drawn from the data bank of an epidemiological study matched for sex and age with controls according to a randomisation "after blocks" method. The Italian version of the Composite International Diagnostic Interview Simplified were carried out by physicians. Psychiatric diagnosis was formulated according to DSM-IV criteria. The Italian version of the Mood Disorder Questionnaire (MDQ) was administered to identify manic symptoms and bipolar disorders. Diagnosis of FM were carried out by rheumatologist according to the criteria of American College of Rheumatology.
Subjects with FM showed a higher comorbidity with Generalised Anxiety Disorder, Panic Disorder and Major Depressive Disorder than controls. The study showed a high frequency of manic symptoms (MDQ positive) in the sample of fibromyalgic patients (59%), approximately double that found in the control sample (P < 0.001).
Clinical studies have shown the efficacy of antidepressants, especially tricyclic antidepressants, in the treatment of FM. The clinical difficulty in identifying hypomanic episodes is well known particularly where previous and not present episodes are concerned as in depressive patients. These data would suggest further studies on the subject are needed and more caution also in prescribing antidepressants in a population apparently at high risk for bipolar disorders.
PMCID: PMC1779782  PMID: 17177985
12.  Prevalence of Bipolar Disorder symptoms in Primary Care (ProBiD-PC) 
Canadian Family Physician  2011;57(2):e58-e67.
To describe the prevalence of patients who screen positive for symptoms of bipolar disorder in primary care practice using the validated Mood Disorders Questionnaire (MDQ).
Prevalence survey.
Fifty-four primary care practices across Canada.
Adult patients presenting to their primary care practitioners for any cause and reporting, during the course of their visits, current or previous symptoms of depression, anxiety, substance use disorders, or attention deficit hyperactivity disorder.
Main outcome measures
Subjects were screened for symptoms suggestive of bipolar disorder using the MDQ. Health-related quality of life, functional impairment, and work productivity were evaluated using the 12-Item Short-Form Health Survey and Sheehan Disability Scale.
A total of 1416 patients were approached to participate in this study, and 1304 completed the survey. Of these, 27.9% screened positive for symptoms of bipolar disorder. All 13 items of the MDQ were significantly associated with screening positive for bipolar disorder (P < .05). Patients screening positive were significantly more likely to report depression, anxiety, substance use, attention deficit hyperactivity disorder, family history of bipolar disorder, or suicide attempts than patients screening negative were (P < .001). Health-related quality of life, work or school productivity, and social and family functioning were all significantly worse in patients who screened positive (P < .001).
This prevalence survey suggests that more than a quarter of patients presenting to primary care with past or current psychiatric indices are at risk of bipolar disorder. Patients exhibiting a cluster of these symptoms should be further questioned on family history of bipolar disorder and suicide attempts, and selectively screened for symptoms suggestive of bipolar disorder using the quick and high-yielding MDQ.
PMCID: PMC3038834  PMID: 21642707
13.  The Mood Disorder Questionnaire improves recognition of bipolar disorder in psychiatric care 
BMC Psychiatry  2003;3:8.
We investigated our translation of The Mood Disorder Questionnaire (MDQ) as a screening instrument for bipolar disorder in a psychiatric setting in Finland.
In a pilot study for the Jorvi Bipolar Study (JoBS), 109 consecutive non-schizophrenic psychiatric out- and inpatients in Espoo, Finland, were screened for bipolar disorder using the Finnish translation of the MDQ, and 38 of them diagnostically interviewed with the SCID.
Forty subjects (37%) were positive in the MDQ screen. In the SCID interview, twenty patients were found to suffer from bipolar disorder, of whom seven (70%) of ten patients with bipolar I but only two (20%) of ten with bipolar II disorder had been previously clinically correctly diagnosed. The translated MDQ was found internally consistent (alpha 0.79) and a feasible screening tool.
Bipolar disorder, particularly type II, remains commonly unrecognized in psychiatric settings. The Mood Disorder Questionnaire is a feasible screen for bipolar disorder, which could well be integrated into psychiatric routine practice.
PMCID: PMC169168  PMID: 12854971
14.  The accuracy of the Italian version of the Hypomania Checklist (HCL-32) for the screening of bipolar disorders and comparison with the Mood Disorder Questionnaire (MDQ) in a clinical sample 
The study measured the accuracy of the Italian version of the Hypomania Checklist (HCL-32) for self-assessment as a screening instrument for bipolar disorder (BPD) in a psychiatric setting and compared results with a previous study, carried out in a comparable sample and in the same setting, using the Mood Disorder Questionnaire (MDQ).
123 consecutive subjects attending a psychiatric division were screened for BPD using the Italian translation of the HCL-32, and diagnostically interviewed with the SCID by physicians. The sample of the previous study using the MDQ consisted of 154 subjects.
On the basis of the SCID: 26 received a diagnosis of bipolar/schizoaffective disorder, 57 were diagnosed as having at least another psychiatric disorder in Axis-I, whilst 40 were unaffected by any type of psychiatric disorder. Comparing the bipolar with all other patients the HCL-32 showed a good accuracy: cut-off 8: sensitivity 0.92-specificity 0.48; cut-off 10: sensitivity 0.88-specificity 0.54; cut-off 12: sensitivity 0.85-specificity 0.61. The accuracy for BPD-II (10) remains good: cut-off 8: sensitivity 0.90-specificity 0.42; cut-off 10: sensitivity 0.80-specificity 0.47; cut-off 12: sensitivity 0.80-specificity 0.54. The comparison with the MDQ performance shows that both screening tools may show good results, but HCL-32 seems to be more sensitive in detecting BPD-II.
Our results seem to indicate good accuracy of HCL-32 as a screening instrument for BPD in a psychiatric setting, with a low rate of false negatives, and a fairly good degree of identification of BPD-II.
PMCID: PMC1420280  PMID: 16524481
15.  Sub-threshold depression and antidepressants use in a community sample: searching anxiety and finding bipolar disorder 
BMC Psychiatry  2011;11:164.
To determine the use of antidepressants (ADs) in people with sub-threshold depression (SD); the lifetime prevalence of mania and hypomania in SD and the link between ADs use, bipolarity and anxiety disorders in SD.
Study design: community survey. Study population: samples randomly drawn, after stratification from the adult population of municipal records. Sample size: 4999 people from seven areas within six Italian regions. Tools: Questionnaire on psychotropic drug consumption, prescription; Structured Clinical Interview NP for DSM-IV modified (ANTAS); Hamilton Depression Rating Scale (HAM-D); Mood Disorder Questionnaire (MDQ); Short Form Health Survey (SF-12). SD definition: HAM-D > 10 without lifetime diagnosis of Depressive Episode (DE).
SD point prevalence is 5.0%. The lifetime prevalence of mania and hypomania episodes in SD is 7.3%. Benzodiazepines (BDZ) consumption in SD is 24.1%, followed by ADs (19.7%). In SD, positive for MDQ and comorbidity with Panic Disorder (PD) or Generalized Anxiety Disorders (GAD) are associated with ADs use, whereas the association between a positive MDQ and ADs use, without a diagnosis of PD or GAD, is not significant. Only in people with DE the well-being (SF-12) is higher among those using first-line antidepressants compared to those not using any medication. In people with SD no significant differences were found in terms of SF-12 score according to drug use.
This study suggests caution in prescribing ADs to people with SD. In people with concomitant anxiety disorders and SD, it should be mandatory to perform a well-designed assessment and evaluate the presence of previous manic or hypomanic symptoms prior to prescribing ADs.
PMCID: PMC3206417  PMID: 21985128
16.  Hypomanic Experience in Young Adults Confers Vulnerability to Intrusive Imagery After Experimental Trauma 
Clinical Psychological Science  2014;2(6):675-684.
Emotional mental imagery occurs across anxiety disorders, yet is neglected in bipolar disorder despite high anxiety comorbidity. Furthermore, a heightened susceptibility to developing intrusive mental images of stressful events in bipolar disorder and people vulnerable to it (with hypomanic experience) has been suggested. The current study assessed, prospectively, whether significant hypomanic experience (contrasting groups scoring high vs. low on the Mood Disorder Questionnaire, MDQ) places individuals at increased risk of visual reexperiencing after experimental stress. A total of 110 young adults watched a trauma film and recorded film-related intrusive images for 6 days. Compared to the low MDQ group, the high MDQ group experienced approximately twice as many intrusive images, substantiated by convergent measures. Findings suggest hypomanic experience is associated with developing more frequent intrusive imagery of a stressor. Because mental imagery powerfully affects emotion, such imagery may contribute to bipolar mood instability and offer a cognitive treatment target.
PMCID: PMC4230964  PMID: 25419498
bipolar disorder; mental imagery; trauma film; involuntary memory; intrusive imagery
17.  The prevalence of bipolar spectrum disorder in elderly patients with recurrent depression 
Despite a growing body of knowledge on bipolar spectrum disorder (BSD), relatively little is known about the clinical characteristics of BSD in elderly people. We investigated the prevalence of BSD in elderly patients with recurrent depression.
Patients and methods
A total of 65 elderly outpatients (≥60 years of age) who met the Diagnostic and Statistical Manual of Mental Disorders IV criteria for recurrent major depressive disorder participated in the study. BSD was diagnosed according to the criteria developed by Ghaemi et al and the Mood Disorder Questionnaire (MDQ) was used to assess bipolarity.
Of 65 subjects, eleven (16.9%) and 54 (83.1%) were diagnosed with BSD and unipolar depression, respectively. A total of 32.3% (n=22) had a positive screen for bipolar disorder, and we found a significant association between the BSD criteria and the criteria for a positive MDQ (P<0.001). Patients with BSD had a longer duration of illness (P=0.040) and more prior depressive episodes (P<0.001) than did those with unipolar depression. The BSD criteria of first-degree relative with bipolar disorder (P=0.030), antidepressant-induced hypomania (P=0.034), hyperthymic personality (P=0.001), and atypical depression (P=0.030) were highly associated with MDQ-positive patients.
Our results indicate that many depressed elderly patients have bipolar-related illness; moreover, some features of the depression are associated with bipolarity.
PMCID: PMC4020892  PMID: 24855364
bipolarity; unipolar depression; MDQ; elderly
18.  Correlation between mental health co‐morbidity screening scores and clinical response in collaborative care treatment for depression 
Mental Health in Family Medicine  2010;7(3):129-133.
The hypothesis for this paper is that adult patients who have higher screening scores for mental health co‐morbidities and depression have a greater likelihood of not responding to treatment with collaborative care management (CCM) for their depression within six months.
For the 334 patients in this study, the primary endpoints were if the patient was in remission at six months (PHQ‐9 score <5) or if they were non‐responsive (NR) (PHQ‐9 >50% of baseline score). Initial evaluation included screening for alcoholism (AUDIT), anxiety (GAD‐7) and bipolar disorders (MDQ).
The differences in marital status, percentage of minority patients, gender, initial PHQ‐9 and AUDIT scores were not statistically significant. Mood Disorders Questionnaire (MDQ) screening was more likely to be negative for the group in remission (96.2% vs 90.0%, P=0.049) and positive for the NR group (8.0% vs 2.1%, P=0.026). GAD‐7 screening was significantly lower in the remission group (9.85) than in the NR group (11.53, P=0.009).
Results of multiple logistic regression analysis demonstrated that age, gender, race, marital status, PHQ‐9 score and AUDIT score were not related to the odds of being NR. A one‐point higher GAD‐7 score was associated with approximately 6% higher adjusted odds of being NR. Patients with a positive MDQ were associated with elevated odds of non‐response (adjusted OR=3.4714, P=0.044) when controlling for all other variables.
A higher initial screening score for anxiety or bipolar disorder is associated with a statistically significant increase in the relative risk of patients in CCM not responding to current treatments for depression within six months.
PMCID: PMC3018955  PMID: 22477934
collaborative care management; co‐morbidity; depression
19.  Is Caregiver-Adolescent Disagreement Due to Differences in Thresholds for Reporting Manic Symptoms? 
Cross-informant disagreement is common and results in different interpretations of a youth's behavior. Theoretical explanations for discrepancies typically rely on scale level analyses. This article explores whether caregivers and adolescents differ in when they notice and report symptoms of youth mania depending on the severity of overall manic disturbance.
Participants were 459 adolescent-caregiver pairs recruited at either a community mental health center or an academic medical center. Adolescents were most likely to have a primary diagnosis of unipolar depression (37%) or attention-deficit/hyperactivity disorder/disruptive behavior disorder (36%). Nineteen percent of adolescents received a bipolar spectrum disorder diagnosis (4% bipolar I and 15% bipolar II, cyclothymia, or bipolar not otherwise specificed). Caregivers were primarily biological mothers (74%) or grandparents (8%). Adolescents and caregivers independently completed the Mood Disorder Questionnaire (MDQ) about the adolescent.
Item response theory analyses of the entire sample indicated that in general, both caregivers and adolescents reserved endorsement of mania symptoms for the most severely ill half of participants. Comparisons of caregiver and adolescent report of symptoms on the MDQ indicated two significant differences. Caregivers were more likely to report irritability at significantly lower severity of mania than adolescents. Adolescents endorsed only increased energy or hyperactivity at lower severities than caregivers.
Adolescents and caregivers will have different concerns and might report different symptoms consistent with whom the symptom impacts first. Caregivers are more likely to report behaviors such as irritability, whereas adolescents are more likely to report subjective feelings such as feeling more energetic or more hyperactive.
PMCID: PMC3243459  PMID: 22040188
20.  The Use of Antidepressants in the Long-Term Treatment Should not Improve the Impact of Fibromyalgia on Quality of Life 
Antidepressant (AD) drugs are effective in the short term treatment of fibromyalgia (FM). It may be useful to study the long-term impact of AD on patients with FM.
One-year follow-up study on 23 females with FM divided into groups on AD (ADg-N=7), and not taking AD (NADg-N=11). Evaluation at t1 and at the end (t2) with the Fibromyalgia Impact Questionnaire (FIQ); at t2 with: SCID-IV; Mood Disorder Questionnaire (MDQ); Short Form-12; Hamilton Depression Rating Scale (HAM-D); Functioning Assessment Short Test (FAST)
After a year the AD group showed a worst impact of the disease by FIQ (p=0.017), worsened quality of life by SF-12 (p<0.01), and disability linked to bipolar symptoms by FAST (p=0.05). About 40% of the sample was screened positive at MDQ without difference in the two groups. The patients who recovered from a depressive episode did not differ between ADg and NADg (20% vs 33.3%), and were fewer than expected from the literature (40-60%). The HAM-D score at the end of the trial was worse in the ADg (p<0.03).
Observational research on few patients, not specifically designed to test the hypothesis. The results have a heuristic value only.
The results should be read in the light of the high prevalence of patients screened positive for Bipolar Disorders and of the well-known poor response of the mood symptoms to antidepressants in Bipolar Depression. The deterioration in the long-term management of FM patients following AD treatments suggests the need for new and robust studies.
PMCID: PMC3735921  PMID: 23986787
Fibromyalgia; Antidepressants; Efficacy; Long-Term Treatment; Quality of life.
21.  Prevalence of bipolar spectrum disorder in Korean college students according to the K-MDQ 
The purpose of this study was to assess the prevalence of bipolar spectrum disorder (BSD) in the general Korean population.
A sample of college students (n = 1026) was stratified to reflect geographical differences accurately in Korean college students. The Korean version of the Mood Disorder Questionnaire (K-MDQ) was administered and an epidemiological survey carried out between November 2006 and February 2007. BSD was defined as a score of at least seven K-MDQ symptoms that co-occurred and resulted in minimal or more functional impairment.
The prevalence of BSD was 18.6% (95% confidence interval [CI] 16.2–21.0) in total, being 19.8% (95% CI 16.3–23.2) in men and 17.5% (95% CI 14.2–20.8) in women. The prevalence of BSD was more common in rural dwellers than in urban dwellers (P = 0.008, chi-square test). Univariate and multivariate regression models showed that rural residence was a significant factor associated with BSD. There were significant relationships between BSD and gender, age, and socioeconomic status.
The prevalence of BSD found in the present study is higher than that reported by other epidemiological studies in Korea and in international studies.
PMCID: PMC3699257  PMID: 23836973
general population; bipolar disorder; epidemiological study; Mood Disorder Questionnaire
22.  The Farsi version of the Hypomania Check-List 32 (HCL-32): Applicability and indication of a four-factorial solution 
BMC Psychiatry  2011;11:14.
Data from the Iranian population for hypomania core symptom clusters are lacking. The aim of the present study was therefore to apply the Farsi version of the Hypomania-Check-List 32 (HCL-32), and to explore its factorial structure.
A total of 163 Iranian out-patients took part in the study; 61 suffered from Major Depressive Disorder (MDD), and 102 suffered from Bipolar Disorders (BP). Participants completed the Mood Disorder Questionnaire (MDQ) and the Hypomania Checklist (HCL-32). Exploratory factor analyses were used to examine the properties of the HCL-32. A ROC-curve analysis was performed to calculate sensitivity and specificity.
The HCL-32 differentiated between patients with MDD and with BP. Psychometric properties were satisfactory: sensitivity: 73%; specificity: 91%. MDQ and HCL-32 did correlate highly. No differences were found between patients suffering from BP I and BP II.
Instead of the two-factorial structure of the HCL-32 reported previously, the present pattern of factorial results suggest a distinction between four factors: two broadly positive dimensions of hypomania ("physically and mentally active"; "positive social interactions") and two rather negative dimensions ("risky behavior and substance use"; "difficulties in social interaction and impatience").
The Farsi version of the HCL-32 proved to be applicable, and therefore easy to introduce within a clinical context. The pattern of results suggests a four factorial solution.
PMCID: PMC3036591  PMID: 21251272
23.  Prevalence of psychiatric morbidity among urban elderlies: Lucknow elderly study 
Indian Journal of Psychiatry  2014;56(2):154-160.
Paucity of systematic studies in elderly mental health in an aging population is an urgent need, which is required to address services and planning issues for health.
The present study aims to investigate the distribution of physical, neuropsychiatric, and cognitive disorders of a community sample of elderlies with certain socioeconomic data.
Materials and Methods:
A door-to-door household survey was conducted to identify houses with elderlies (≥55 years) in two urban localities of Lucknow. Mini mental state examination (MMSE), Survey Psychiatric Assessment Schedule (SPAS)/Mood Disorder Questionnaire (MDQ) and physical and neurological examination were used for screening all consenting elderlies. MMSE positive participants were assessed on Cambridge Mental Disorders of the Elderly Examination-Revised for diagnosis of cognitive disorders; SPAS/MDQ positives were assessed on Schedule for Clinical Assessment in Neuropsychiatry based clinical interview for diagnosis of neuropsychiatric disorders other than cognitive disorders (using ICD-10 criteria). Routine and indicated laboratory/radiological investigations on all and on MMSE/SPAS (organic section) positive/physically ill participants respectively were done to confirm organic and/or physical illness. Only percentages were calculated to find the distribution of morbidity.
The sample had proportionate age structure as that of the surveyed population and had balanced gender representation in each age deciles. Prevalence of neuropsychiatric disorders (with/without comorbidities) was 11.8% in the elderlies (60 years and above) highest being in the 60-69 years age group. Being women and of lower socioeconomic status was more commonly associated with a neuropsychiatric diagnosis. 7.6% of the elderlies had cognitive impairment. Overall findings suggest a prevalence rate of 17.34% of total psychiatric morbidity among elderlies. A significant number had comorbid physical illness diagnoses.
More than half the elderlies had some diagnosable physical or mental ailment. The study familiarizes us to the significant amount of physical and psychiatric comorbidity in the particular age group. About one-fifth was found to suffer from psychiatric morbidity, which any health services for the elderly should be oriented towards.
PMCID: PMC4040063  PMID: 24891703
Cambridge mental disorders of the elderly examination-revised; cognitive impairment; comorbid physical illness; elderly; prevalence; psychiatric morbidity
24.  Measuring Intrusive Prospective Imagery using the Impact of Future Events Scale (IFES): Psychometric properties and relation to risk for Bipolar Disorder 
We define intrusive prospective imagery as the experience of mental imagery of events that may happen in the future and which come to mind involuntarily. This everyday phenomenon may be exacerbated in psychological disorders such as bipolar disorder (Holmes, Geddes, Colom, & Goodwin, 2008) although specific measures to assess this have been lacking. We recently developed the Impact of Future Events Scale (IFES; Deeprose & Holmes, 2010), which is further examined in the current paper. In Study 1, adults volunteers (N=50) completed the IFES on two occasions, with 1-week between measurements. This revealed acceptable test-rest reliability. In Study 2, (N=90) IFES showed good internal consistency and confirmed two predictions. First, in the total sample risk for bipolar disorder (MDQ; Hirschfield et al., 2000) and IFES Total Score correlated positively. Second, when the sample was split into high (MDQ ≥ 7) and low (MDQ ≤ 6) bipolarity risk groups, higher IFES Total Scores were observed in the high risk group. We conclude that 1) IFES presents a useful measure for assessing intrusive prospective imagery with acceptable test-retest reliability and good internal consistency and 2) risk for bipolar disorder is associated with elevated IFES Total Scores with potentially important clinical implications.
PMCID: PMC3442225  PMID: 22984633
Mental imagery; intrusion; prospective cognition; Impact of Future Events Scale; IFES; bipolar disorder
Archives of general psychiatry  2003;60(11):1097-1108.
To estimate six-month prevalence of comorbid psychiatric disorders among juvenile detainees by demographic subgroups (gender, race/ethnicity, and age).
Epidemiologic study of juvenile detainees. Master’s level clinical research interviewers administered the Diagnostic Interview Schedule for Children (DISC 2.3) to randomly selected detainees.
A large temporary detention center for juveniles in Cook County, Illinois (which includes Chicago and surrounding suburbs).
Randomly selected, stratified sample of 1829 African American, non-Hispanic white, and Hispanic youth (1172 males, 657 females, ages 10–18) arrested and newly detained.
Main Outcome Measures
Diagnostic Interview Schedule for Children (DISC 2.3).
Significantly more females (56.5%) than males (45.9%) met criteria for 2 or more of the following disorders: major depressive, dysthymic, manic, psychotic, panic, separation-anxiety, overanxious, generalized anxiety, obsessive compulsive, attention deficit-hyperactivity, conduct, oppositional-defiant, alcohol, marijuana, and other substance; 17.3% of females and 20.4% of males had only one disorder. We also examined types of disorder: affective, anxiety, substance use and ADHD/behavioral. The odds of having comorbid disorders were higher than expected by chance for most demographic subgroups, except when base rates of disorders were already high, or when cell sizes were small. Nearly 14% of females and 11% of males had both a major mental disorder (psychosis, manic episode, or major depressive episode) and a substance use disorder. Compared to participants with no major mental disorder (the residual category), those with a major mental disorder had significantly greater odds (1.8–4.1) of having substance use disorders. Nearly 30% of females and over 20% of males with substance use disorders had major mental disorders. Rates of some types of comorbidity were higher among non-Hispanic whites and older adolescents.
Comorbid psychiatric disorders are a major health problem among detained youth. We recommend directions for research and discuss how to improve treatment and reduce health disparities in the juvenile justice and mental health systems.
PMCID: PMC2893728  PMID: 14609885

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