Research report
Cross validation with the mood disorder questionnaire (MDQ) of an instrument for the detection of hypomania in Spanish: The 32 item hypomania symptom check list (HCL-32)

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Abstract

Background

The detection and diagnosis of present or past hypomanic episodes is of key importance for the differential diagnosis between depressive disorders and type II bipolar disorder. However, there are few instruments available to satisfactorily screen for the latter condition. The Hypomania Symptom Checklist-32 (HCL-32) is a self-applied questionnaire with 32 hypomania items and 8 severity and functional impact items which is being developed in several European countries for this purpose. Our aim was to develop and validate the psychometric properties of the HCL-32 scale in Spain in patients with bipolar disorder and to compare its properties with other instruments available for the detection of bipolar II disorder.

Methods

Patients were selected from 15 psychiatric outpatient departments, diagnosed with type I or type II bipolar disorder (BDI and BDII) and unipolar major depression (MD) according to DSM-IV-TR criteria. A control group of healthy subjects (HS) was likewise assessed. The patient selection criteria included a well-established diagnosis and a stable disorder and pharmacological treatment. The HCL-32 was administered to 237 subjects distributed among the above groups, on two occasions four weeks apart. We analysed the internal consistency, test–retest reliability and discriminative capacity of the HCL-32.

Results

The internal consistency of the Spanish version of the HCL-32, evaluated by Cronbach's alpha, was 0.94. Mean of affirmative questions by group were 21.2 (SD 5.8) for BDI, 19.3 (SD 6.2) for BDII, 8.6 (SD 6.6) for MD and 6.6 (SD 6.1) for HS, with statistically significant differences between them (Kruskal–Wallis test, p < 0.001). Concurrent validity using the diagnosis variable was 0.72. Test–retest reliability was 0.90. We analysed the best cut-off point by means of a ROC curve analysis; for 14 affirmative responses, a sensitivity of 0.85 95%CI (0.78, 0.91) and specificity of 0.79, 95%CI (0.72, 0.87) were obtained. The positive and negative probability ratios were 4.1 and 5.3 (1/0.19 respectively). HCL-32 shows a dual factor structure of items, one as an energy-activity factor and another one as a factor involving items related to disinhibition and problems with self-control and attention.

Limitations

The sample size of bipolar patients (particularly type BDII) should be increased in further studies.

Conclusions

The Spanish version of the HCL-32 has good psychometric properties and sufficient sensitivity and specificity, detecting 8 out of every 10 patients with BD. The HCL-32 is a useful screening tool of patients with bipolar disorder in clinical settings. In its present form it adequately discriminates between bipolar and unipolar or healthy subjects, but not between BD I and BII.

Introduction

Different epidemiological studies indicate a prevalence of bipolar II disorder of around 5% of the population (Berk et al., 2005). However, a systematic check on the existence of a history of hypomania or hypomanic features (symptoms or conduct) yields greater prevalence rates for this disorder (Benazzi and Akiskal, 2003, Hadjipavlou et al., 2004). The correct identification of a prior episode of hypomania is required to correctly diagnose bipolar II disorder. The clinical guidelines published by the American Psychiatric Association indicate that bipolar II disorder is often misdiagnosed initially as major depressive disorder, leading patients to receive incorrect treatment (American Psychiatric Association, 2002). Studies indicate that an accurate diagnosis of bipolar disorders usually takes from 8 to 10 years (Ghaemi et al., 1999). As BDII patients tend to see a psychiatrist when they are depressed (Hantouche et al., 1998, Hirschfeld et al., 2003), an instrument that would be able to detect prior hypomania would be extremely useful, because hypomanic symptoms may be masked by depressive symptoms.

The results obtained from recent studies indicate that the diagnostic criteria of the American Psychiatric Association (American Psychiatric Associacion, 1994) for BDII are highly specific but not very sensitive. A self-applied instrument for the detection of hypomanic episodes would be of great clinical use, reducing the time required to reach a correct diagnosis and eligible for use in epidemiological studies (Benazzi and Akiskal, 2003, Angst et al., 2005). The Hypomania Checklist-32 (HCL-32) is a self-applied questionnaire being internationally developed. It aims at identifying hypomanic symptoms in patients with major depressive disorder, helping to establish a diagnosis of BDII in usual clinical practice (Hantouche et al., 2003, Akiskal et al., 2003, Angst et al., 2005, Carta et al., 2006).

The purpose of this study was to develop a Spanish version of the HCL-32 and describe its psychometric characteristics for the detection of patients with bipolar disorder in clinical practice, and to set a cut-off point. The Spanish adaptation of the HCL-32 was performed in this study together with the validation of the Spanish version of the Mood Disorders Questionnaire (MDQ) (Sánchez-Moreno et al., 2005), which is a brief instrument, especially designed for the detection of bipolar disorder. The original English version has been validated in psychiatric and general population. The MDQ has shown adequate sensitivity and specificity for psychiatric clinical practice, correctly identifying 7 out of every 10 patients with bipolar disorder, and ruling out 9 out of every 10 subjects without bipolar disorder (Hirschfeld et al., 2000). A further objective of the present study was to compare the sensitivity and specificity of both questionnaires.

Section snippets

Method

The study was conducted in outpatient clinics of the Psychiatry Departments of 15 centres in different regions in Spain. Participation in the study was proposed to a consecutive sample of adult patients attending the clinics for follow-up relating to their clinical condition. The study was approved by the Hospital Clinic de Barcelona Ethics Committee and subsequently submitted to the research ethics committees of the other centres involved for their agreement to participate. Written informed

Sample description

The patients and the healthy subjects were included consecutively at the respective centres, from December 2004 to May 2005. Two hundred and thirty-six participants provided written consent to participate. There were 118 bipolar patients (62 BDI and 56 BDII) 58 with unipolar depressive disorder and 60 controls. Nearly all the participants who completed the first visit attended the second retest visit (226 participants, 95.8%). Table 1 shows the demographic and clinical characteristics of the

Discussion

Hypomania is perhaps the most difficult psychiatric syndrome to rule out retrospectively (Vieta et al., 2005). However, the retrospective detection of hypomania is crucial for a correct diagnosis of bipolar disorder, and particularly for BDII, and for treatment accuracy. Unfortunately, the misdiagnosis of BDII as unipolar depression is still very frequent, and may carry serious consequences (Ghaemi et al., 1999). The availability of a good screening tool for past hypomania episodes would be

Acknowledgements

The authors thank the following organisations and people for their scientific and logistic contributions to the project; S. Zaragoza and M. Puig, at PSYNCRO, Neuropsychological Research Organization, S.L.; M. De Gracia, Psychology Department, Basic Psychology Area, Universitat de Girona. This study was funded by GlaxoSmithKline, S.A.

The authors would like to acknowledge the following investigators in the EDHIPO (Hypomania Detection Study) group: Jesus Artal, Jacqueline Mayoral, Antonio Bulbena,

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