Brief report
Reducing the Hypomania Checklist (HCL-32) to a 16-item version

https://doi.org/10.1016/j.jad.2010.01.004Get rights and content

Abstract

Background

The under-recognition of hypomanic symptoms by both clinicians and patients is a major clinical problem which contributes to misdiagnosis and diagnostic delay in patients with bipolar disorder. The recent development of validated screening instruments for hypomania, such as the Hypomania Checklist (HCL-32), may help to improve the detection of bipolar disorder. In this study, we assess whether it is possible to reduce the number of items on the HCL-32 without any loss in the screening tool's ability to reliably differentiate between bipolar disorder (BD) and major depressive disorder (MDD).

Methods

Using our large samples of patients with DSM-IV defined bipolar I disorder (BD-I) (n = 230) and recurrent MDD (n = 322), we performed item correlations in order to identify potentially redundant items in the HCL-32. We then tested the performance of a shortened 16-item HCL questionnaire within a separate sample of patients with BD (including BD-I, BD-II and BD-NOS) (n = 59) and MDD (n = 76).

Results

The structure of the 16-item HCL demonstrated two main factors similar to those identified for the HCL-32 (an ‘active-elated’ factor and a ‘risk-taking/irritable’ factor). A score of 8 or more on a shortened 16-item version of the HCL had excellent ability to distinguish between BD and MDD. The sensitivity (83%) and specificity (71%) of the 16-item version were very similar to those for the full 32-item HCL.

Limitations

The HCL-16 was derived after subjects had completed the full HCL-32. It will be important to test the validity of a ‘stand-alone’ 16-item HCL questionnaire.

Conclusions

A shortened 16-item HCL (the HCL-16) is potentially a useful screening tool for hypomania within busy clinical settings.

Introduction

Distinguishing between major depressive disorder (MDD) and bipolar disorder (BD) is a common problem in clinical practice. BD is frequently misdiagnosed as MDD (Ghaemi et al., 2000) and many bipolar patients wait several years before being correctly diagnosed (Berk et al., 2007). A key factor is the under-recognition of hypomanic symptoms by both clinicians and patients (Ghaemi et al., 2002). The correct diagnosis of BD (rather than MDD) has important implications for long-term prognosis and treatment choices, especially with regard to the use of antidepressants, which may be of limited value in the treatment of bipolar depression and may (at least for a proportion of patients) be unhelpful (Mcelroy et al., 2008, Sachs et al., 2007, Smith et al., 2009, Smith et al., 2008, Sharma et al., 2005; Rybakowski et al., 2010).

In recent years several screening instruments for hypomania have been developed in order to improve the detection of bipolar disorder (for a detailed review, please see Allen and Smith (2008)). These include the Mood Disorder Questionnaire (MDQ) (Hirschfeld et al., 2003a; Hirschfeld et al., 2005; Hirschfeld et al., 2003b); the Bipolar Spectrum Diagnostic Scale (BSDS) (Ghaemi et al., 2005) and the Hypomania Checklist (HCL-32) (Angst et al., 2005; Meyer et al., 2007). The MDQ seems to be most helpful for detecting severe bipolar disorder (such as bipolar I disorder, BD-I) within secondary care samples whereas the BSDS performs well in detecting bipolar II disorder (BD-II) (Phelps and Ghaemi, 2006).

The HCL-32 was developed by Angst et al. (2005) and was based on the previously described Hypomania Checklist-20 (Allilaire et al., 2001). The primary goal of the HCL-32 was to identify hypomanic components in patients with MDD in order to help the clinician to diagnose BD-II in psychiatric and general medical practice. The multi-lingual Hypomania Checklist, which has been shown to not be influenced by current mental state, has been developed and tested internationally. The HCL-32 is a promising screening questionnaire for the correct identification of both BD-I and BD-II in a range of clinical and non-clinical settings (Meyer et al., 2007) but it's length and format may make it difficult to use in busy clinical practice (such as primary care).

In this study, we assess whether it is possible to reduce the number of items on the HCL-32 while at the same time maintaining its ability to reliably differentiate between BD and MDD. We first performed item correlations in order to identify possible redundant items on the HCL-32 within our large samples of patients with DSM-IV defined recurrent MDD and BD-I. We then tested the performance of a shortened HCL questionnaire within a separate sample of patients with BD (including BD-I, BD-II and BD-NOS) and MDD.

Section snippets

Stage 1: Correlational analysis to identify potentially redundant items on the HCL-32

Subjects with recurrent major depressive disorder (MDDR, N = 322) and bipolar I disorder (BD-I, N = 260) were recruited as part of ongoing molecular genetic studies (Forty et al., 2009b; Green et al., 2006; Raybould et al., 2005; McGuffin et al., 2005). All participants were aged 18 years or over and were of UK/Eire white ethnicity.

All subjects were interviewed using the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) (Wing et al., 1990) and psychiatric and general practice case-notes

Stage 1: Correlational analysis to identify potentially redundant items on the HCL-32

Although the BD-I group had a significantly younger age at interview when compared to the MDDR group [47 (17) median, (interquartile range), 51 (16) p = 0.019], there was no significant difference in illness duration between the two groups [22 years (19), 21 years (18.75), p = 0.80]. There was no significant difference in gender between the BD-I [70.8% female] and MDDR [67.4% female] samples [p = 0.38]. As expected, total HCL-32 scores were significantly lower in the MDDR sample, compared to the BD-I

Discussion

We have reduced the number of items on the Hypomania Checklist by half without any substantial loss in the ability to differentiate between BD (broadly defined as BD-I, BD-II and BD-NOS) and MDD. Using a shortened version of the questionnaire, the HCL-16, a cut off of greater than 7 was found to give the best combination of sensitivity (true bipolars) (83%) and specificity (true non-bipolars) (71%) with a positive predictive value of 69.0% and a negative predictive value of 84.4%. The

Conclusions

In summary, we suggest that clinicians in busy clinical practice may find the shortened HCL-16 a useful screening tool for the assessment of possible bipolar disorder in patients presenting with recurrent depression. The HCL-16 may also be of benefit in research studies (such as large-scale genetic studies) (McGuffin et al., 2003) which seek to screen large numbers of “unipolar” depressed populations for the presence of hypomanic features and could improve diagnostic homogeneity within these

Role of funding source

Funding for this study was provided by the Medical Research Council (MRC) and the Wellcome Trust. DJS is funded by a Postdoctoral Fellowship from the National Institute of Health Research (NIHR). EG is funded by an MRC/Welsh Assembly Government Partnership Award.

The funding sources had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

Conflict of interest

All authors declare that they have no conflicts of interest.

Acknowledgements

We are grateful to all patients and their families who have participated in this research.

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