Preliminary communication
The HCL-32: Towards a self-assessment tool for hypomanic symptoms in outpatients

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Abstract

Background

Bipolar disorders (BP) are frequently diagnosed and treated as pure depression initially; accurate diagnosis often being delayed by 8 to 10 years. In prospective studies, the presence of hypomanic symptoms in adolescence is strongly predictive of later bipolar disorders. As such, an instrument for self-assessment of hypomanic symptoms might increase the detection of suspected and of manifest, but under-treated, cases of bipolar disorders.

Methods

The multi-lingual hypomania checklist (HCL-32) has been developed and is being tested internationally. This preliminary paper reports the performance of the scale in distinguishing individuals with BP (N = 266) from those with major depressive disorder (MDD; N = 160). The samples were adult psychiatry patients recruited in Italy (N = 186) and Sweden (N = 240).

Results

The samples reported similar clinical profiles and the structure for the HCL-32 demonstrated two main factors identified as “active/elated” hypomania and “risk-taking/irritable” hypomania. The HCL-32 distinguished between BP and MDD with a sensitivity of 80% and a specificity of 51%.

Limitations

Although the HCL-32 is a sensitive instrument for hypomanic symptoms, it does not distinguish between BP-I and BP-II disorders.

Conclusions

Future studies should test if different combinations of items, possibly recording the consequences of hypomania, can distinguish between these BP subtypes.

Introduction

The APA guidelines on the management of bipolar disorders (BP) state that bipolar-II disorder (BP-II) is frequently misdiagnosed as unipolar major depressive disorder (MDD) and as a result may receive inadequate or inappropriate treatment (American Psychiatric Association, 2002).

This notion is compatible with recent work in the field suggesting several reasons for the under-diagnosis and under-treatment of BP (Akiskal et al., 2000, Angst, 1998, Angst et al., 2003b, Benazzi, 2004, Ghaemi et al., 2002, Hirschfeld et al., 2003c, Judd and Akiskal, 2003, Lish et al., 1994, Szadoczky et al., 1998). First, individuals who experience depression do not always perceive hypomania as pathological, and as such do not spontaneously report it to clinicians (Scott, 2002). Also, the latter do not always make relevant direct inquiries of patients presenting with MDD (Angst and Gamma, 2002). The consequences are that the correct diagnosis and treatment may be delayed by 8–10 years (Hirschfeld et al., 2003c, Lish et al., 1994). Furthermore, the recognition of hypomania may require more subtle inquiry than detailed in the currently available structured diagnostic interviews (SCID, CIDI) and the diagnostic criteria in DSM-IV and ICD-10 may be less reliable and valid than previously believed. An expert group recently concluded that the current diagnostic criteria have high specificity but might have too low a sensitivity and that a greater focus on certain symptoms (such as activation levels) or less emphasis on symptom duration may improve recognition of those at risk of BP episodes (Angst et al., 2003a, Hantouche et al., 1998). Although not all researchers agree with these proposals, there is emerging evidence for a dimensional view of hypomania and mania (e.g. Angst et al., 2003a). As found previously in studies of depressive disorders (e.g. Flett et al., 1997, Haslam and Beck, 1994, Ruscio and Ruscio, 2000), Meyer and Keller's (2003) study failed to find evidence for latent classes for hypomania but did find evidence for a dimensional structure supporting the idea of an affective spectrum from ‘normal’ highs through to hypomania and mania (Angst, 1999, Korszun et al., 2004).

The above suggests that a self-assessment screening instrument for hypomania would be clinically useful and timesaving as well as aiding epidemiological research. Early attempts to screen for BP focused on the identification of individuals at risk of developing mood disorders in non-clinical populations. The measures targeted personality traits, did not explore the episodic nature of hypomania and failed to incorporate measures of the potential negative consequences of any changes in behavior, affect and cognition (e.g. Alloy et al., 1999, Depue et al., 1981, Meyer and Hautzinger, 2003). Other self-report measures have not been promoted as screening instruments but assess symptoms, such as the Self-Report Inventory for Mania (SRMI) by Shugar et al. (1992), the hypomania subscale of the symptom checklist 90-Revised (SCL-90R; Hunter et al., 2000) and the Brief Bipolar Disorder Scale (Dennehy et al., 2004), or rate the severity of symptoms in individuals with a diagnosis of BP, e.g. the Altman Self-Rating Scale (ASRM) and the Internal State Scale (Bauer et al., 1991, Geiselmann and Bauer, 2000). A specific screening instrument for BP is the Mood Disorder Questionnaire (MDQ) of Hirschfeld et al., 2000, Hirschfeld et al., 2003b; on the basis of its content it seems to be sensitive to identify BP-I disorder but probably less so for BP-II disorder (Benazzi, 2003b, Mago, 2001, Zimmermann et al., 2004). The MDQ was tested first in a tertiary care clinical sample and showed a sensitivity of 73% and a specificity of 90% (two thirds of the sample had BP-I); in a population sample (Hirschfeld et al., 2003a) the sensitivity was 28% and the specificity was 97% for BP.

These results and the demands for a screening instrument for the spectrum of bipolar manifestations (Benazzi and Akiskal, 2003b) encouraged us to transform the previously described hypomania checklist-20 (Allilaire et al., 2001, Angst, 1992, Angst et al., 2003b, Hantouche et al., 1998) into a more elaborate self-administered questionnaire, the hypomania checklist-32 (HCL-32). The primary goal of the HCL-32 is to identify hypomanic components in patients with MDD in order to help the clinician to diagnose BP-II and other BP spectrum disorders (Angst et al., 2003a) presenting in psychiatric and general medical practice. A secondary goal is the development of a final potentially shorter multi-lingual version with established cut-off scores for hypomania.

Section snippets

The hypomania checklist (HCL-32)

J.A. and T.M first conceptualized the HCL-32. It comprises a checklist of possible symptoms of hypomania that are rated yes (present or typical of me) or no (not present or not typical) by the subject. A German version was created that was translated into English by a professional translator and then re-translated back into German (by T.M. and J.A.). The English version was distributed for re-drafting by all co-authors and the final agreed-upon version was re-edited by an English psychiatrist

Description of samples

The two samples are described in Table 1. The Italian sample included 27 patients with BP-I, 97 with BP-II and 62 with MDD. There were significant gender differences in the sample, with the highest proportion of women among BP-II, and the lowest proportion among BP-I patients. The Swedish sample included 75 patients with BP-I, 67 with BP-II and 98 with MDD. Subjects with BP-II were significantly younger than those with MDD and BP-I.

Italian sample

Analysis of the % of BP and MDD patients endorsing the

Discussion

The impetus for this study was the desire to develop a robust self-assessment screening tool for BP that could be used across countries and continents. For this reason great care was taken in the design and selection of questions on hypomanic symptoms, and the translation–re-translation process was used to ensure that the subject could rate items independently and without ambiguity. The samples in both Italy and Sweden used ‘softer’ criteria for BP reflecting the increasing commitment of the

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