Evidence-based assessment/Bipolar disorder in adults (assessment portfolio)/extended version

What is a "portfolio"?

 * For background information on what assessment portfolios are, click the link in the heading above.
 * Does all of this feel like TMI? Click here to go to a condensed version.

Diagnostic criteria for bipolar disorder in adults
Bipolar Disorder (BP) is characterized by extreme fluctuations in mood (or emotional dysregulation that ranges from mania (as shown by displays or feelings of extreme happiness, unrealistic overachievement and anger), to depression (as shown by displays or feelings of sadness, changes in appetite or weight and irritability. It has a lifetime risk of about 1%, with heritability estimated at up to 80%. It is important to note that these moods exceed normal responses to life events, represent a change from the individual's normal functioning, and cause problems in daily activities.

ICD-11 Diagnostic Criteria
 * Bipolar Type I Disorder
 * Bipolar type I disorder is an episodic mood disorder defined by the occurrence of one or more manic or mixed episodes. A manic episode is an extreme mood state lasting at least one week unless shortened by a treatment intervention characterized by euphoria, irritability, or expansiveness, and by increased activity or a subjective experience of increased energy, accompanied by other characteristic symptoms such as rapid or pressured speech, flight of ideas, increased self-esteem or grandiosity, decreased need for sleep, distractibility, impulsive or reckless behavior, and rapid changes among different mood states (i.e., mood lability). A mixed episode is characterized by either a mixture or very rapid alternation between prominent manic and depressive symptoms on most days during a period of at least 2 weeks. Although the diagnosis can be made based on evidence of a single manic or mixed episode, typically manic or mixed episodes alternate with depressive episodes over the course of the disorder.
 * Note: The ICD-11 lists 18 additional subcategories of Bipolar type I disorder. They can be found here.

Changes in DSM-5
 * Bipolar Type II Disorder
 * Bipolar type II disorder is an episodic mood disorder defined by the occurrence of one or more hypomanic episodes and at least one depressive episode. A hypomanic episode is a persistent mood state characterized by euphoria, irritability, or expansiveness, and excessive psychomotor activation or increased energy, accompanied by other characteristic symptoms such as grandiosity, decreased need for sleep, pressured speech, flight of ideas, distractibility, and impulsive or reckless behavior lasting for at least several days. The symptoms represent a change from the individual’s typical behavior and are not severe enough to cause marked impairment in functioning. A depressive episode is characterized by a period of almost daily depressed mood or diminished interest in activities lasting at least 2 weeks accompanied by other symptoms such as changes in appetite or sleep, psychomotor agitation or retardation, fatigue, feelings of worthless or excessive or inappropriate guilt, feelings or hopelessness, difficulty concentrating, and suicidality. There is no history of manic or mixed Episodes.
 * Note: The ICD-11 lists 13 additional subcategories of Bipolar type II disorder. They can be found here.
 * The diagnostic criteria for Bipolar Disorder changed slightly from DSM-IV to DSM-5. Summaries are available here and here.

Base rates of BD in different clinical settings and populations
This section describes the demographic setting of the population(s) sampled, base rates of diagnosis, country/region sampled, and the diagnostic method that was used. Using this information, clinicians will be able to anchor the rate of adolescent depression that they are likely to see in their clinical practice.


 * To see prevalence rates across multiple disorders, click here.

Psychometric properties of screening instruments for adult bipolar disorder
The following section contains a list of screening and diagnostic instruments for adult bipolar disorder. The section includes administration information, psychometric data, and PDFs or links to the screenings.
 * Screenings are used as part of the prediction phase of assessment; for more information on interpretation of this data, or how screenings fit in to the assessment process, click here.

Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable
 * For a list of more broadly reaching screening instruments, click here.

Likelihood ratios and AUCs of screening measures for bipolar disorder in adults
Note: Area Under Curve (AUC, or AUROC) is equal to the probability that a classifier will rank a randomly chosen positive diagnosis of Bipolar Disorder higher than a randomly chosen negative diagnosis of Bipolar Disorder[15].
 * For a list of the likelihood ratios for more broadly reaching screening instruments, click here.

More on high preforming bipolar screening measures
7 Up 7 Down Inventory (7U7D)


 * The 7 Up 7 Down Inventory is a recently developed and validated questionnaire with 14 items of manic and depressive tendencies carved from the General Behavior Inventory, a well-validated but cumbersome interview. For both mania and depression factors, 7 items produced a psychometrically adequate measure applicable across both aggregate samples. Internal reliability of the Mania scale was .81 (youth) and .83 (adult) and for Depression was .93 (youth) and .95 (adult) .The 7 Up 7 Down Inventory, along with the accompanying research article can be found here

Bipolar Spectrum Diagnostic Scale (BSDS)


 * The Bipolar Spectrum Diagnostic Scale (BSDS) is a diagnostic tools that can assess for bipolar disorder in those who have Bipolar Disorder I, Bipolar Disorder II and Bipolar Disorder NOS. It was designed to help detect milder versions of bipolar disorder . It is a self-report measure, and it has been shown to be generally effective in detecting bipolar disorder, though this effectiveness is not shown in individuals who have low insight. The sensitivity of the BSDS is due to its focus on energy and drive rather than the mood symptoms present during hypomanic symptoms . The threshold for a positive diagnosis is 13 points. The BSDS effectively screened out unipolar patients, maintained good sensitivity across the bipolar spectrum and low rate of false positives..

Mood Disorder Questionnaire (MDQ)


 * The Mood Disorder Questionnaire (MDQ) is a self-report scale for bipolar disorder which focuses more on mood symptoms. It is very effective in detecting bipolar I disorder but less sensitive at detecting bipolar II disorder and Not Otherwise Specified (NOS).

Interpreting adult bipolar disorder screening measure scores

 * For information on interpreting screening measure scores, click here.
 * Also see the page on likelihood ratios in diagnostic testing for more information

Gold standard diagnostic interviews

 * For a list of broad reaching diagnostic interviews sortable by disorder with PDFs (if applicable), click here.

Recommended diagnostic interviews for adult bipolar disorder
Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

Severity interviews for bipolar disorder
Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

Process phase
The following section contains a list of process and outcome measures for bipolar disorder in adults. The section includes benchmarks based on published norms and on mood samples for several outcome and severity measures, as well as information about commonly used process measures. Process and outcome measures are used as part of the process phase of assessment. For more information of differences between process and outcome measures, see the page on the process phase of assessment.

Process measures
There are many processes that may be considered important when evaluating an adult with Bipolar Disorder; however, due to the diversity of the population and symptom expression, there are too many to narrow down. Clinical judgment is recommended when deciding what additional measures should be included (e.g. executive functioning, sensory processing, cognitive flexibility). The measure provided below are commonly used to assess and provide important information regarding levels of daily functioning of individuals with Bipolar Disorder.

More information on process measure coming soon.

Outcome and severity measures
This table includes clinically significant benchmarks for adult bipolar disorder specific outcome measures


 * Information on how to interpret this table can be found here.
 * Additionally, these vignettes might be helpful resources for understanding appropriate adaptation of outcome measures in practice.
 *  For clinically significant change benchmarks for the CBCL, YSR, and TRF total, externalizing, internalizing, and attention benchmarks,  see here.

Treatment

 * Please refer to the page on bipolar disorder for more information on available treatment for bipolar disorder or go to the Effective Child Therapy pages for | Severe Mood Swings & Bipolar Spectrum Disorders
 * Relatives Education and Coping Toolkit (REACT) is currently freely available at https://reacttoolkit.uk/. This is a resource/project of The Sprectrum Centre for Mental Health Research from Lancaster University. A team of clinicians, researchers and relatives of people with psychosis or bipolar disorder at Lancaster, Liverpool and London have developed the Relatives Education and Coping Toolkit (REACT). REACT provides National Institute for Health and Care Excellence (NICE) recommended information and support to relatives and friends of people with mental health problems associated with psychosis or bipolar disorder through a digital, peer-supported, self-management toolkit.
 * The team at Spectrum Centre also conducted a study linked to REACT called IMPART which looked at what would happen if they tried to deliver REACT as part of routine clinical care in Early Intervention Teams in the United Kingdom's National Health Service (NHS). This study identified key factors that impact implementation and may be useful for informing implementation plans for other digital health interventions.
 * RECOVERY TOOLKIT #eRecoveryToolkit, #RecoveryBD, #PersonalRecovery is freely accessible at https://www.lancaster.ac.uk/health-and-medicine/research/spectrum/. Inspired from a greater body of work around recovery, people with lived experience of bipolar disorder and researchers at Spectrum Centre have created a multi-media recovery toolkit. The aim of the toolkit is to provide accessible information and promote discussion around personal discovery in order to understand and aid people’s recovery journeys. The toolkit contains an animation, an e-booklet and video narratives of relatives and clinicians.

External resources

 * 1) ICD-10 diagnostic criteria
 * 2) Find-a-Therapist (a curated list of find-a-therapist websites where you can find a provider)
 * 3) OMIM (Online Mendelian Inheritance in Man)
 * 4) 125480
 * 5) 611536
 * 6) 309200,
 * 7) 611535
 * 8) 603663
 * 9) eMedicine information
 * 10) Effective Child Therapy information on Bipolar Disorder
 * 11) *Effective Child Therapy is website sponsored by Division 53 of the American Psychological Association (APA), or The Society of Clinical Child and Adolescent Psychology(SCCAP), in collaboration with the Association for Behavioral and Cognitive Therapies (ABCT). Use for information on symptoms and available treatments.
 * 12) The Psych Show with Dr. Ali Mattu videos (geared towards public; might send to client)
 * 13) How to Cope with Bipolar Disorder
 * 14) Top 10 Bipolar Myths