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

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* Medical disclaimer: This page is for educational and informational purposes only and may not be construed as medical advice. The information is not intended to replace medical advice offered by physicians. Please refer to the full text of the Wikiversity medical disclaimer.

## 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.

## Preparation phase
### 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.
   * 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.
   Changes in DSM-5
   * 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.
| Demography | Setting | Base Rate | Diagnostic Method |
| United States, Canada, Puerto Rico, Germany, Taiwan, Korea, New Zealand | Community Epidemiological Samples | 0.3 - 1.5% | Structured and semi-structured diagnostic interviews |
| United States | Community Epidemiological Samples | BPI - 1%; BPII - 1.1%; Subthreshold BP - 2.4% | World Health Organisation Composite International Diagnostic Interview |
| United States | Community samples (older adolescents) | 1% | K-SADS Semi-Structured Interview |
| United States | US National Epidemiological Catchment Area (ECA) database | 0.8 - 5.1% (manic and subthreshold mania) | Diagnostic Interview Schedule (DIS) |
| United States | US National Comorbidity Survey (NCS) | 0-4% (small community sample; reappraisal study) | World Health Organisation Composite International Diagnostic Interview |
| United States and other countries | Community sample | BPI - 0.6%; BPII- 1.8%; Cyclothymia - 0.4-1% | Unspecified |
| United States, Europe, Asia | Community Samples | BPI - 0.6%; BPII - 0.4%; Subthreshold BP - 1.4%; Bipolar Spectrum Disorder - 2.4% | World Health Organisation Composite International Diagnostic Interview |
| United States | National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) | BPI - 3.3% | The Alcohol Use Disorder and Associated Disabilities Interview Schedule-IV (AUDADIS-IV) |
| United States | Outpatient Clinic Sample | 9.8% | Review of medical records, questionnaire data |
| United States | Outpatient Clinic Sample | 21.3% | MDQ, SCID |

## Prediction phase
### 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.
* For a list of more broadly reaching screening instruments, click here.
| Measure | Format (Reporter) | Age Range | Administration/ Completion Time | Inter-rater reliability | Test-retest reliability | Construct validity | Content validity | Highly recommended | Free and Accessible PDFs |
| HCL-32 (Hypomania Checklist) | Self-report | Adult | 10-15 minutes | Not applicable | | G | G | Y | Self-report Assessment Center Online Version |
| BSDS (Bipolar Spectrum Diagnostic Scale) | Self-report | Adult | 15 minutes | Not applicable | | G | G | | Online version Downloadable PDF Version (English) Assessment Center Online Version |
| GBI (General Behavior Inventory) | Self-report | Adult | 15-20 minutes | Not applicable | A | G | A | | Downloadable PDF Self-Report English Scoring instructions and information Assessment Center Online Version |
| MDQ (Mood Disorder Questionnaire) | Self-report | Adult | 5 minutes | Not applicable | A | A | A | | Adult Self-Report (Long, English) Adult Self-Report (Short, English) Assessment Center Online- long version Assessment Center Online- short version |
Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

### Likelihood ratios and AUCs of screening measures for bipolar disorder in adults

* For a list of the likelihood ratios for more broadly reaching screening instruments, click here.
| Screening Measure (Primary Reference) | Area Under Curve (AUC) and sample size | DiLR+ (score) | DiLR- (score) | Population |
| BSDS (Bipolar Spectrum Diagnostic Scale) | 0.81 | (13) | 0.36 (4.93) | Clinical |
| HCL-32 (Hypomania Checklist) | 0.80 | (14) | 0.28 (2.45) | Clinical |
| MDQ (Mood Disorder Questionnaire) | 0.78 | (7) | 0.22 (5.4) | Clinical |
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].

### 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

## Prescription phase
### 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

Diagnostic instruments for BPSD :
| Measure | Format (Reporter) | Age Range | Administration/ Completion Time | Interrater Reliability | Test-Retest Reliability | Construct Validity | Content Validity | Highly Recommended | Free and Accessible Measures |
Note: L = Less than adequate; A = Adequate; G = Good; E = Excellent; U = Unavailable; NA = Not applicable

### Severity interviews for bipolar disorder

| Measure | Format (Reporter) | Age Range | Administration/ Completion Time | Interrater Reliability | Test-Retest Reliability | Construct Validity | Content Validity | Highly Recommended | Free and Accessible Measures |
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.
Clinically significant change benchmarks with common instruments for bipolar disorder :
| Benchmarks Based on Published Norms ||||||||
| Measure | Subscale | Cut-off scores | Cut-off scores | Cut-off scores | Critical Change (unstandardized scores) | Critical Change (unstandardized scores) | Critical Change (unstandardized scores) |
| Measure | Subscale | A | B | C | 95% | 90% | SE$_{difference}$ |
| CBCL T-scores (2001 Norms) | Total | 49 | 70 | 58 | 5 | 4 | 2.4 |

### 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.
| t | This user tweets on Twitter as REACTTOOLKIT. |

## External resources

* ICD-10 diagnostic criteria
* Find-a-Therapist (a curated list of find-a-therapist websites where you can find a provider)
* OMIM (Online Mendelian Inheritance in Man)
** 125480
** 611536
** 309200,
** 611535
** 603663
* eMedicine information
* Effective Child Therapy information on Bipolar Disorder
** 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.
* The Psych Show with Dr. Ali Mattu videos (geared towards public; might send to client)
** How to Cope with Bipolar Disorder
** Top 10 Bipolar Myths