진단에서설문지, 척도의활용과이점

2008년도대한우울조울병학회하계연수교육

Tae Hyon, MD, PhDMood Disorders Clinic & Affective Neuroscience Laboratory

Department of PsychiatrySeoul National University Bundang Hospital

Diagnostic Criteria

Bipolar I Bipolar I Bipolar I

Hyperthymia Cyclothymia Bipolar II

Dysthymia MDD

Dysthymic Major Depressive

Hypom

anic

Man

ic

Low Reliability

Reliability for Hypomania Dx.

Under diagnosis► patients not reporting ► arbitrary criteria in DSM-IV► non-expert interviewers

EPIDEP report► bipolar II disorder: 22% of MDE (1st), 40% (2nd)

Good reliability► interview by trained clinicians► semi-structured form

Simpson et al. 2002; Hantoche et al. 1998; Akiskal and Benazzi 2005

Diagnosis of Bipolar Disorder

Bipolar I disorder

Bipolar II disorder► under-detected

► arbitrary criteria: duration, severity, function

Bipolar spectrum disorder► new concept

Diagnostic Performance of Variables Associated with Bipolar Outcome

VariableVariable Sensitivity Sensitivity (%)(%)

Specificity Specificity (%)(%)

Pharmacological hypomania 32 100

Bipolar family history 56 98

Loaded pedigrees 32 95

Hypersomnic-retarded depression 59 88

Psychotic depression 42 85

Postpartum onset 58 84

Onset of depression before age 26 71 68

Akiskal et al., 1983 J Affect Disord

A Proposed Broad Spectrum of Bipolar Disorders

Bipolar Bipolar ½½ Schizobipolar disorder

Bipolar IBipolar I Manic depressive illness

Bipolar I Bipolar I ½½ Depression with protracted hypomania

Bipolar IIBipolar II Depression with spontaneous discrete hypomanic episode

Bipolar II Bipolar II ½½ Depression superimposed on cyclothymia

Bipolar IIIBipolar III Depression plus hypomania in association with antidepressant or somatic treatment

Bipolar III Bipolar III ½½ Prominent mood swings in association with substance and/or alcohol abuse

Bipolar IVBipolar IV Depression superimposed on hyperthymia

Akiskal & Pinto 1999 Psychiatr Clin North Am

Cues in the History Suggesting Bipolarity

1.1. Recurrent major depressive episodes (>3)Recurrent major depressive episodes (>3)

2.2. Early age of onset of major depressive episode (age < 26)Early age of onset of major depressive episode (age < 26)

3.3. Family history of bipolar disorder in firstFamily history of bipolar disorder in first--degree relativedegree relative

4.4. HyperthymicHyperthymic personality (at baseline, personality (at baseline, nondepressednondepressed state)state)

5.5. Atypical depressive symptoms (DSMAtypical depressive symptoms (DSM--IV criteria)IV criteria)

6.6. Brief major depressive episodes (on average, < 3 months)Brief major depressive episodes (on average, < 3 months)

7.7. Psychotic major depressive episodesPsychotic major depressive episodes

8.8. Postpartum depressionPostpartum depression

9.9. AntidepressantAntidepressant--induced mania or hypomaniainduced mania or hypomania

10.10. Antidepressant Antidepressant ““wearwear--offoff”” (acute but not prophylactic response)(acute but not prophylactic response)

11.11. Lack of response to Lack of response to ≥≥

adequate antidepressant treatment trialsadequate antidepressant treatment trials

Ghaemi et al., 2002 Can J Psychiatry

A Proposed Definition of Bipolar Spectrum Disorder

A. At least one major depressive episodeB. No spontaneous hypomanic or manic episodesC. Either or the following, plus at least 2 items from Criterion D, or

both of the followings plus 1 item from criterion D:1. A family history of bipolar disorder in first-degree relative2. Antidepressant-induced mania or hypomania

D. If no items from criterion C are present, 6 of the followings 9 criteria are needed

1. Hyperthymic temperament (at baseline, nondepressed)2. Recurrent major depressive episodes (>3)3. Brief major depressive episodes (on average, < months)4. Atypical depressive symptoms (DSM-IV criteria)5. Psychotic major depressive episodes6. Early age of onset of major depressive episode (age

Depressive Symptomatology Suggesting Bipolarity

Atypical symptoms

Psychotic depression

Mixed depressive state

More than 2 of followingsMore than 2 of followings

-- Mood reactivityMood reactivity

-- Increased appetite or Increased appetite or weightweight

-- HypersomniaHypersomnia

-- Lead paralysisLead paralysis

-- Interpersonal Interpersonal hypersensitivityhypersensitivity

More than 3 of followingsMore than 3 of followings

-- IrritabilityIrritability

-- DistractibilityDistractibility

-- Racing thoughtsRacing thoughts

-- TalkativenessTalkativeness

-- AgitationAgitation

-- Hostility, aggressionHostility, aggression

-- HyperactivityHyperactivity

-- ImpulsivityImpulsivityBenzzi & Akiskal, 2005 J Affect DisordSato et al., 2003 Acta Psychiatr Scand

Benazzi, 2003 PNBP

Interview Skill to Diagnose Bipolarity

Depressive episodeDepressive episode HistoryHistory

““((Hypo)maniaHypo)mania””

Mixed depressed stateMixed depressed state if not found

if hypomanic symptoms (+)

if not found

TemperamentTemperament

Family historyFamily history

To diagnose “bipolar spectrum disorder”,

consider…

• History (course)• Depressive symptoms• Temperament• Family history

Mood Disorders Clinic, SNUBH

A Problem in Diagnosing Bipolar Disorder

comprehensive interview► time and labor

► is it practical ?

self-report can help

Tools applicable…

Mood Disorder Questionnaire (MDQ) 1

The Bipolar Spectrum Diagnostic Scale (BSDS) 2

Hypomania Checklist (HCL-32) 3

1. Hirschfeld et al. Am J Psychiatry 2000;157:1873-18752. Ghaemi et al. J Affect Disord 2005;84:273-2773. Angst et al. J Affect Disord 2005;88:217-233

MDQ : routine screening for bipolar disorder in patients for whom antidepressants are being considered (FDA,2004)

Sensitivity and Specificity

Study Authors Scale Population Sensitivity Specificity

1Hirschfeld et al.

(2000) MDQ

Adult outpatient psychiatry

0.73 0.90

2Hirschfeld et al.

(2003)MDQ

Community adult population

0.28 0.97

3 Miller et al. (2004) MDQ Adult outpatient

psychiatry0.58 0.67

4Ghaemi et al.

(2005) BSDS

Adult outpatient psychiatry

0.76 0.93

Mood Disorder Questionnaire

(K-MDQ)

• 13 items, 5 min.

• ≥

7

• Sensitivity 0.75

Specificity 0.69

Jun et al. 2005

Mood Disorders Clinic & Affective Neuroscience Lab., SNUBH

MDQ further findings

Spanish version (de Dios et al., 2008)► cutoff=7; sensitivity=73%, specificity=83%

Turkish version (Konuk et al., 2007)► cutoff=7; sensitivity=64%, specificity=77%

Italian version (Hardoy et al., 2005)► cutoff=6; sensitivity=76%, specificity=86%

in UK study (Twiss et al., in press)► cutoff=7; sensitivity=76%, specificity=86%

► excluding supplementary questions;

cutoff=9; sensitivity=90~88%, specificity=90%

Bipolar Spectrum Disorder Scale

(K-BSDS)

• 19 items

6 depressed, 9 hypomanic

• < 10 min.

• ≥

13

• Sensitivity 0.76

Specificity 0.93

Ghaemi 2005

Ha et al.

Mood Disorders Clinic & Affective Neuroscience Lab., SNUBH

Bipolar vs. Controls

0

10

20

30

40

50

60

70

80

90

100

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

BSDS item

positive

%

Bipolar(N=194)

control (N=1977)*

****

*

*

*

*

*

*

*

*

**

*

Positive % in each items : 24.9% ~ 87.6 % in bipolar disorder10.2% ~ 93.2 % in MDD

Item 1,2,11 (기분변동) : 양극성장애환자군과정상대조군에서통계적으로유의한차이가없음. * : P

Bipolar vs. Unipolars

0

10

20

30

40

50

60

70

80

90

100

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19

BSDS item

positive %

bipolar (N=194)

MDD (N=59)

*

*

**

** *

**

*

*

* *

Factor analysis in BSDS

Factor 1 : depressive mooditem 3, 4, 5, 6, 7, 9 (eigen value=4.15, 21.84% variance)

Factor 2 : fluctuation of mooditem 1, 2, 10, 11 (eigen value=1.94, 10.22% variance)

Factor 3 : hypomanic mooditem 12, 13, 19, 21, 22, 23 (eigen value=1.43, 7.53%)

Factor 4 : manic moodItem 20, 26, 27 (eigen value=1.06, 5.60% variance)

Mood Disorders Clinic & Affective Neuroscience Lab., SNUBH

Bipolar (N=194)control (N=1977)

Cut off 13점sensitivity

: 72.68% (141명/194명)specificity

: 54.77% ( 1083명/ 1977명)

Cut off 16점sensitivity

: 58.25% (113명/194명)specificity

: 77.03% ( 1523명/ 1977명)0

10

20

30

40

50

60

70

80

90

100

1 3 5 7 9 11 13 15 17 19 21 23 25

sum of BSDS

%

sensitivity

specificity

Bipolar vs. Controls

Mood Disorders Clinic & Affective Neuroscience Lab., SNUBH

Bipolar (N=194)MDD (N=59)

Cut off 13점sensitivity

: 72.68% (141명/194명)specificity

: 52.54% ( 31명/ 59명)

Cut off 16점sensitivity

: 58.25% (113명/194명)specificity

: 72.89% ( 43명/ 59명)0

10

20

30

40

50

60

70

80

90

100

1 3 5 7 9 11 13 15 17 19 21 23 25

Sum of BSDS

%

sensitiv ity

specificity

Bipolar vs. Unipolars

Mood Disorders Clinic & Affective Neuroscience Lab., SNUBH

HCL-32

32 lists of hypomanicsymptoms

to detect bipolar II among MDD

at cutoff=14, Ss=80, Sp=51(Angst et al., 2005)

at cutoff=14, Ss=85, Sp=79(Vieta et al., 2007)

HCL-32

CutoffCutoffBipolar allBipolar all Bipolar IIBipolar II

SensitivitySensitivity SpecificitySpecificity SensitivitySensitivity SpecificitySpecificity

8 92 48 90 42

10 88 54 80 47

12 85 61 80 54

seems more sensitive for bipolar II diagnosis than MDQ

(Carta et al., 2006)

Limitations

a high false positive rate

symptom-based approach

Rating Scale

measuring severity

not diagnostic

examples► HAMD

► MARDS

► IDC

Differences in Item Scores

More in Bipolar More in MDD

Guilty feelings

Pessimism

Outlook: self and future

Hypersomnia

Increased appetite

Inability to feel

Energy/fatigue

Somatic compalints

Poor insight

in bipolar, ►

more negative thoughts►

more atypical symptomsin unipolar, ►

more somatic or energy symptoms►

numbnessmore appropriate measure with IDS

Limitations of Rating Scales

not evaluate all aspects of depression

atypical symptoms not included

mixed states

not mood specific items►discriminant validity: somatic symptoms (HAMD),

bullemia nervosa (MADRS)

►insight

►sexual…

Designed …

to be administered by psychiatrists

symptom severity►0 = no symptoms present►1 = mild►2 = moderate►3 = severe►(both objective assessment and self-report)

timeframe►“now and the last couple of days”

http://www.barwonhealth.org.au/bdrs/

http://www.barwonhealth.org.au/bdrs/

Three Factor Model

Conclusion

diagnosis of bipolar disorder is becoming of importance

broader diagnosis should consider not only symptomatic presentations, but also external validators

practical need for auxiliary tools

inventories and rating scales can help diagnosis and follow-up

Interview Skill to Diagnose Bipolarity

Depressive episodeDepressive episode HistoryHistory

““((Hypo)maniaHypo)mania””

Mixed depressed stateMixed depressed state if not found

if hypomanic symptoms (+)

if not found

TemperamentTemperament

Family historyFamily history

To diagnose “bipolar spectrum disorder”,

consider…

• History (course)• Depressive symptoms• Temperament• Family history

Mood Disorders Clinic, SNUBH

Quiz

양극성장애 진단에 도움이 될 수 있는 자가보고 설문지의

종류와 각각의 절단점을 설명하시오.

양극성장애 선별 설문지의 문제점 및 이를 보완할 수 있는

방법을 기술하시오.

Quiz

양극성장애 진단에 도움이 될 수 있는 자가보고 설문지의 종류와 각각

의 절단점을 설명하시오.

►

MDQ: 7점 이상

►

BSDS: 13점 이상 (또는 16점 이상)

►

HCL-32: 14점 이상

►

그러나, 더 많은 조사결과와 sample의 특성을 고려할 필요

양극성장애 선별 설문지의 문제점 및 이를 보완할 수 있는 방법을 기

술하시오.

►

민감도와 특이도가 만족스럽지 않을 수 있다.

►

두 가지 척도를 함께 사용함으로써 보완

►

진단은 면담을 통해 확인해야 한다.

►

증상 외에도 우울증의 병력이나 기질, 가족력의 확인이 필요하다.

진단에서 설문지, 척도의 활용과 이점��2008년도 대한우울조울병학회 하계연수교육Diagnostic CriteriaReliability for Hypomania Dx.Diagnosis of Bipolar DisorderDiagnostic Performance of Variables Associated with Bipolar OutcomeA Proposed Broad Spectrum of �Bipolar DisordersCues in the History Suggesting BipolarityA Proposed Definition of �Bipolar Spectrum DisorderDepressive Symptomatology �Suggesting BipolarityInterview Skill to Diagnose BipolarityA Problem in Diagnosing Bipolar DisorderTools applicable…슬라이드 번호 13Sensitivity and Specificity슬라이드 번호 15MDQ further findings슬라이드 번호 17Bipolar vs. ControlsBipolar vs. UnipolarsFactor analysis in BSDS슬라이드 번호 21슬라이드 번호 22HCL-32HCL-32LimitationsRating ScaleDifferences in Item ScoresLimitations of Rating Scales슬라이드 번호 29Designed …Three Factor ModelConclusionInterview Skill to Diagnose BipolarityQuizQuiz