Bipolar I disorder can be difficult to diagnose, potentially leading to significant delays in patient care. This underscores the importance of measurement-based care using standardized psychiatric rating scales to aid in screening, diagnosis, and assessing patient progress over time. This video will review the most frequently used scales for bipolar I disorder and how to incorporate them into your clinical practice.
Bipolar I disorder is a chronic condition that can be difficult to diagnose. Standardized psychiatric rating scales are useful clinical tools that can supplement your patient interview with objective information.
If used when patients first report symptoms, scales can potentially help you reach a correct diagnosis more quickly. Scales can also help you monitor symptoms to determine if a patient is responding to treatment.
The American Psychiatric Association (APA) endorses the use of objective assessment tools including scales both in screening and in monitoring symptoms over time.1
Measurement-based care uses patient-reported rating scales along with evidence-based practice guidelines to screen patients and to assess patient progress over time.2 The APA supports the use of measurement-based care in the treatment of mental health conditions, which can potentially improve patient outcomes.1
Today, we will review scales used in screening and assessing symptom severity in patients with bipolar I disorder. We will focus on some characteristics that are important to consider in choosing a scale and how to incorporate clinical scales into your practice. We will also walk through an example using the Rapid Mood Screener (RMS) for screening bipolar I patients who may be misdiagnosed with major depressive disorder (MDD).
There are several important factors to consider when choosing a scale in clinical practice. These include the following:
- Whether the scale is validated in that disease state
- Whether the scale has been shown to be reliable
- The administration method of the scale: clinician rated vs patient self-report
- The length of time it takes to complete and score the scale
- And lastly, whether the scale is for use in clinical practice or in clinical trials
The number of psychiatric rating scales and screening tools available can make choosing one seem difficult. Our scale selection tool at NP Psych Navigator can help you narrow it down.
When choosing a scale in clinical practice, you must identify one that assesses the disease state you are screening.
For example, if you believe a patient previously diagnosed with MDD may have bipolar I disorder, you can screen for this condition using the Mood Disorder Questionnaire (MDQ) or the Rapid Mood Screener or RMS. The MDQ and the RMS have both been validated in patients with bipolar I disorder.3,4
You must also consider whether a scale is valid for the disease state you are screening for.
Validity is the degree to which the scale measures what it is supposed to measure, or how well its questions reflect the goal of the evaluation.5,6
Reliability is the ability of the scale to communicate consistent and reproducible information.6
Scales can be administered by the healthcare provider (HCP) or via self-report from the patient.
Some scales can be lengthy or time-consuming. The time to complete and score a scale should be considered for practicality in the clinical setting.
Advantages to self-rated scales include ease of administration and not requiring clinician or staff time, which translates to lower expense.5,7 Patient-rated scales are also useful in evaluating or allowing insight into subjective states.6 One downside of self-rated scales is reliability. Patients may lack insight or over-report or under-report symptoms when completing these scales.5
Clinician-rated scales may be more costly than self-rated scales and put further requirements on healthcare providers’ training and office visit times.7
Clinician and patient-rated scales can be used in conjunction to minimize bias and identify symptoms that may not be picked up on either type of scale if used alone.7 Both types of scales can help improve patient communication with providers and allow them to feel more involved in creating their care plan.7
You, as a healthcare provider, will find what is best for your patients and your practice, as well as what scales and administration methods fit your clinical needs.
We must also consider the setting in which scales are generally used.
For example, the MDQ is commonly used in clinical practice as a screening tool for bipolar disorder. It is a short, self-report scale that should take 5 minutes to complete and can also be quickly scored by the clinician.8
The RMS is also used in clinical practice, is very brief, and can help you quickly screen for bipolar I disorder risk factors and mania.3
The Montgomery-Asberg Depression Rating Scale (MADRS), on the other hand, is seldom used in clinical practice. This questionnaire is frequently used in clinical trials to evaluate the severity of major depressive symptoms in response to treatment.7,9
The Young Mania Rating Scale (YMRS) is another scale used in clinical trials and research to assess the severity of manic symptoms. It can also be used as a bipolar I disorder screening scale.10
While diagnostic tests can provide definitive information regarding the presence or absence of a condition, screening tests are meant to inform our next steps.
It is important to determine the extent to which screening tests like psychiatric scales can identify the presence or absence of a condition so that the results encourage appropriate clinical decision-making.11 In this vein, it is important to consider sensitivity and specificity.
Sensitivity is the ability of a screening test to detect a true positive. A highly sensitive test will have few true cases missed.11 Specificity is the ability of a screening test to detect a true negative. A highly specific test should result in a negative screen among patients without the condition.11
Let’s look in more detail at the NP Psych Navigator website and its convenient tool to sort through rating scales.
You can use these drop-down menus to narrow your search and quickly find the scale you need. You can also download some of the scales to print for clinical use.
It is important to stress that most scales are not intended to be diagnostic. Scales should not be used alone to establish a diagnosis or treatment plan. Scales provide objective information that healthcare providers can use in considering the next step in evaluation. If results on a scale are positive, that is a signal to further evaluate the patient’s current and past symptoms to determine which diagnosis or diagnoses may be present. A thorough and structured clinical interview is important in this situation.
Up to 33% of bipolar disorder patients may screen negative on scales despite having the disorder.12 As always, we must consider the results from the scale in the wider context of the patient’s history and medical examination.
Now we’ll explore bipolar I disorder and how a deeper understanding of and ability to effectively use clinical rating scales can assist in caring for patients with this condition.
Bipolar disorder is commonly misdiagnosed, with some patients waiting years after symptom onset to receive a correct diagnosis.8 One survey found that in over one-third of patients with bipolar disorder, receiving their correct diagnosis took at least 10 years.8 This delayed diagnosis is associated with poorer long-term outcomes and deterioration in cognitive function.13
Bipolar disorder is most commonly misdiagnosed as MDD. This is in part because patients with bipolar I disorder are more likely to present to care with depressive symptoms rather than manic symptoms.14
Up to 22% of primary care patients diagnosed with recurrent MDD may have undiagnosed bipolar I disorder.15
It is important for clinicians to remember that MDD is a diagnosis of exclusion. In making a diagnosis of MDD, a clinician must rule out depressive symptoms as secondary to a general medical condition (such as hypothyroidism), to substance or medication use, or to a different psychiatric diagnosis like bipolar I disorder.16
An incorrect diagnosis of MDD and treatment with an antidepressant can trigger mania in patients with bipolar disorder, underlining the importance of accurate diagnosis.13,17
Symptoms of bipolar disorder may overlap with symptoms of other psychiatric disorders, including but not limited to attention deficit hyperactivity disorder (ADHD), borderline personality disorder, schizoaffective disorder, and substance use disorders.18 Patients with bipolar disorder are also at higher risk for comorbid conditions including anxiety disorders and substance use disorders.18 The symptomatic overlap and mimicry of other conditions can complicate the diagnostic picture.
Psychiatric rating scales may be appropriate to use when a patient reports a history of current depressive or manic symptoms. They may also be appropriate in a patient reporting a family history of bipolar disorder or MDD.
Following diagnosis and initiation of treatment, severity rating scales should be a routine part of follow-up care to assess any potentially ongoing manic and depressive symptoms. By continuing to obtain quantitative data from validated scales, healthcare professionals are better able to assess their patient’s response to treatment and to inform future care decisions.19
I must stress, making a correct diagnosis in a patient with bipolar I disorder is very important. Initiating therapy with some common antidepressants can precipitate a manic episode in a patient with bipolar I disorder. This diagnosis should be considered before starting antidepressant medications. In fact, screening is recommended to rule out bipolar disorder before a diagnosis of MDD is made.3
We will now explore in a bit more detail which bipolar rating scales to use in clinical trials and which ones to use in clinical practice.
Two commonly used rating scales in clinical trials are the MADRS and the YMRS.
The MADRS is a clinician-rated tool used to assess the severity of major depressive symptoms.9 It is a 10-item questionnaire evaluating core emotional and depressive symptoms: apparent sadness, reported sadness, inner tension, reduced sleep, reduced appetite, concentration difficulties, lack of energy, the inability to feel, pessimistic thoughts, and suicidal thoughts.6 In this tool, items are scored 0 to 6, with 6 representing the most severe rating. This tool is frequently used in bipolar depression clinical trials to measure treatment response.6 It is not commonly used in clinical practice.9
The YMRS is one of the most widely used clinician-rated scales for evaluating severity of manic symptoms.10 It can also be used as a screening scale for bipolar I disorder.
The YMRS is a clinician interview that takes 15 to 30 minutes and covers most, but not all, manic symptoms. This scale does not include depressive symptoms.6,10
Seven items in the YMRS are rated from 0 to 4, while the 4 core symptoms are rated 0 to 8. These core symptoms of mania (irritability, pressured speech, bizarre thought content, and disruptive or aggressive behavior) are thus weighted double the other items.10
The YRMS is mainly used to assess the severity of manic symptoms in clinical trials.10
Two commonly used screening tools in clinical practice are the MDQ and RMS.
The MDQ is one of the most widely used and translated measures that screens for a lifetime history of manic or hypomanic episodes.8
It is a self-report, single-page questionnaire that can take as little as 5 minutes for a patient to complete and can be quickly scored by a healthcare provider. It contains 3 sections. The first section is comprised of 13 questions that ask the patient if they feel that they have been their usual self, including questions about energy levels, self-confidence, and irritability. The second section asks if any of the items in the first section have occurred at the same time. The third and final section asks the patient to rate how much of a problem the symptoms have been in their daily interactions.8
The MDQ has good sensitivity and specificity. It can correctly identify 70% of patients with bipolar I disorder and screen out 90% of patients without bipolar I disorder.8
The RMS is a 6-item, self-report screening questionnaire that can take less than 5 minutes for a patient to complete. The first 3 items screen for bipolar I disorder risk factors, and the final 3 screen for manic symptoms.3
We know that bipolar I disorder is commonly misdiagnosed as MDD in primary care.3 In fact, as many as 1 in 5 patients being treated for MDD could actually have undiagnosed bipolar disorder.20 To address this important and unmet need, the RMS was developed. The RMS is a validated screening tool developed to differentiate bipolar I disorder from MDD in adult patients with depressive symptoms who have been diagnosed with MDD.3
The RMS was developed with the goal of creating a practical and accurate measure to screen for bipolar I disorder using clear and precise wording.3
The sensitivity of the RMS for identifying patients with bipolar I disorder is 88%, and the specificity is 80%.3
Specifically, the RMS asks about characteristics associated with bipolar I disorder, including:
- Number of prior depressive episodes
- Onset of depression before age 18
- Discontinuation of an antidepressant because it caused feelings of being irritable or hyper
The RMS also covers a history of manic symptoms:
- Has there been a week when the patient was more talkative than usual and had racing thoughts?
- Has there been a week when they felt unusually happy, outgoing, or energetic?
- Has there been a week when they needed much less sleep than usual?
Let’s consider a situation when administering the RMS would be appropriate. A patient comes into your clinic with her completed initial paperwork. Upon review, you note that she reports experiencing symptoms of depressed mood, decreased sleep, weight loss, and difficulty concentrating over the past 3 weeks.
You remember that it is common for patients with bipolar disorder to present with depressive symptoms.3 You judge her to be a candidate for the RMS, and you ask her to complete it in the waiting room before you bring her into the examination room. It takes her about 2 minutes to complete the RMS.
You review the RMS results before calling her back. The patient has endorsed 4 items on the RMS. This signals a high likelihood of bipolar I disorder.3 While the highest estimated accuracy for predicting bipolar I disorder was observed with 4 or more “yes” responses, 3 or more also signaled a higher likelihood of bipolar I disorder.3
You note that she is an appropriate patient for a full clinical evaluation. Here are some tips on following through with the clinical interview.
You can use the patient’s answers on the RMS to guide your interview questions. For instance, you could say, “You answered ‘yes’ to the question ‘Have you ever had a period of at least 1 week during which you were more talkative than normal with thoughts racing in your head?’ Can you tell me a little bit more about what that was like for you?”
Based on the patient’s “yes” responses on the RMS, be sure to probe for mania criteria from the DSM-5, but also probe for items she did not endorse on the RMS.
Ask the patient about any personal or family history of psychiatric disorders, including bipolar disorder. Complete a comprehensive review of medication, and obtain a social history, including a thorough substance use history. You will make your final diagnostic decision based on the totality of evidence—the RMS, the patient’s responses to a structured clinical interview, the patient’s history, and any medical evaluation you conduct—and not solely on the RMS findings.
In summary, psychiatric rating scales for bipolar disorder are an important and effective way to gather objective evidence about a patient’s symptoms and functioning. However helpful they are, we must not make the mistake of relying solely on scales for ruling in or ruling out a diagnosis. Do not assume that because a patient screens positive or negative on a scale that they do or do not have the disorder in question. Always follow scale administration with an interview to probe for possible symptoms, and to make your diagnosis based on the totality of the evidence available to you. And, as always, use your clinical judgment when making new diagnoses.
Finally, although it is widely accepted that it is important to track patients’ progress with validated psychiatric rating scales, there is gross underutilization of such instruments.5 Several readily available scales are brief, useful, and easy to incorporate into clinical practice.
Thank you all for joining me today to review psychiatric scales used to screen for, diagnose, and manage bipolar disorder. I do hope you find that the material reviewed is useful to your clinical practice. NP Psych Navigator is pleased to offer a centralized site from which to search and access many psychiatric rating scales. I look forward to seeing you next time!
American Psychiatric Association; subgroup to the working group on quality and performance measurement charged by the council on quality care. Position statement on utilization of measurement-based care. 2018. https://www.psychiatry.org/getattachment/2079de44-fb6c-47da-ad13-ef18e6d00908/Position-Utilization-of-Measurement-Based-Care.pdf
- Xiao L, Qi H, Zheng W, et al. The effectiveness of enhanced evidence-based care for depressive disorders: a meta-analysis of randomized controlled trials. Transl Psychiatry. 2021;11(1):531.
- McIntyre RS, Patel MD, Masand PS, et al. The Rapid Mood Screener (RMS): a novel and pragmatic screener for bipolar I disorder. Curr Med Res Opin. 2021;37(1):135-144.
- Hirschfeld RM, Williams JB, Spitzer RL, et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Am J Psychiatry. 2000;157(11):1873-1875.
- Wood J, Gupta S. Using rating scales in a clinical setting: a guide for psychiatrists. Curr Psychiatry. 2017;16(2)21-25.
- Rating scales and safety measurements in bipolar disorder and schizophrenia - a reference guide. Psychopharmacol Bull. 2017;47(3):77-109.
- Uher R, Perlis RH, Placentino A, et al. Self-report and clinician-rated measures of depression severity: can one replace the other? Depress Anxiety. 2012;29(12):1043-1049.
- Hirschfeld RM. The Mood Disorder Questionnaire: a simple, patient-rated screening instrument for bipolar disorder. Prim Care Companion J Clin Psychiatry. 2002;4(1):9-11.
- Demyttenaere K, Jaspers L. Trends in (not) using scales in major depression: a categorization and clinical orientation. Eur Psychiatry. 2020;63(1):e91.
- Miller CJ, Johnson SL, Eisner L. Assessment tools for adult bipolar disorder. Clin Psychol (New York). 2009;16(2):188-201.
- Trevethan R. Sensitivity, specificity, and predictive values: foundations, pliabilities, and pitfalls in research and practice. Front Public Health. 2017;5:307. doi:10.3389/fpubh.2017.00307
- Suppes T. Bipolar disorder in adults: assessment and diagnosis. Updated August 11, 2022. Accessed September 1, 2022. https://www.uptodate.com/contents/bipolar-disorder-in-adults-assessment-and-diagnosis?search=bipolar%20diagnosis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
- Patel R, Shetty H, Jackson R, et al. Delays before diagnosis and initiation of treatment in patients presenting to mental health services with bipolar disorder. PLoS One. 2015;10(5):e0126530.
- Swann AC, Geller B, Post RM, et al. Practical clues to early recognition of bipolar disorder: a primary care approach. Prim Care Companion J Clin Psychiatry. 2005;7(1):15-21.
- Smith DJ, Griffiths E, Kelly M, Hood K, Craddock N, Simpson SA. Unrecognised bipolar disorder in primary care patients with depression. Br J Psychiatry. 2011;199(1):49-56.
- Muzina DJ, Colangelo E, Manning JS, Calabrese JR. Differentiating bipolar disorder from depression in primary care. Cleve Clin J Med. 2007;74(2). doi:10.3949/ccjm.74.2.89
- Singh T, Rajput M. Misdiagnosis of bipolar disorder. Psychiatry (Edgmont). 2006;3(10):57-63.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013.
- Scott K, Lewis CC. Using measurement-based care to enhance any treatment. Cogn Behav Pract. 2015;22(1):49-59. doi:10.1016/j.cbpra.2014.01.010
- Hirschfield RM, Cass AR, Holt DC, et al. Screening for bipolar depression in patients treated for depression in a family medicine clinic. J Am Board Fam Pract. 2005;18(4):233-239.
This resource is intended for educational purposes only and is intended for US healthcare professionals. Healthcare professionals should use independent medical judgment. All decisions regarding patient care must be handled by a healthcare professional and be made based on the unique needs of each patient.
NP Psych Navigator is sponsored by AbbVie Inc. The contributor is a paid consultant for AbbVie Inc. and was compensated for her time.
The Rapid Mood Screener tool was developed with funding and input provided by AbbVie and external experts, who received financial support from AbbVie for research, honoraria and/or consulting services depending on the author.
AbbVie Medical Affairs
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