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Mood Screening in Bipolar I Disorder Podcast

In this peer insights podcast, Dr McIntosh and Dr Mattingly explore the topic of mood screening in bipolar I disorder and how measurement-based care tools such as the Rapid Mood Screener (RMS) can help identify patients who may have bipolar I disorder.

Transcript:

Dr Mattingly (GM): Welcome to today’s podcast on mood screening in bipolar I disorder. Today, we're going to explore a critical issue in mental health practice, and that is the screening for bipolar I disorder (BP-1). I’m Dr Greg Mattingly, and I’m joined by my colleague, Dr Diane McIntosh. Today, we’ll unpack the clinical challenges associated with the accurate diagnosis of bipolar I disorder, discuss why early identification of bipolar I is essential, and explore how implementing measurement-based tools into clinical practice can help improve outcomes for your patients. Thanks for joining me, Diane. 

Dr McIntosh (DM): Well, thank you, Greg. It’s really a pleasure to be here to discuss this very important topic. Studies show that bipolar I can be frequently misdiagnosed, and this diagnostic uncertainty can lead to long-lasting and serious consequences for patients.1,2 Today’s conversation will delve into the prevalence of misdiagnosis, the importance of measurement-based care, and some research data on these topics. We’ll delve deeper into the rationale behind using validated screening tools and other practical strategies that help improve diagnostic accuracy for bipolar I in clinical practice. 

GM: Let’s begin by grounding the conversation in something that we now refer to as checking a patient’s mental health vital statistics, or measurement-based care. The concept of measurement-based care, which is also sometimes referred to as routine monitoring, involves the systematic collection and use of validated patient-reported outcome measures to help inform clinical judgment. This is similar to the way that a primary care clinician would check a variety of routine vitals to measure health and track clinical management.3 You know, in mental health, these typically include symptom rating scales that can be administered throughout the course of care. The utility of measurement-based care extends far beyond just gathering data. From the beginning of a patient’s journey, these tools can assist with differential diagnoses and help reduce diagnostic errors. They also can help save time and increase efficiency in a clinical visit. They can also offer a more structured way to assess treatment response over time, and measurement-based care encourages more active patient engagement by making the treatment process more transparent and collaborative.3,4  

DM: Precisely. Measurement-based care can help to provide a more structured approach to a patient’s clinical visit by integrating screening, symptom monitoring, and treatment planning into each encounter.3 It can actually also help to foster stronger collaboration and enhance communication between a patient and their clinician. This may offer a shared framework for understanding disease progression and therapeutic response.4 

Of course, there are various factors to consider when using these tools in clinical practice. While time constraints in a busy clinical setting are a valid concern, it's worth noting that these are designed to be brief—usually taking five to 8 minutes per visit to complete. Another important consideration is ensuring that the selected tools are not only validated and reliable but also sensitive enough to detect meaningful changes in symptoms over time.3 Lastly, evidence suggests it’s beneficial to collect symptom severity data from patients frequently, including shortly before or during a clinical encounter.5 

GM: You know, the clinical utility of measurement-based care is well-supported in the literature and has also been really valuable here in our clinical practice. Research has shown that integrating measurement-based care into outpatient psychiatric care can help improve patient outcomes. According to studies, measurement-based care has been associated with shortening the time to symptom remission, enhancing treatment retention, reducing the risk of clinical deterioration, and, probably most important, promoting collaboration in care.4 

For example, a randomized clinical trial compared measurement-based care to standard care for 120 patients with moderate to severe major depressive disorder, or MDD.6 

In the standard care group, psychiatrists selected treatment based on clinical need, and pharmacotherapy consisted of two commonly used antidepressants across both groups to analyze the effect of measurement-based care. Clinicians could choose the specific antidepressant and dose within the study’s recommended dose range.6 

Patients receiving measurement-based care, guided by clinical guidelines, with symptom rating scales, achieved significantly higher response and remission rates, with faster improvement and greater symptom reduction than those receiving standard care.6 

DM: Yet, despite the mounting evidence, it’s unfortunate that the use of measurement-based care in clinical practice is still lagging today. There are many brief and validated symptom rating scales available, yet one study found that less than 18% of psychiatrists and 11% of psychologists in the United States routinely administer these scales to their patients.5 

A 2021 cross-sectional survey, conducted within a large integrated health system in Pennsylvania and Maryland, assessed primary care physicians' use of standardized tools for depression and other mental illnesses. While many physicians were aware of these tools, their routine use was inconsistent. Many physicians relied more on subjective assessments rather than standardized instruments, and integration of these tools into electronic medical records varied across practices.7 

Another primary care study, involving the implementation of PROMIS, or Patient-Reported Outcomes Measurement Information System, found that even when symptom scores were available, clinicians seldom referenced them in their clinical notes. Among patients with elevated PROMIS scores, documentation rates for symptoms like fatigue and depression were below 50%, which may indicate limited integration into routine care.8 

GM: Diane, this is not just a missed opportunity for better patient care, but inconsistent outcome monitoring has been shown to have detrimental effects on providers, clinics, and the broader healthcare system. For example, without systematic, ongoing tracking of treatment effectiveness, it can be difficult for providers to assess whether their quality improvement efforts are making an impact.5  

On a larger level, aggregated data on symptom severity, when collected over time, can help determine if a new clinical initiative is driving better outcomes. At the healthcare system level, these data can be even more powerful, as they may demonstrate competency to accreditation organizations, provide value to payers, and justify investment in evidence-based programs. For payers, in particular, aggregated outcome data can potentially guide the design of benefit structures and reimbursement policies that more effectively promote the well-being of enrollees and compensate clinicians within the practice.5 

Diane, let’s examine, more specifically, the use of measurement-based care in bipolar I disorder. Are screening tools routinely used for BP-1 in the primary care setting? 

DM: Well, for bipolar I, a survey from 2023 found that only 30% of primary care providers use tools to screen for bipolar disorder, while in contrast, 87% of primary care providers reported using tools to screen for MDD.2 This disparity suggests a gap between the routine screening for bipolar disorder compared to depression, which shifts us to the core clinical challenge of accurately diagnosing bipolar I.  

As we know, bipolar I is a chronic condition characterized by episodes of mania and, usually, but not necessarily, episodes of depression. Patients may also have periods when they don’t meet the full criteria but continue to be burdened by sub-syndromal symptoms. A bipolar I diagnosis can result in disability, reduced quality of life, and premature mortality.1,9 

Greg, what do you consider to be the biggest challenge when it comes to diagnosing bipolar I?  

GM: You know, misdiagnosis. A common clinical issue is the frequent misdiagnosis of bipolar I, quite commonly as major depression. A recent meta-analysis of 10 studies found that more than 15% of all patients diagnosed with depression in primary care actually had unrecognized bipolar disorder.1,9,10 

DM: That statistic is deeply concerning. I believe the challenge lies in how similar the presenting symptoms of bipolar and unipolar depression are. In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, or the DSM-5, we can see that criteria overlap between depressive episodes that are associated with MDD and those associated with bipolar I, which complicates diagnostic clarity.1,11,12  

GM: Diane, you’re spot on. In a long-term observational study that followed patients for an average of 12.8 years, patients with bipolar I were shown to experience depressive symptoms 32% of the weeks, while they experienced symptoms of mania just 9% of the weeks.13 This imbalance suggests patients may be more likely to present clinically in the depressive state, while the manic symptoms are often undetected. 

DM: As we can imagine, the consequences of this can be profound. It’s estimated that some bipolar I patients may not receive an accurate diagnosis for five to 10 years. In my own practice, I’ve diagnosed patients in their 50s and 60s who have had bipolar symptoms since their teens. Research shows that patients may seek medical help during a depressive episode much more frequently than they do during a manic or hypomanic episode. Patients may need to present to their doctor with manic symptoms before an accurate bipolar I diagnosis can be reached. When you’re feeling euphoric, and perhaps even grandiose, going to your doctor isn’t always a top choice.11 In addition, in a large-scale survey, bipolar I patients misdiagnosed with MDD saw an average of four different healthcare providers before they received an accurate diagnosis. In the same study, over a third of patients waited more than 10 years to get a bipolar diagnosis.14,15 

GM: So, Diane, it’s a revolving door for some of these patients. This brings us to the importance of early identification, as the therapeutic strategies for MDD and bipolar I differ significantly. While antidepressant monotherapy may be appropriate for the management of major depression, current treatment guidelines do not recommend antidepressant monotherapy for the management of bipolar I.16,17 According to the American Psychiatric Association’s guidelines, bipolar I may be managed with an atypical antipsychotic or a mood stabilizer, or a combination of the two together.16 

DM: Well, exactly, and the American Psychiatric Association advises caution regarding the use of antidepressants in patients with bipolar I, as they may potentially induce manic episodes or increase mood instability—a phenomenon known as treatment-emergent affective switch.17 

Given the evidence of frequent misdiagnosis, diagnostic delays, and the concerns associated with misdiagnosis, let’s review the screening tools available for bipolar I. 

GM: So, I think three screening tools stand out: the Patient Health Questionnaire-9, or PHQ-9; the Mood Disorder Questionnaire, or MDQ; and the Rapid Mood Screener, or RMS. 

The PHQ-9 is widely used in primary care and is often integrated into electronic health record systems.18 Developed in 1999, it screens for major depression through 9 self-rated items based on DSM-4 criteria, including one item assessing functional impairment and another that automatically screens for suicidality. It offers a sensitivity of 74% and a specificity of 91%.1,19 

DM: Yes, and there’s also the PHQ-2, which is a brief version composed of the first two items of the PHQ-9. It evaluates the frequency of depressed mood and anhedonia. It is also used as a pre-screener for the full PHQ-9.20 Many healthcare systems have integrated it into their electronic workflows.21 

GM: Diane, in contrast, the Mood Disorder Questionnaire, or MDQ, screens for a lifetime history of manic symptoms and is among the more widely used screening tools for bipolar I.2 It’s one we use in our clinic. It includes 13 yes/no questions that help uncover the presence of manic or hypomanic syndromes derived from both the DSM-4 criteria and clinical experience. Scoring is fairly straightforward, and in validation studies, the MDQ showed a sensitivity of around 78% and a specificity of about 86%.1,15,22  

For a screen to be considered positive, at least 7 of the 13 items are typically endorsed. Patients must also indicate that their symptoms occurred during the same time period and resulted in at least moderate impairment.2 

DM: The final option is the Rapid Mood Screener, or RMS. It’s emerged as an evidence-based tool used in clinical practice to help screen for possible bipolar I in patients diagnosed with MDD,1,15 and it’s the tool I use in my practice. 

The RMS was developed by a multidisciplinary group of mental health and psychometric experts and was validated in an observational study that included 139 participants with a confirmed diagnosis of bipolar I or MDD. Participants in that study completed a draft version of the bipolar I screening tool and additional study measures, including the MDQ.15  

Based on the responses to the draft screening tool, the development team selected the items that would collectively provide the best balance of specificity and sensitivity while using the smallest possible number of items.15 

The RMS has 6 questions that the patient can answer in under two minutes. Patients will answer the 6 questions using a “Yes” or “No.” Three questions screen for factors related to depression, and the other three screen for manic features of bipolar I. A score of four or more “Yes” responses is considered a positive screen, with a sensitivity of 88% and specificity of 80%.15  

GM: Wow. So, the RMS not only screens for past manic symptoms that are the hallmark of a bipolar I diagnosis, but it also evaluates depressive characteristics that are more probabilistic factors of a bipolar I diagnosis versus MDD.15  

It’s important to note that both the MDQ and the RMS are screening and not diagnostic tools. You know, they are used to help flag the need for a more comprehensive evaluation.15  

DM: Exactly, Greg. From my understanding, tools like the RMS are especially useful when there is clinical suspicion of bipolar I, such as when a patient’s current presentation or description of new symptoms raises concern about the possibility of bipolar I. It can provide a low-burden, quick way to prompt further diagnostic investigation for bipolar I. I personally use the RMS for all of my depressed patients, even if bipolar I is not top of mind, because I know I have only a cross-sectional view of the patient, and sometimes it’s difficult to gather a history of mania. When you’re really depressed, it’s really difficult to remember ever feeling good.  

GM: One hundred percent, Diane. You know, but unlike the PHQ, the RMS and MDQ don’t seem to be used as often in the primary care setting.  

DM: Yep, that’s true, and we touched on this earlier. As you recall, we previously discussed a survey that found that less than one-third of primary care providers use tools to screen for bipolar disorder. That same survey also evaluated the awareness and use of screening tools among HCPs across specialties and found that while 85% of HCPs were aware of the Mood Disorder Questionnaire, only 29% reported current use, with primary care providers in line with that statistic at 28%.2 

GM: However, using screening tools for bipolar I in the primary care setting may be especially valuable because, as we stated earlier, many patients with bipolar I seek help during a depressive episode, which can potentially translate into a misdiagnosis of major depression. In these situations, patients may receive inappropriate treatment and potentially even exacerbate their underlying bipolar condition.17 The use of bipolar screening tools in the primary care setting offers a critical opportunity to identify bipolarity early and help improve our patients’ outcomes. 

DM: While the RMS is not a diagnostic tool, it can be used as a strong indicator to pursue further evaluation using the DSM-5-TR criteria. Of note, the RMS is available online to US healthcare providers on the website rapidmoodscreener.com. 

GM: Diane, that brings us to what I think is the real takeaway here. For clinicians, especially those in primary care who see patients with depressive symptoms, this kind of tool can potentially make a real difference in your patients’ lives. As we’ve discussed, missing a diagnosis of bipolar I disorder, or mistaking it for unipolar depression, may lead to years of inappropriate pharmacologic management and poor patient outcomes. Tools like the RMS are well-validated, practical, filled out by the patient, and can screen for possible bipolar I. I would recommend that we check those mental health vital statistics and that all patients with depression be screened with the MDQ or the RMS to help improve outcomes for your patients.  

DM: Well, I couldn’t agree more, Greg. Our conversation has highlighted the benefits of integrating measurement-based care into routine practice, which includes the use of validated, accessible screening tools that can help uncover potentially hidden bipolarity in depressed patients. By using these tools routinely, we may be able to help close the gap between symptom presentation and accurate diagnosis in bipolar I. Thank you so much for joining us today. And thank you, Greg, for having this really important discussion with me. 

GM: Diane, always great to be with you on these types of projects. Thank you to our listeners for joining us on Psych Navigator!   

Greg Mattingly, MD 
Gregory Mattingly, MD, is the chief executive officer of Midwest Research Group and an associate clinical professor at Washington University. He has been the principal investigator for over 450 clinical trials across various therapeutic areas within psychiatry. Dr Mattingly is also the president of the American Professional Society of ADHD and Related Disorders (APSARD) and is a scientific advisory board member for the World Federation of ADHD. Additionally, Dr Mattingly serves as a speaker for multiple organizations, contributing to disseminating knowledge and advancements in treatment options.  

Diane McIntosh, MD, FRCPC  
Diane McIntosh, MD, FRCPC, is a highly regarded psychiatrist and mental health innovator. She is the founder and chief executive officer of RAPIDS Health and Chief Neuroscience Officer at TELUS. She has held numerous prominent positions, including clinical assistant professor at the University of British Columbia and clinical director at the Department of National Defense's Post-Traumatic Stress Disorder Clinic in Nova Scotia. Dr McIntosh is also a published author and recipient of various accolades, including the King Charles III Coronation Medal for her psychiatric advocacy and education contributions.  


References
  1. Vossos H, Nwosu-Izevbekhai O. Mood disorders and rapid screening: a brief review. J Ment Health Clin Psychol. 2024;8(2):51-54. doi:10.29245/2578-2959/2024/2.1314

  2. Thase ME, Stahl S, McIntyre RS, et al. Screening for bipolar I disorder using the Rapid Mood Screener: results from a nationwide health care provider survey. Prim Care Companion CNS Disord. 2023;25(2):22m03322. doi:10.4088/PCC.22m03322
  3. Jensen-Doss A, Douglas S, Phillips D, et al. Measurement-based care as a practice improvement tool: clinical and organizational applications in youth mental health. Evid Based Pract Child Adolesc Ment Health. 2020;5(3):233-250. doi:10.1080/23794925.2020.1784062
  4. Bailey K, Lo LA, Chauhan B, et al. Using a quality improvement approach to implement measurement-based care (MBC) in outpatient general psychiatry. Jt Comm J Qual Patient Saf. 2023;49(10): 563-571. doi:10.1016/j.jcjq.2023.06.009
  5. Fortney JC, Unutzer J, Wrenn G, et al. A tipping point for measurement-based care. Psych Serv. 2017;68(2):179-188. doi:10.1176/appi.ps.201500439
  6. Guo T, Xiang YT, Xiao L, et al. Measurement-based care versus standard care for major depression: A randomized controlled trial with blind raters. Am J Psychiatry. 2015; 172(10): 1004-1013. doi:10.1176/appi.ajp.2015.14050652
  7. Waheed A, Afridi AS, Rana M, et al. Knowledge and behavior of primary care physicians regarding utilization of standardized tools in screening and assessment of anxiety, depression, and mood disorders at a large integrated health system. J Prim Care & Comm Health. 2024;15:1-7. doi:10.1177/21501319231224711
  8. Kroenke K, Talib TL, Stump TE, et al. Incorporating PROMIS symptom measures into primary care practice-a randomized clinical trial. J Gen Intern Med. 2018;33(8):1245-1252. doi:10.1007/s11606-018-4391-0
  9. Oliva V, Fico G, De Prisco M, et al. Bipolar disorders: an update on critical aspects. Lancet Reg Health Eur. 2024;48:101135. doi:10.1016/j.lanepe.2024.101135
  10. Daveney J, Panagioti M, Waheed W, et al. Unrecognized bipolar disorder in patients with depression managed in primary care: a systematic review and meta-analysis. Gen Hosp Psychiatry. 2019;58:71-76. doi:10.1016/j.genhosppsych.2019.03.006
  1. Yang R, Zhao Y, Tan Z, et al. Differentiation between bipolar disorder and major depressive disorder in adolescents: from clinical to biological biomarkers. Front Hum Neurosci. 2023;17:1192544. doi: 10.3389/fnhum.2023.1192544
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  4. Hirschfeld RM, Lewis L, Vornik LA. Perceptions and impact of bipolar disorder: how far have we really come? Results of the national depressive and manic-depressive association 2000 survey of individuals with bipolar disorder. J Clin Psychiatry. 2003;64(2):161-174.
  5. 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. doi:10.1080/03007995.2020.1860358
  6. American Psychiatric Association. Practice Guideline for the Treatment of Patients With Bipolar Disorder. 2nd ed. American Psychiatric Association; 2010.
  7. McIntyre RS, Laliberté F, Germain G, et al. The real-world health resource use and costs of misdiagnosing bipolar I disorder. J Affect Disord. 2022;316:26-33. doi:10.1016/j.jad.2022.07.069
  8. Bruni T, LaLonde L, Maragakis A, et al. The use of electronic health record tools to improve evidence-based treatment of adolescent depression in primary care. Acad Ped. 2021;21(7):1195-1202. doi:10.1016/j.acap.2021.05.022
  9. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606-613. doi:10.1046/j.1525-1497.2001.016009606.x  
  10. Levis B, Sun Y, He C, et al. Accuracy of the PHQ-2 alone and in combination with the PHQ-9 for screening to detect major depression: systematic review and meta-analysis. JAMA. 2020;323(22):2290-2300. doi:10.1001/jama.2020.6504
  11. Garber BB, Chen J, Beliveau A, et al. Using the Patient Health Questionnaire-2 to improve depression screening in head and neck cancer patients. Am J Otolaryngol. 2023;44(2):103724. doi:10.1016/j.amjoto.2022.103724
  12. Hirschfeld RM, Williams JB, Spitzer RL, et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Am Jour Psych. 2000;157(11):1873-1875. doi:10.1176/appi.ajp.157.11.1873 


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. 

Psych Navigator is sponsored by AbbVie Medical Affairs. The contributors are paid consultants for AbbVie Medical Affairs and were compensated for their time. 

The Rapid Mood Screener is not a diagnostic tool. 

The Rapid Mood Screener 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.

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