Screening for Bipolar I Disorder and the Rapid Mood Screener: Results of a Nationwide Health Care Provider Survey

Prim Care Companion CNS Disord 2023;25(2):22m03322

To cite: Thase ME, Stahl SM, McIntyre RS, et al. Screening for bipolar I disorder and the Rapid Mood Screener: results of a nationwide health care provider survey. Prim Care Companion CNS Disord. 2023;25(2):22m03322.
To share: https://doi.org/10.4088/PCC.22m03322

© 2023 Physicians Postgraduate Press, Inc.

^aDepartment of Psychiatry, University of Pennsylvania, Perelman School of Medicine, Philadelphia, Pennsylvania
^bDepartment of Psychiatry and Neuroscience, University of California Riverside School of Medicine, California
^cDepartment of Psychiatry, University of Toronto, Toronto, Ontario, Canada
^dSeaside Behavioral Health, Virginia Beach, Virginia
^eSchool of Nursing, the University of Texas at Austin, School of Nursing, Austin, Texas
^fAbbVie, North Chicago, Illinois (at the time of the study)
^gDepartment of Psychiatry/Behavioral Science, University of South Carolina School of Medicine, Greenville, South Carolina
^hDepartment of Family Medicine and Department of Psychiatry, University of Tennessee College of Medicine, Memphis, Tennessee
ⁱUniversity of Barcelona, Institute of Neuroscience, Hospital Clinic, IDIBAPS, CIBERSAM, Barcelona, Catalonia, Spain
*Corresponding author: Michael E. Thase, MD, Department of Psychiatry, Mood and Anxiety Disorders Treatment and Research Program, 3535 Market St, Ste 670, Philadelphia, PA 19104-3309 (thase@pennmedicine.upenn.edu).

Although mania is the hallmark symptom of bipolar I disorder, depression is the leading cause of associated morbidity, and most patients seek treatment during a depressive episode.¹ Routine screening for depression is recommended in primary care settings,² but this same standard of care is not as well established for patients whose depressive symptoms suggest bipolar disorder.^3,4 Not surprisingly, misdiagnosis of bipolar I disorder as major depressive disorder (MDD) is a common problem and a significant unmet medical need for individuals with this disorder. For example, 69% of individuals with bipolar disorder surveyed in one large study⁵ reported being initially misdiagnosed, with unipolar depression cited as the most common misdiagnosis (60%). A recent meta-analysis⁶ supported previous findings of diagnostic inaccuracy showing that over 3 in 20 patients with depression actually had unrecognized bipolar disorder. Timely diagnosis of bipolar disorder is a critical concern since delays are associated with worse outcomes^7,8 and the potential for inappropriate treatment with antidepressant monotherapy, which is associated with risk of mood destabilization or treatment-emergent mania.⁹ Effective screening for bipolar disorder can lead to enhanced clinical assessment, which may help improve diagnostic accuracy and circumvent iatrogenic use of antidepressants.¹⁰

Since bipolar disorder is a diagnosis made over time and in consideration of prior mood episodes,¹¹ comprehensive clinical assessment comprises cross-sectional evaluation of depressive symptoms and inquiry into the history of manic (suggesting bipolar I disorder), hypomanic (suggesting bipolar II disorder), and mixed mood symptoms. While overlapping depressive symptoms in bipolar disorder and MDD and the lack of a clear-cut boundary separating bipolar I and bipolar II¹² complicate the clinical picture, screening tools have been proposed as a way to improve the detection of bipolar disorder.^11,13 Although several are available, their use in clinical practice settings is limited by barriers including short office visits, uncertainty about when to screen, and inadequate knowledge of bipolar disorder symptoms.^3,4 Currently, the 15-item Mood Disorder Questionnaire (MDQ),¹⁴ which screens for a lifetime history of manic or hypomanic episodes, is among the best known and most widely used screening tools for bipolar I or II disorder. For a positive screen, 7 of 13 MDQ manic symptom items must be endorsed, and on 2 additional items, patients must affirm that several of these symptoms have occurred during the same time period and caused at least moderate impairment.

The Rapid Mood Screener (RMS) is a newly introduced self-administered screening tool that was developed to differentiate bipolar I disorder from MDD in patients with depressive symptoms (full version available at https://doi.org/10.1080/03007995.2020.1860358).¹⁵ Validated in an observational study of patients with bipolar I disorder, the pragmatic 6-item RMS not only screens for hallmark manic symptoms, but also evaluates depressive characteristics (eg, earlier age at depression onset, prior negative response to antidepressant treatment, multiple depressive episodes) that are more likely to indicate bipolar disorder than MDD.¹⁶ When 4 or more RMS items were endorsed (“yes”), which is considered a positive screen for bipolar I disorder, sensitivity (the true positive rate) was 88% and specificity (the true negative rate) was 80%. The clearly worded items of the RMS can be completed in less than 2 minutes during or outside of a clinical visit (eg, online, via electronic medical record system, waiting room), making the RMS a patient-friendly screener that can be easily integrated into clinical practice to alert the clinician that more thorough diagnostic evaluation is warranted.

Even though routine screening for bipolar disorder is suggested to improve the accuracy and efficiency of diagnostic evaluation, published information pertaining to health care provider (HCP) experience and insight into bipolar disorder screening is scant. To better understand the current clinical practice landscape regarding screening tool use, we conducted a nationwide survey of primary care and psychiatric HCPs to evaluate MDD and bipolar disorder screening awareness and behavior, with specific attention paid to the acceptability of the MDQ and the RMS.

METHODS

A nationwide electronic survey of HCPs was conducted from June 1 to June 12, 2020, to evaluate current screening practices for bipolar disorder and MDD, familiarity with screening tools, current use of bipolar screeners, and attitudes about the RMS and MDQ (see Supplementary Appendix 1 for survey questions); participants were blinded to the sponsor of the survey (AbbVie). Potential participants were identified in databases of providers who participate in market research and invited by e-mail to complete the 10-minute survey.

The overall quota of interviews was 200; a representative sample of HCPs was stratified by specialty (primary care: primary care practitioners [PCPs], general nurse practitioners [NPs] and physician assistants/associates [PAs]; psychiatric: psychiatrists, psychiatric NPs and PAs) and screened for eligibility (Table 1). HCPs who met eligibility criteria were instructed to answer all questions in the context of their work in outpatient settings. All data were self-reported; responses were anonymous, with no identifiable information collected during the survey.

To assess screening tool use, HCPs were asked if they currently use a screening tool for depression or bipolar disorder (yes/no), and, if so, they entered the name(s) of the tool(s) they use. Experiences with the MDQ were specifically queried, and bipolar disorder screening tool attributes (eg, minimal number of items, sensitivity, specificity, easy scoring) were rated (1 [Not at all important] to 7 [Extremely important]).

The RMS was then introduced as a potential new screening tool for bipolar disorder, and participants were instructed to review it. The RMS was shown as a stand-alone element (Figure 1A), and HCPs were asked to rate how it compared to other bipolar disorder screening tools (1 [Much worse] to 7 [Much better]). On a scale of 1 (Extremely unlikely) to 7 (Extremely likely), HCPs were asked how likely they were to use the RMS to screen new patients with depressive symptoms or a depression diagnosis and to rescreen patients with a depression diagnosis. HCPs then rated how they thought that availability of the RMS would impact their practice, with response choices ranging from “I would begin screening for bipolar disorder” to “The RMS would not impact my practice.”

After answering these RMS-specific questions, respondents were shown the RMS and the MDQ side-by-side on the screen with the position of each tool randomly determined; a table comparing the specifications of each tool was also presented (Figure 1B). HCPs were instructed to review the two screeners, after which they were asked which tool they were more likely to use. Finally, HCPs rated the RMS and the MDQ (presented sequentially in randomly ordered questions) according to how well screening tool attributes described each tool; the percentage of HCPs who rated an attribute as 6 (Describes very well) or 7 (Describes extremely well) was tallied per tool, and the percentages were compared.

Statistics

Findings were reported by descriptive statistics. PCP and psychiatric subgroup comparisons were made to determine whether there was a significant difference at a 95% confidence level; a minimum sample size of n = 20 was required to compare. Additional comparisons were made between the RMS and the MDQ; statistical significance was determined at the .05 level. Collected data were analyzed using IBM SPSS Data Collection Professional/Dimensions.

RESULTS

A total of 426 HCPs were screened for eligibility; 151 were excluded for not meeting inclusion qualifications, and 51 HCPs left the survey before completing it in full. Additionally, 19 surveys were not included because the sample size quota for the specialty had already been met, and 2 surveys were not included because the total number of participants for the survey had been reached. A total of 203 respondents completed the survey; 3 completed surveys were excluded from reporting for failing quality control checks (eg, contradictory answers). Per quota, 200 surveys were retained for analysis (primary care = 130 [PCPs = 100; NPs/PAs = 30]; psychiatric = 70 [psychiatrists = 50, psychiatric NPs/PAs = 20]).

HCP Sample Characteristics

The HCP sample was relatively well distributed by geographic region (West = 19%, Midwest = 26%, South = 29%, Northeast = 26%). The majority of HCPs saw outpatients with bipolar disorder in a private office setting (72%); other settings included outpatient treatment center/clinic (11%) and community mental health center (10%). The mean monthly adult patient load (standard deviation [SD]) for the total number of HCPs was 76 (60.6) patients with MDD (primary care = 58 [45.9]; psychiatric = 110 [69.2]) and 37 (40.6) patients with bipolar disorder (primary care = 20 [20.9]; psychiatric = 68 [48.9]). Psychiatric HCPs versus primary care HCPs reported making more monthly diagnoses of MDD (48 [33.9] vs 24 [23.3]) and bipolar disorder (33 [32.5] vs 9 [14.4]) (P < .05 for both).

Perspectives on Screening for MDD and Bipolar Disorder

A total of 82% of HCPs reported that they currently use a tool to screen for MDD, with significantly more primary care HCPs (87%) than psychiatric HCPs (71%) screening (P = .008). When asked to fill in the name of the tool(s) that they used to screen for MDD, 81% indicated that they use a tool other than the MDQ (Figure 2A). The Patient Health Questionnaire (PHQ)¹⁷ was the most common other tool mentioned (61%), with 55% of HCPs specifically indicating that they use the PHQ-9 and 16% indicating the PHQ-2. In comparison, only 32% of HCPs (primary care = 30%, psychiatric = 36%) reported using a tool to screen for bipolar disorder, with respondents most commonly mentioning the MDQ as the tool that they used (20%) (Figure 2B).

When asked about the MDQ specifically, 85% of HCPs reported that they were aware of the tool, 54% said they had used it, and 29% reported current use (primary care = 28%, psychiatric = 30%). There was an open attitude about future bipolar screening tool use among the 136 HCPs who currently do not screen, with 60% saying that they would definitely or likely consider using a bipolar screener in the future. When HCPs rated the attributes that they valued in a bipolar disorder screening tool, sensitivity, easy-to-answer questions, specificity, providing decision-making confidence, being practical to use, and easy scoring were among the attributes that HCPs valued the most; significantly more psychiatric HCPs than primary care HCPs valued good sensitivity (P = .026) (Figure 2C).

Perceptions of the RMS

A total of 168 HCPs had enough knowledge of bipolar disorder screening tools to rate the RMS. Over two-thirds of these HCPs thought that the RMS was at least somewhat better than other tools, while 23% thought it was about the same (Figure 3A); “I am not familiar enough with other screener tools for bipolar disorder to make a comparison” was an option for respondents who did not indicate current MDQ usage in a previous question. Most HCPs (84%) indicated that the RMS would have a positive impact on their practice, resulting in likely screening of new patients with depressive symptoms or a depression diagnosis and more screening of patients suspected of having bipolar I disorder (Figure 3B). Further, a total of 68% of HCPs (primary care = 74%, psychiatric = 57% [P = .017]) indicated that they were likely to use the RMS to rescreen current patients with a depression diagnosis, further suggesting a role for the RMS in clinical practice.

The RMS Versus the MDQ

In sequentially presented, randomly ordered questions, HCPs rated the attributes of the RMS and MDQ. A significantly higher percentage of HCPs said that the screening tool qualities they valued better described the RMS than the MDQ across all attributes (P < .05) (Figure 4A). Particularly large differences in favor of the RMS were observed for brevity (46-point differential), practicality (38 points), easy scoring (38 points), and easy-to-answer questions (37 points). If both the RMS and MDQ were available, the majority of both primary care and psychiatric HCPs indicated that they would use the RMS to screen for bipolar disorder (Figure 4B). Pragmatic features were most often cited as compelling reasons to adopt the RMS in practice, with ability to complete the tool in less than 2 minutes (72% of HCPs), small number of questions (66%), easy scoring (66%), and easily understood questions (60%) among the most relevant qualities noted for the RMS. Most HCPs (74%) envisioned the RMS used in a paper format, 62% thought it would be filled out by the patient alone before an office visit, and 48% thought that the RMS would be included in a patient’s electronic health record.

DISCUSSION

In a nationwide survey of primary care and psychiatric HCPs, 84% of HCPs said that the RMS would have a positive impact on their practice, with significantly more HCPs indicating that they were more likely to use the RMS than the MDQ (81% vs 19%; P < .05). Three of 4 respondents said they were likely to use the RMS to screen new patients with depressive symptoms, and almost 70% indicated that they would rescreen patients with an existing depression diagnosis. The RMS was strongly preferred to other bipolar disorder screening tools, including the widely recognized but underutilized MDQ. Across specialties, over two-thirds of respondents reported that the RMS was at least somewhat better than other bipolar disorder screening tools, suggesting that this new bipolar I disorder screening tool would be useful in clinical practice settings.

Barriers to accessing psychiatric services (eg, lack of providers, distance to providers, appointment wait times, insurance coverage)^18,19 mean that clinical encounters for depression frequently occur in primary care, and many patients with bipolar disorder are treated exclusively in this setting.²⁰ Although misdiagnosis of bipolar disorder in primary care has been identified as a serious issue,^5,6,21 diagnostic challenges may exist for psychiatric practitioners as well. In one study,¹⁹ for example, primary care physicians misdiagnosed or failed to detect bipolar disorder in 78% of patients who screened positive for bipolar I or II disorder, but psychiatrists also missed the diagnosis in over half (53%) of patients. While the MDQ is the most widely known screening tool for bipolar disorder, responses to our survey indicated that current usage was low for psychiatric (30%) and primary care (28%) HCPs alike, suggesting that the availability of the RMS could improve screening and identification of bipolar disorder across clinical practice settings. Most primary care and psychiatric HCPs reported that if the RMS and MDQ were both available, they would be more likely to use the RMS, which was preferred across all screener tool attributes that are important to HCPs (eg, brevity, easy-to-answer questions, sensitivity, specificity, easy scoring).

Self-reported bipolar disorder screening tools other than the MDQ are available, but like the MDQ, they may rely on screening for manic symptoms only or be too long or complicated to be easily administered within the timeframe of a typical office visit. For example, the 32-item Mania/Hypomanic Checklist (HCL-32)²² and the 48-item Hypomanic Personality Scale²³ include only hypomania or mania items. While the 161-item Mood Spectrum Self-Report (MOODS-SR)²⁴ and the General Behavior Inventory (GBI)^25–27 (52–73 items) both include manic and depressive symptoms, their usefulness in clinical practice is likely restricted by excessive length. The Bipolar Spectrum Diagnostic Scale (BSDS),²⁸ which also includes manic and depressive symptoms, has a 2-part format that consists of 19 sentences that are rated and scored as individual items and as a complete story. Also of note is the 10-minute, patient-completed MoodCheck,^29,30 which is a comprehensive tool that consists of the BSDS and additional questions about family history of mood disorders and elements of the Bipolarity Index. The Bipolarity Index³¹ is a clinician-rated diagnostic measure that rates 5 dimensions of bipolarity (hypomania/mania, age at onset of first mood symptoms, illness course/features, response to antidepressants/mood stabilizers, and family history of mood/substance use problems) on a spectrum, with a score ≥ 50 indicating a high probability of bipolar disorder. Finally, the 27-item Mood Swings Questionnaire (MSQ),³² which was designed to improve the recognition of bipolar II disorder in depressed patients, has 3 initial screening questions that must be answered “yes” before the remaining questions are answered (a “no” answer is presumptive of unipolar depression) and while it is available, it may not necessarily be intuitive for use in the clinic. Even though these and other screening tools exist to screen for illness across the bipolar spectrum, the low percentage of HCPs who reported bipolar screening suggests that the RMS will be a valuable addition to the bipolar I disorder screening tool armamentarium.

Beyond our survey results indicating a marked preference for the RMS over the MDQ, head-to-head comparison of sensitivity and specificity can be made based on results from the RMS validation study since both screeners were administered in the same bipolar I analysis population.¹⁵ Of note, when an RMS screen was positive for bipolar I disorder (4 or more “yes” responses), sensitivity was 88% and specificity was 80%, while a positive MDQ screen yielded sensitivity of 86% and specificity of 78%. Additionally, since practicality was highly valued by HCPs in our survey, it is important that the RMS has less than half the number of items that the MDQ has, it screens for both bipolar I depression features and manic symptoms, uses a simpler scoring algorithm, and is estimated to take 2 minutes to complete versus the commonly cited 5-minute completion time for the MDQ.^33–35 However, while the differences between the RMS and MDQ are interesting and potentially important, conclusions about the advantage of one screening tool over another would necessitate further research in a real-world setting.

Of note, the RMS has not been validated in patients with bipolar II disorder, a common illness type, so participants with this disorder were not included in our survey and outcomes cannot be generalized to this group of patients. As in the case of positive RMS screening, complete diagnostic evaluation for bipolar disorder is also warranted in cases in which screening yields a subthreshold positive RMS result or if there are other clinical suspicions. For example, if bipolar II is suspected, screening with the MDQ or another tool that screens for bipolar II may be prudent since the RMS has been validated only in patients with bipolar I. Interestingly, MDQ sensitivity was shown to be considerably higher for identifying bipolar I disorder (66.3%) than for identifying bipolar II disorder (38.6%),³⁶ suggesting that identifying bipolar II may be especially challenging.

In our nationwide survey, HCPs were introduced to the RMS, a pragmatic new screening tool designed to differentiate bipolar disorder from MDD in patients with depressive symptoms. This brief self-administered tool, which screens for manic symptoms and bipolar I disorder characteristics in less than 2 minutes, was enthusiastically received by survey respondents, with an overwhelming majority reporting that they would be likely to use it. Across specialties, most HCPs believed that the RMS would have a positive impact on their practices, leading to more screening for bipolar I disorder. Screening with the RMS could help clinicians recognize patients who would benefit from a comprehensive diagnostic evaluation, which could in turn lead to more timely and accurate diagnosis of bipolar I disorder and improved patient outcomes. In the future, not only may the use of tools such as the RMS be helpful in traditional clinical practice, but these tools may also suit big data analyses,³⁷ enabling the application of artificial intelligence algorithms to improve clinicians’ diagnostic accuracy and further refinements of classifications toward precision psychiatry. Again, the full version of the RMS and a guide for HCPs is freely available for download at https://doi.org/10.1080/03007995.2020.1860358.

Submitted: May 16, 2022; accepted October 20, 2022.
Published online: April 25, 2023.
Author contributions: All authors participated in the writing, editing, and critical revision for intellectual content and approval of the final version of this manuscript. All authors met International Committee of Medical Journal Editors (ICMJE) authorship criteria and agree to be accountable for all aspects of the work. Neither honoraria nor payments were made for authorship.
Relevant financial relationships: Dr Thase has received grants from the Agency for Healthcare Research and Quality, Alkermes, Allergan (now AbbVie), National Institute of Mental Health, Otsuka, Pharma Neuroboost, and Roche; has acted as an advisor or a consultant for Alkermes, AstraZeneca, Bristol-Myers Squibb, Cerecor, Eli Lilly, Allergan (now AbbVie), Gerson Lehman Group, GlaxoSmithKline, Guidepoint Global, Lundbeck, MedAvante, Merck, Neuronetics, Novartis, Ortho-McNeil Pharmaceuticals, Otsuka, Pamlab, Pfizer, Shire, Sunovion, and Takeda; has received royalties from American Psychiatric Association, Guilford Publications, Herald House, and W.W. Norton & Company; and holds equity in MedAvante Inc. Dr Stahl served as a consultant to Acadia, Alkermes, Allergan, AbbVie, Axsome, Clearview, Eisai Pharmaceuticals, Gedeon Richter, Intra-Cellular Therapies, Karuna, Levo Therapeutics, Lundbeck, Merck, Neurocrine, Otsuka, Relmada, Sage Therapeutics, Sunovion, Supernus, Taliaz, Teva, Tris Pharma, and VistaGen; he holds options in Genomind, Lipidio, and Delix; he has served on speakers bureaus for Acadia, Lundbeck, Otsuka, Perrigo, Servier, Sunovion, and Teva; and he has received research and/or grant support from Acadia, Allergan/AbbVie, Avanir, Braeburn Pharmaceuticals, Eisai, Eli Lilly, Harmony Biosciences, Indivior, Intra-Cellular Therapies, Ironshore, Neurocrine, Otsuka, Pear Therapeutics, Sage, Shire Sunovion, Supernus, and Torrent. Dr McIntyre has received research grant support from the Canadian Institutes of Health Research (CIHR)/Global Alliance for Chronic Diseases (GACD)/National Natural Science Foundation of China (NSFC) and the Milken Institute and speaker/consultation fees from Lundbeck, Janssen, Alkermes, Neumora Therapeutics, Boehringer Ingelheim, Sage, Biogen, Mitsubishi Tanabe, Purdue, Pfizer, Otsuka, Takeda, Neurocrine, Sunovion, Bausch Health, Axsome, Novo Nordisk, Kris, Sanofi, Eisai, Intra-Cellular Therapies, NewBridge Pharmaceuticals, Viatris, AbbVie, and Atai Life Sciences. Dr McIntyre is a CEO of Braxia Scientific Corp. Ms Matthews-Hayes has received speaker fees from AbbVie (formerly Allergan), Neurocrine, and Otsuka pharmaceuticals and has served on advisory boards or as a consultant for AbbVie (formally Allergan) and Neurocrine. She has also been a paid consultant for Psychiatry Times and Psych Congress Bipolar disease state CME, sponsored by Intra-Cellular Therapies, Inc. Dr Rolin has no conflicts of interest to disclose. Dr Harrington was an employee of AbbVie at the time of the research and may hold stock. Dr Patel was an employee of AbbVie at the time of the research and may hold stock. Dr Maletic has received research support from or served as a consultant or speaker for Acadia, Alfasigma, Alkermes, Allergan (now AbbVie), Axsome, Biogen/Sage, Intra-Cellular Therapies, Ironshore, Janssen, Lundbeck, Otsuka, Relmada, Sunovion, Supernus, and Takeda. Dr Jackson has been a consultant and speakers/advisory board member for and received honoraria from Allergan (now AbbVie), Genentech, Otsuka, and Sunovion. Dr Vieta has received grants and served as consultant, advisor, or speaker for AB-Biotics, AbbVie, Angelini, AstraZeneca, Bristol-Myers Squibb, Dainippon Sumitomo Pharma, Farmindustria, Ferrer, Gedeon Richter, GlaxoSmithKline, Janssen, Lundbeck, Otsuka, Pfizer, Roche, SAGE, Sanofi-Aventis, Servier, Shire, Sunovion, Takeda, the Brain and Behaviour Foundation, the Generalitat de Catalunya (PERIS), the Spanish Ministry of Science, Innovation and Universities (CIBERSAM), EU Horizon 2020, and the Stanley Medical Research Institute.
Funding/support: This research was funded by AbbVie.
Role of the sponsor: AbbVie participated in the study design, research, analysis, data collection, interpretation of data, and the review and approval of the publication. All authors had access to relevant data and participated in the drafting, review, and approval of this publication. No honoraria or payments were made for authorship.
Acknowledgments: Writing and editorial assistance were provided to the authors by Carol Brown, MS, of Prescott Medical Communications Group (Chicago, IL), which was funded by AbbVie. Project development assistance was provided by Mary Keever, MMR, BS, of Material (formerly Lieberman Research Worldwide), Charlotte, North Carolina, and funded by AbbVie.
Previous presentations: Presented at the NEI Virtual Poster Library; 2020 • American Association of Nurse Practitioners Annual Meeting; October 21–24, 2020 (virtual).
Supplementary material: See accompanying pages.

Clinical Points

• Effective screening can lead to enhanced assessment and improved identification of bipolar I disorder in clinical practice.
• The Rapid Mood Screener (RMS) is a self-administered screening tool that was developed to differentiate bipolar I disorder from major depressive disorder in patients with depressive symptoms.
• In a nationwide survey of health care providers, three-quarters of respondents reported that the RMS would have a positive impact on their practice, with almost half saying they would screen more patients for bipolar disorder.