Readability of English-Language Self-Report Measures in Bipolar Disorder

Joseph Nickel, MD; Sujeeth Shanmugam, BS; Niki Jona, BS; Kaushal Shah, MD, MPH; Predrag Gligorovic, MD, MHA

Prim Care Companion CNS Disord 2025;27(3):24m03892

Abstract

Objective: Self-report measures have been used as a tool to evaluate mania and depressive symptoms and aid in diagnosing bipolar disorder. The American Medical Association recommends that the evaluation reading be at a fifth- to sixth-grade level. The research literature has previously established that questionnaires regarding other psychiatric conditions have been written at an elevated reading level compared to the recommended guidelines. The objective of this study was to calculate the overall readability of measures in bipolar disorder and the individual readability of the items and instructions sections.

Methods: Measures in assessing bipolar disorder were selected from a publicly available literature search in the PsycINFO, PubMed, PubMed Central, and Google Scholar databases. Nine English-language measures met the inclusion criteria and were analyzed. The readability of each measure was analyzed via 4 validated formulas, Gunning Fog, Simple Measure of Gobbledygook, FORCAST, and Flesch Reading Ease, through an external website (readable.com). Measures with an average readability greater than 6.00 were considered above the recommended reading level.

Results: All measures had at least 1 component (instructions or items) written above the recommended reading level. The mean reading level of the instructions and items sections were 9.35 (SD = 1.45; range, 7.03–11.51) and 8.78 (SD = 1.73; range, 5.59–11.31), respectively.

Conclusion: The results indicate that using these measures in populations with low reading literacy may be a limitation in correctly identifying manic and depressive symptomology. If the self-report symptom tool is utilized with a higher readability than the average patient, it may not be guaranteed that this tool will improve the diagnosis process.

Prim Care Companion CNS Disord 2025;27(3):24m03892

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