Screening Instruments Do Work for Bipolar Disorder, But Not by Themselves

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Editor's note: Read Dr Zimmerman's rejoinder, Faith is Not Enough: Self-Administered Questionnaire Screening for Bipolar Disorder.

LETTER TO THE EDITOR

We appreciate the article “Diagnosing Bipolar Disorder in Clinical Practice: Underdiagnosis, Overdiagnosis, and Screening”¹ by Mark Zimmerman, MD, and the concerns regarding “what niche” screening instruments for bipolar disorder (BD) should occupy. We also agree that the gold standard for the diagnosis of bipolar spectrum disorders is a comprehensive, clinical evaluation. As co-developers of the Bipolar Spectrum Diagnostic Scale (BSDS), which is referenced in the article,² we believe that screening scales for bipolar spectrum disorders can play a useful role in certain clinical settings, when used with appropriate caveats.

The article opines, “It is not clear how a screening scale for bipolar disorder would be helpful in a psychiatric setting." (italics added). To be sure, psychiatrists do not need screening questionnaires to diagnose BD spectrum disorders, if they carry out a thorough clinical evaluation. However, not infrequently, they fail to do so.³ A screening instrument can help guide the clinical interview and reduce the time needed to make a diagnostic assessment. Thus, many of the questions a skilled psychiatrist would ask to determine the likelihood of a bipolar disorder are already embedded in the BSDS, which can be completed by the patient while still in the waiting room.

A BSDS score of 0—or less than 5—is by no means dispositive, but it can usefully redirect the clinical interview into more fruitful areas of inquiry, all other things being equal. (Clearly, a strong history of repeated major mood episodes, a strong family history of BD spectrum disease, and many other factors, can and should override a low score on any screening instrument). We also believe the combined use of more than 1 screening instrument—for example, combining the BSDS with the Temperament Evaluation of the Memphis, Pisa, Paris, and San Diego Autoquestionnaire (TEMPS-A) scale⁴—can result in an even more accurate diagnosis, extending to mood temperaments, which the current DSM system largely ignores. Combining screening instruments may also reduce the rate of false negatives and positives, though this idea has not been systematically tested.

Finally, we believe there is obviously a niche for BD screening instruments in the general practice and primary care settings—a topic not addressed in the article.Most primary care physicians have neither the time nor, in most cases, the training to carry out a comprehensive psychiatric evaluation. A very high score on one or more of the screening instruments can guide the primary care clinician in making a referral to a psychiatrist. We believe that this sequence is likely to reduce the under-diagnosis of BD spectrum disorder, and that the risk of false positive screening in primary care settings can be assessed by psychiatric specialists.

Dr Ghaemi is professor, Mood Disorders Program and Department of Psychiatry, Tufts University Medical School, Boston, MA. Dr Pies is professor emeritus of psychiatry and lecturer on bioethics and humanities, SUNY Upstate Medical University; clinical professor of psychiatry, Tufts University School of Medicine; and editor in chief emeritus of Psychiatric Times® (2007-2010). The authors report no conflicts of interest concerning the subject matter of this article.

Want more clinical tips for managing mood disorders in your patients? Join us at the Annual Psychiatric Times® World CME Conference October 15-17th, to hear tips and latest clinical updates. S. Nassir Ghaemi, MD, is speaking on Friday, October 16 at 10:15 AM PST in a Medical Crossfire®: Should Bipolar Depression Be Treated With Antidepressants?, and at 11:10 AM PST in a talk titled Combination Therapy in Bipolar Disorder. Register online: https://www.gotoper.com/conferences/psychtimes/meetings/psychtimes20conference#registration​

References

1. Zimmerman M. Diagnosing Bipolar Disorder in Clinical Practice: Underdiagnosis, Overdiagnosis, and Screening. Psychiatric Times. September 11, 2020. Accessed October 7, 2020. https://www.psychiatrictimes.com/view/diagnosing-bipolar-disorder-clinical-practice-underdiagnosis-overdiagnosis-and-screening​

2. Ghaemi SN, Miller CJ, Berv DA, Klugman J, Rosenquist KJ, Pies RW. Sensitivity and specificity of a new bipolar spectrum diagnostic scale. J Affect Dis. 2005;84:273-277.

3. SmithD J, Ghaemi SN. Is underdiagnosis the main pitfall when diagnosing bipolar disorder? Yes. BMJ.2010;340 c854.

4. Akiskal HS, Akiskal KK, Haykal RF, et al. TEMPS-A: progress towards validation of a self-rated clinical version of the Temperament Evaluation of the Memphis, Pisa, Paris, and San Diego Autoquestionnaire. J Affect Disord. 2005;85(1-2):3-16.