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Salud mental

versão impressa ISSN 0185-3325

Resumo

CORONA, Rodrigo; BERLANGA, Carlos; GUTIERREZ-MORA, Doris  e  FRESAN, Ana. La detección de casos de trastorno bipolar por medio de un instrumento de tamizaje: el Cuestionario de Trastornos del Animo versión en español. Salud Ment [online]. 2007, vol.30, n.2, pp.50-57. ISSN 0185-3325.

Bipolar spectrum disorder which includes bipolar I, bipolar II, ciclothymia and bipolar disorder, not otherwise specified often goes unidentyfied, underdiagnosed, or confounded with major depressive disorder. There are several considerations that try to explain this frequent omission. One crucial aspect is that, the first mood episode at onset is often a depressive one, and some bipolar patients present multiple depressive episodes prior to their first episode of mania. Additionally, long-term evaluation of patients with bipolar I or II disorders, reveal that depressive symptoms occur more common than manic or hypomanic symptoms. Another plausible explanation is that bipolar patients frequently underreport symptoms of mania. Thus it is not surprising to find that in many patients, may elapse about 10 years from the first time for they seek treatment until a clinician finally makes the correct diagnosis. As a consequence, such patients may suffer poorer outcomes, subsyndromal symptoms and a course of illness marked by more sever symptoms, chronic mood episodes, increased recurrence and more impaired psychosocial functioning. The correct diagnosis of bipolar disorder becomes an important and crucial issue, if it is considered that there is a current trend to understand better this affective illness as a spectral disorder. This concept helps to identify different subtle subtypes of bipolarity which often are unrecognized, by means of the actual diagnostic criteria. This diagnostic reformulation is based on the phenomenological manifestations of the entities, as well as in other specific clinical aspects, such as comorbidity, predominant episodes, genetic information and treatment response to among others. Thus, correct recognition of bipolar disorder will bring an important benefit to patients and may reduce erratic treatments and improve outcome.

Several epidemiological studies report that the global prevalence of bipolar I disorder is around 1%, in the general population, but when considering all subtypes included in the bipolar spectrum, this lifetime prevalence increases up to 5%. As a consequence of an incorrect diagnosis, patients are often undertreated or receive an erroneous pharmacological treatment, mainly with antidepressants, which complicate outcome by promoting manic or hypomanic reactions and may have devastating consequences in the further clinical intents to stabilize the disorder.

In order to increase the recognition of an illness, the correct utilization of a clinical screening procedure is mandatory. Several screening instruments exist for a variety of psychiatric disorders. However, only until recently, some of them have been developed specifically to identify bipolar disorders. The Mood Disorder Questionnaire, was the first screening instrument specifically developed to detect bipolar cases in clinical settings. It is a self-report, single-page, paper and pencil inventory than can be quickly and easily scored by a physician, a nurse or by trained medical staff assistance. It is composed of 13 questions which are answered with a positive or negative fashion, elaborated from the bipolar diagnostic criteria and clinical experience and inquires about possible manic symptoms. In the original report of its development and validation, it was concluded that it is a useful screening instrument for bipolar spectrum disorders, with a good sensitivity (0.73) and a very good specificity (0.90).

Method:

The questionnaire has been translated to other languages and has been used in non-clinical settings, with very good standards of performance. Since there is not a Spanish version of it, we decided to translate this instrument and to design a trial for the following purposes: 1) to obtain a validated and understandable Spanish version of the questionnaire. 2) To determine its sensibility and specificity in a sample of patients with affective disorders. 3) To identify its optimal cutoff score for screening purposes. The first step in our study consisted in the development of a translated version of the instrument. For that purpose a translation- retranslation procedure was utilized, in which four clinical psychiatrists with experience in treating bipolar patients made each one a separate translation. Then, all the versions were discussed until a consensus was reached in a final version. This version was retranslated to English and, after making some adjustments, the final version in Spanish was concluded.

The study aimed to determine the clinimetric parameters of the Mood Disorder Questionnaire in its Spanish version, was conducted at the outpatient affective disorders clinic in the National Institute of Psychiatry Ramón de la Fuente, in México City. Patients with an age of 18 years and over who looked for psychiatric consultation, due to the presence of affective disorder were invited to participate. After explaining the procedure and the purposes of the study, all those who accepted to participate, signed 51 an informed consent document. This study was approved by the Ethical Committee of our institution. All patients completed the Mood Disorder Questionnaire. Two experienced clinical psychiatrists, blind to the questionnaire results, applied the Structural Clinical Interview for DSM-IV (SCID) to obtain the specific affective diagnosis in all the patients.

Clinical and demographic data, as well as results from the clinical interview and questionnaire’s scores, were obtained and then analyzed. Sensitivity and specificity for each Mood Disorder Questionnaire score, were plotted by using results from the SCID interview as a standard. Sensitivity (percent of criterion standard diagnosis correctly diagnosed by the questionnaire) and specificity (percent of criterion standard noncases correctly identified as noncases by the questionnaire) were obtained by using different symptoms, threshold that ranged from 5 to 10 points in order to determine the optimal screen threshold.

Results:

A total of 100 patients were included in the study. Mean age for the complete group was 35.3 years and 64% were female. According to the SCID results, 49 patients had a diagnosis within the bipolar spectrum disorder and 51 had a unipolar affective diagnosis. Each group included patients with both first and recurrent episodes, and with and without comorbidities. The questionnaire was completed by the total sample of patients covering the total range of answer’s possibilities, from non-positive responses (1% of the sample) to 13 positive responses (15% of the sample). Mean score (± SD) was 8.06 (3.5) with a significant difference between patients in the bipolar group (10.3 ± 2.7) and patients in the unipolar group (5.8 ± 2.7); t = -8.2, 98 gl, p<0.001. Using different cutoff scores sensitivity and specificity were calculated, observing that with a 10 point cutoff score, equilibrated sensitivity (0.71) and specificity (0.92) levels were obtained.

Conclusions:

The study was aimed to obtain an adequate translated version into Spanish of the Mood Disorder Questionnaire, and to determine its sensitivity and specificity, according to an optimal cutoff score, for correctly detecting bipolarity from a sample of affective disorder patients. With a reliable procedure of translation process, we obtained a satisfactory, understandable and easy to use version for patients. Similar to other reports, a structured clinical interview was utilized to obtain the patients diagnoses. After evaluating with different cutoff scores, we found that a score of 10, gives an adequate distribution for levels of sensitivity and specificity. However, lower scores (between 7 and 9), also give adequate levels of sensitivity and specificity. It is important to consider, that our study was done in a very specific sample of patients who had only affective disorders. With these type patients it is necessary to raise the bar sufficiently to obtain adequate results. In other studies that included non-affective patients the questionnaire worked well with lower cutoff points.

The operating characteristics of the Mood Disorder Questionnaire in its Spanish version are sufficiently good to consider its application as a reliable screening instrument for detecting bipolar spectrum disorders at least, in an affective disorders clinical setting. Further studies are needed to evaluate whether the instrument would be useful in other psychiatric settings as well as in community or primary care samples, and also to determine the best cutoff point depending in the characteristics of the population in which it is being used.

Palavras-chave : Affective disorders bipolar spectrum; Mood Disorder Questionnaire; sensitivity; specificity; screening procedure.

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