Young Mania Rating Scale (YMRS)

The Young Mania Rating Scale (YMRS) is a Clinician administered tool used to rate the severity of symptoms of mania (Young, Biggs, Ziegler & Meyer, 1978) across clinical and research settings. The YMRS was originally developed in 1978 and normed with psychiatric inpatients based on a semi structured interview and observations over an 8 hour period. Today the YMRS combines the clients self-report of symptoms of mania over the past 48 hours with the clinician observations during interview (Miller, Johnson & Eisner, 2009) and is now a commonly used tool to screen for manic symptoms and monitor the severity of manic symptoms (Lukasiewicz et al., 2013). Used to assess the severity of manic symptoms, this tool is often used to monitor the progress of interventions (Miller, Johnson & Eisner, 2009).

It is an 11 item scale assessing mood, motor activity/ energy levels, interest in sex, sleep, irritability, rate and frequency of speech, flight of ideas, grandiosity, aggressive behaviour, appearance, and insight into current presentation. It should be noted that the YMRS does not map onto the DSM 5 criteria for mania as it does not account for distractibility, increases in goal directed activity or excessive involvement in pleasurable activities that have a potential fir painful consequences (DSM-5). As such this tool is not a diagnostic assessment.

Each item is composed of 5 explicitly defined levels of severity.  Severity ratings for 7 items are scored on a scale of 0 -4. The remaining 4 items are double weighted to account for poor cooperation of client when unwell and are scored on a scale of 0 – 8. Item ratings are sum to produce a total score between 0 -60. A score <29 indicates that the person is experiencing “severe” mania (Wciorka et al., 2011).

Although weighting items increases the complexity of scoring and interpreting, it has not affected the psychometric properties of the scale. The YMRS is reported to have high interrater reliability for total scores (0.93) and individual item scores (0.66 -0.92) (Young et al., 1978). It also has been found to have good internal reliability, with Cronback alpha coefficients ranging from 0.8 – 0.91. The YMRS has demonstrated high convergent validity with other assessment measures of mania including the Bech-Rafaelsen Mania Rating Scale (Spearman’s Rho = 0.90). Furthermore, the YMRS statistically differentiates between clients; before and 2 weeks after treatment (Young et al., 1978); mania from symptoms of ADHD (Serrano, Ezpeleta, Alda, Matalí, & San, L., 2011). Finially, the YMRS has demonstrated validity across cultural populations including Korea (Seon-Cheol & Joonjo, 2016) and Poland (Wciorka et al., 2011).

References

Lukasiewicz, M., Gerard, S., Besnard, A., Falissard, B., Perrin, E., Sapin, H., Tohen, M., Reed, C., Azorin, J.-M. and The emblem study group (2013), Young Mania Rating Scale: how to interpret the numbers? Determination of a severity threshold and of the minimal clinically significant difference in the EMBLEM cohort. Int. J. Methods Psychiatr. Res., 22: 46–58. doi:10.1002/mpr.1379

Miller, C. J., Johnson, S. L., & Eisner, L. (2009). Assessment Tools for Adult Bipolar Disorder. Clinical Psychology : A Publication of the Division of Clinical Psychology of the American Psychological Association16(2), 188–201. http://doi.org/10.1111/j.1468-2850.2009.01158.x

Seon-Cheol, P., & Joonjo, C. (2016). Using the Young Mania Rating Scale for Identifying Manic Symptoms in Patients with Schizophrenia. Yonsei medical Journal, 57, 1298-1299.

Serrano, E., Ezpeleta, L., Alda, J., Matalí, J., & San, L. (2011). Psychometric Properties of the Young Mania Rating Scale for the Identification of Mania Symptoms in Spanish Children and Adolescents with Attention Deficit/Hyperactivity Disorder. Psychopathology, 44(2), 125-132.

Wciorka, J., Schaeffer, E., Switaj, P., Waszkiewicz, J., Krasuska, K., Wegrzyn, J., & Wozniak, P. (2011). Bech-Rafaelsen Mania Scale and Young Mania Rating Scale–comparison of psychometric properties of the two instruments for rating a manic syndrome. Psychiatry Poland, 45, 61-78.

Young, R.C., Biggs, J.T., Ziegler, V.E., & Meyer, D.A. (1978). The rating scale for mania: reliability, validity and sensitivity. British Journal of Psychiatry, 133, 429-435.

General Behavior Inventory (GBI)

The General Behavior Inventory (GBI), first developed by Depue et al. (1981), was designed to identify the presence and severity of depressive and manic/hypomanic symptoms, as well as to assess for cyclothymia in adults. In their attempts to explore predisposition to bipolar disorder, the authors created a behavioural paradigm to identify persons at risk. Though intended for use in an adult population, a slightly modified version of the GBI has demonstrated potential as a parent-report measure of mood symptomatology amongst children and adolescents (Youngstrom, Findling, Danielson, & Calabrese, 2001). In addition, a short version has been developed via factor analysis that allows for it to be a screening tool in both adult and adolescent populations (Youngstrom, Murray, Johnson, & Findling, 2016).

The original self-report includes three dimensions, or subscales, that comprise 73 items on which respondents use a 4-point Likert-type scale (0 = never or hardly ever; 3 = very often/almost constantly) to indicate the frequency with which they experience a behaviour over the past year. The Depression scale sums 45 of the items whilst the Hypomanic/Biphasic scales combined sum 28 items. Questions include: “Have you become sad, depressed, or irritable for several days or more without really understanding why?” and “has your mood or energy shifted rapidly back and forth from happy to sad or high to low?” As suggested by Depue, Krauss, and Spoont (1987), the items may be scored using a dichotomous model. This involves dividing the population into cases and non-cases, where those individuals responding 0 or 1 to an item receive 0 points and those responding 2 or 3 to an item receive 1 point. The scale may also be scored in the traditional Likert fashion, where the responses are merely summed. Whilst higher scores reflect increased psychopathology, it is important to note that the GBI is not a diagnostic tool. Research has indicated that the scales can discriminate between bipolar and disruptive behaviour disorders, unipolar and bipolar depression, and mood and disruptive behaviour disorders or no diagnosis (Danielson, Youngstrom, Findling, & Calabrese, 2003).

The GBI has strong psychometric properties. In a recent evaluation study, it demonstrated excellent internal consistency (Cronbach’s ⍺ over .93 for both subscales; Pendergast et al., 2014). Results from the original validation study suggest the tool has good test-retest reliability (r = .73 over 15 weeks), excellent content validity, excellent construct validity, and excellent discriminative validity (Depue et al., 1981). More recent studies have found the GBI to have excellent discriminant validity (Youngstrom, Genzlinger, Egerton, & Van Meter, 2015) and good treatment sensitivity (Youngstrom et al., 2013).

Evidence has shown that gender differences have not compromised the overall psychometric properties of the GBI (Depue & Klein, 1988). However, Chmielewski and colleagues (1995) compared GBI data for African American, Asian American, Caucasian, and Latino samples, and discovered significant cultural differences – Caucasians scored lower than all other groups. Though two decades later, involving a combined Caucasian and African American sample, Pendergast et al. (2015) found that GBI scores were largely invariant across racial groups.

Free access to the GBI: https://cls.unc.edu/files/2014/06/GBI_self_English_v1a.pdf

References
Chmielewski, P. M., Fernandes, L. O., Yee, C. M., & Miller, G. A. (1995). Ethnicity and gender in scales of psychosis proneness and mood disorders. Journal of Abnormal Psychology, 104(3), 464-470. http://doi.org/10.1037/0021-843x.104.3.464

Danielson, C. K., Youngstrom, E. A., Findling, R. L., & Calabrese, J. R. (2003). Discriminative validity of the General Behavior Inventory using youth report. Journal of Abnormal Child Psychology, 31(1), 29-39. https://doi.org/10.1023/A:1021717231272

Depue, R. A., & Klein, D. N. (1988). Identification of unipolar and bipolar affective conditions in nonclinical and clinical populations by the General Behavior Inventory. In D. L. Dunner, E. S. Gershon, & J. E. Barrett (Eds.), Relatives at risk for mental disorders (pp. 179- 202). New York: Raven Press.

Depue, R. A., Krauss, S., & Spoont, M. R. (1987). A two-dimensional threshold model of seasonal bipolar affective disorder. In D. Magnusson & A. Ohman (Eds.), Psychopathology: An interactional perspective (pp. 95-123). New York: Academic Press.

Depue, R. A., Slater, J. F., Wolfstetter-Kausch, H., Klein, D. N., Goplerud, E., & Farr, D. A. (1981). A behavioral paradigm for identifying persons at risk for bipolar depressive disorder: A conceptual framework and five validation studies. Journal of Abnormal Psychology, 90, 381-437.

Pendergast, L. L., Youngstrom, E. A., Brown, C., Jensen, D., Abramson, L. Y., & Alloy, L. B. (2015). Structural invariance of General Behavior Inventory (GBI) scores in Black and White young adults. Psychological Assessment, 27(1), 21-30. http://dx.doi.org/10.1037/pas0000020

Pendergast, L. L., Youngstrom, E. A., Merkitch, K. G., Moore, K. A., Black, C. L., Abramson, L. Y., & Alloy, L. B. (2014). Differentiating bipolar disorder from unipolar depression and ADHD: The utility of the General Behavior Inventory. Psychological Assessment, 26(1), 195-206. http://doi.org/10.1037/a0035138

Youngstrom, E. A., Findling, R. L., Danielson, C. K., & Calabrese, J. R. (2001). Discriminative validity of parent report of hypomanic and depressive symptoms on the General Behavior Inventory. Psychological Assessment, 13(2), 267-276. http://dx.doi.org/10.1037//1040-3590.13.2.267

Youngstrom, E. A., Genzlinger, J. E., Egerton, G, A., & Van Meter, A. R. (2015). Multivariate meta-analysis of the discriminative validity of caregiver, youth, and teacher rating scales for pediatric bipolar disorder: Mother knows best about mania. Archives of Scientific Psychology, 3(1), 112-137.

Youngstrom, E. A., Murray, G., Johnson, S. L., & Findling, R. L. (2016). The 7 Up 7 Down Inventory: A 14-item measure of manic and depressive tendencies carved from the General Behavior Inventory. Psychological assessment, 25(4), 1377-1383. http://doi.org/10.1037/a0033975

Youngstrom, E. A., Zhao, J., Mankoski, R., Forbes, R. A., Marcus, R. M., Carson, W., … Findling, R. L. (2013). Clinical significance of treatment effects with aripiprazole versus placebo in a study of manic or mixed episodes associated with pediatric bipolar I disorder. Journal of child and Adolescent Psychopharmacology, 23(2), 72-9. https://dx.doi.org/10.1089%2Fcap.2012.0024

Mood Disorder Questionnaire (MDQ)

 

Background

The Mood Disorder Questionnaire (MDQ) was created by Hirschfeld and colleagues (2000) to address the need for accurately screening individuals with a bipolar spectrum disorder. Accurate identification of bipolar disorder (BD) is of concern as it’s often unrecognised or inaccurately diagnosed, which results in a delay of diagnosis and appropriate treatment (Lish, et al., 1994). Items on the MDQ are derived from the DSM-IV criteria and experience as a clinician (Hirschfeld, 2000).

Clinical Use

Self-report format, around five minutes to complete, not to be used for diagnostic purposes, only as a screening tool, and a comprehensive evaluation should follow a positive screen outcome.

Administration and Scoring

The MDQ consists of 3 questions. First, there are 13 items that examine manic symptoms. Second and third, enquires whether these symptoms identified have co-occurred, and the severity of the symptoms. To screen positive, the individual must have answered ‘yes’ to a minimum of 7 items on question 1, responded ‘yes’ to question 2, and answered ‘moderate problem’ or ‘serious problem’ to question 3.

Development and Psychometric Properties

The MDQ has achieved adequate internal consistency with a Cronbach’s alpha of 0.79 and 0.90 (Hirschfeld, 2000; Isometsä et al., 2003). The validation study administered the MDQ to patients at five psychiatric clinics in the United States (Hirschfeld, 2000). The results were used to determine cut off points for items, specificity, and sensitivity. Findings demonstrated that the MDQ had a 0.73 sensitivity and a 0.90 specificity when contrasted against other screening questionnaires in psychiatric settings. The researchers then conducted testing in a general population, which identified a 0.28 sensitivity and a 0.97 specificity (Hirschfeld, 2002). An additional study assessed the effectiveness of the MDQ in unipolar and bipolar depressive patients and found a 0.58 sensitivity (higher sensitivity for bipolar 1) and a 0.67 specificity (Miller, Klugman, Berv, Rosenquist, Ghaemi, 2004). Lastly, testing in a primary care setting revealed a 0.58 sensitivity and a 0.93 specificity (Hirschfeld, Cass, Holt, Carlson, 2005).

In sum, the MDQ is a useful screening tool for BD, demonstrating validity in clinical settings and across cultures. However, consideration should be given towards its higher sensitivity to detect BD type 1 compared to other BD on the spectrum, and its low sensitivity in general populations. Additionally, the use of differing cutoff points of items in scoring (e.g., standard or modified cutoff value of 7 for question 1), and the inclusion/exclusion criteria (e.g., more defined BD definition/criteria includes more severe cases, and increases sensitivity) has shown variability in sensitivity and specificity thus, limiting its overall effectiveness (Wang, et al., 2015).

References

Hirschfeld, R. M., Williams, J. B., Spitzer, R. L., Calabrese, J. R., Flynn, L., Keck Jr, P. E., … & Russell, J. M. (2000). Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. American Journal of Psychiatry157, 1873-1875.

Hirschfeld, R. M. (2002). The Mood Disorder Questionnaire: a simple, patient-rated screening instrument for bipolar disorder. Primary care companion to the Journal of Clinical Psychiatry4, 9.

Miller, C. J., Klugman, J., Berv, D. A., Rosenquist, K. J., & Ghaemi, S. N. (2004). Sensitivity and specificity of the Mood Disorder Questionnaire for detecting bipolar disorder. Journal of Affective Disorders81, 167-171.

Hirschfeld, R. M., Cass, A. R., Holt, D. C., & Carlson, C. A. (2005). Screening for bipolar disorder in patients treated for depression in a family medicine clinic. The Journal of the American board of family practice18, 233-239.

Isometsä, E., Suominen, K., Mantere, O., Valtonen, H., Leppämäki, S., Pippingsköld, M., & Arvilommi, P. (2003). The mood disorder questionnaire improves recognition of bipolar disorder in psychiatric care. BMC psychiatry, 3, 8.

Lish, J. D., Dime-Meenan, S., Whybrow, P. C., Price, R. A., & Hirschfeld, R. M. (1994). The National Depressive and Manic-depressive Association (DMDA) survey of bipolar members. Journal of affective disorders31, 281-294.