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Abstract
Objectives: The misdiagnosis of bipolar disorder (BD) as major depressive disorder (MDD) is common in depressed older adults. The self-rated HCL-33 and its external assessment version (HCL-33-EA) have been developed to screen for hypomanic symptoms. This study compared the screening ability of these two instruments to discriminate BD from MDD.Methods: A total of 215 patients (107 with BD and 108 with MDD) and their carers were recruited. Patients and their carers completed the HCL-33 and HCL-33-EA, respectively. The consistency of the total score and the positive response to each item between the two scales was calculated with the intraclass correlation coefficient (ICC) and Cohen's kappa coefficient separately. Receiver operating characteristics (ROC) curves were drawn for both instruments. The optimal cut-off points were determined according to the maximum Youden's Index. The areas under the ROC curve (AUC) of the HCL-33 and HCL-33-EA were calculated separately and compared. The sensitivity and specificity at the optimal cut-off values were also calculated separately for the HCL-33 and HCL-33-EA.Results: The intraclass correlation coefficient (ICC) between the total scores of the HCL-33 and HCL-33-EA was 0.823 (95% CI = 0.774–0.862). The positive response rate on all items showed high agreement between the two instruments. ROC curve analysis demonstrated that the total scores of both HCL-33 and HCL-33-EA differentiated well between MDD and BD, while there was no significant difference in the AUCs between the two scales (Z = 0.422, P = 0.673). The optimal cutoff values for the HCL-33 and HCL-33-EA were 14 and 12, respectively. With the optimal cutoff value, the sensitivities of the HCL-33 and HCL-33-EA were 88.8% and 93.5%, and their specificities were 82.4% and 79.6%.Conclusion: Both the HCL-33 and HCL-33-EA had good screening ability for discriminating BD from MDD in depressed older adults.
Highlights
With the improvement of healthcare services in the past decades, many patients with bipolar disorder (BD) live on into older adulthood
The intraclass correlation coefficient (ICC) between the HCL-33 and HCL-33-EA total scores was 0.823, which is similar to the finding in depressed younger adults (Spearman’s r = 0.46) [19]
The consistency of the total scores on the two instruments was higher in patients cared for by their spouses (ICC = 0.846, 95% confidence interval (CI) = 0.766–0.900), followed by those cared for by offspring (ICC = 0.815, 95% CI = 0.747–0.866), and others (ICC = 0.672, 95% CI = 0.217–0.887), probably because spouses were more familiar with the patients’ mood swings than other carers
Summary
With the improvement of healthcare services in the past decades, many patients with bipolar disorder (BD) live on into older adulthood. The diagnosis of BD is associated with increased health service use and premature mortality in older adults [1]. Older BD patients, those with BD-type II (BD-II) and BD-not otherwise specified (BD-NOS), were most often misdiagnosed as having major depressive disorder (MDD) [6]. The time gap between the first depressive episode and the subsequent first manic/hypomanic episode is longer in older than in younger patients: for example, this gap was 17 years in BD patients aged 60 years and above, while the corresponding figure was only 3.5 years in those aged 40 and below [10]. The late appearance of a manic/hypomanic episode in older BD patients increases the likelihood of their BD being misdiagnosed as MDD. Late recognition of BD results in delayed, inadequate, and inappropriate treatment [11, 12]
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