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Q&A: Dr. Roger McIntyre Discusses New Bipolar Disorder Screener

January 19, 2021
Dr. Roger McIntyre

The recently published Rapid Mood Screener (RMS) is designed to give health care clinicians a fast and accurate way to detect bipolar disorder and distinguish it from major depressive disorder.

“This is the first scalable point of care screening tool for bipolar I disorder we've seen in the field in two decades,” said researcher and study author Roger McIntyre, MD, FRCPC, Professor of Psychiatry and Pharmacology, University of Toronto, Ontario, Canada.

In this Q&A, Dr. McIntyre explains how and why the screener was developed, how it should be used in clinical practice, and the reasons why bipolar disorder is so frequently misdiagnosed and mistaken for depression.

The RMS is available for download here under the “Supplemental material” section.

Q: What was the impetus for the development of the screener?

A: The impetus for developing the Rapid Mood Screener, the RMS as I'll refer to it, is really provided by several aspects about bipolar disorder in the general population and notably in clinical practice.

That being it's a common condition in clinical practice, that being bipolar disorder is commonly encountered in, for example, primary care clinics. Secondly is that the presentation of bipolar disorder in clinical practice is one wherein it's often undifferentiated. 

That, along with other factors, has contributed to the highly replicated observation that individuals with bipolar disorder are very often undiagnosed, or misdiagnosed is the word we prefer to use. In other words, they will visit a healthcare provider. They will receive a diagnosis other than bipolar disorder or no diagnosis at all. But in fact bipolar disorder is in fact the defensible diagnosis.

This observation that misdiagnosis occurs is not a rare observation. It would actually apply to more than three‑quarters of people who have bipolar disorder.

That along with the separate but yet convergent observation that the longer that bipolar disorder continues untreated, the more difficult it is for the treatments to be sufficiently effective, which is sort of intuitive. The longer the illness goes on, the more difficult is it to achieve the patient-desired therapeutic objectives.

So here we have a common condition, a condition that's often presenting in an undifferentiated way in clinical practice. A condition that is most often misdiagnosed, which leads to a delay in not only getting the diagnosis, but following from that, the appropriate treatment.

That contributes unnecessarily to human suffering. Worse, morbidity of the illness leaves people at risk of very tragic outcomes, including but not limited to suicide.

Now across the country there has in fact been recognition of screening tools for bipolar disorder in light of what I just described. The Mood Disorder Questionnaire (MDQ) is perhaps the most well-known screening tool for bipolar disorder. It's been with us for about 2 decades.

A recent survey that we did indicated that about 75 to 85 percent of clinicians had heard of the MDQ, but only about 15 to 20 percent actually use it. So there's clearly an implementation gap.

When we delve further into “why the implementation gap?” what they're saying is they're unhappy with it. What they're not happy with is the fact that there's too many so-called false positives. In other words, someone does not have bipolar and the screening tool is suggesting that they do have bipolar disorder.

There has in fact been push back with respect to the clinical relevance of it, the clinical imperative to use it. So the baby has been thrown out with the bath water, and we've gone back to where we started, if you will, where no one is being screened or very few are being systematically screened for bipolar.

One of the guiding principles of a screening tool that would increase—it wouldn't guarantee but it would increase—the probability that it will be implemented, is that it should be patient administered. We certainly prefer that. Briefer is certainly better than longer.

At the end of the day what we don't need in life and certainly in clinical medicine, we don't need more information. We need actionable information that is accurate. So, does the result from the screening tool, does it have any demonstrative benefit for what the doctor, the nurse, the PA, the nurse practitioner is trying to do with the patient?

The answer is yes. So rather than reinvent the wheel, we had to in fact listen to the stakeholders, being clinicians, and say, OK, 80 percent have heard of it. Only 20 percent are using it. What's the indictment? The indictment is from a psychometric perspective, there's just too many false positives.

So what we did was through the methodology of developing the scale, we effortly made sure that the items, which are briefer in duration than the MDQ, 6 items versus the 13 items, are items that decrease the likelihood of false positives and would certainly preserve, if not enhance, true positive and true negatives. In other words, it would perform better as a screen tool. And that's exactly what we did.

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