The mean MDQ score for BD patients was significantly higher than that of UD; BD-I was higher than BD-II, and BD-II was higher than UD (t-test, P<0.01). The translated MDQ was found internally consistent (alpha 0.79) and a feasible screening tool. The instrument has so far been little investigated by others than its developers. Yes Part of J Clin Psychiatry. Altogether 109 (96%) patients were screened. There were no significant differences between the enrolled patients and patients who did not participate in terms of age and sex. J Affect Disord. The second question asks whether several of the symptoms have been experienced during the same time period, and the third asks about resulting problems, classified as minor, moderate or serious. Nevertheless, even using the standard cut-offs several patients with previously unrecognised bipolar II disorders were identified, and in fact, ignoring the last question completely resulted in lower specificity. Twenty-nine (27%) subjects had negative MDQ but 4–6 positive items in question 1. Exclusion criteria included a past diagnosis of BD, ongoing significant medical or neurological condition(s), depressive disorders secondary to a general medical or neurological condition, or having received electroconvulsive therapy (ECT) in the past month. 1992, 26: 127-140. Determine what stressors are present and the time course of Cite this article. This latter group included four of the five subjects (5% of the total) with negative MDQ who were clinically suspected of possibly suffering from bipolar disorder. There are disagreements with respect to the scoring of the MDQ. Our findings support the value and feasibility of screening for bipolar disorder with the MDQ in psychiatric settings. Given the relatively good resources and interest in bipolar disorder in the Jorvi psychiatric facilities, we expect recognition to be at least not worse than elsewhere in Finland. Their mean age was 37.9 ± 11.4 years, and 56 (51%) were female. Isometsä, E., Suominen, K., Mantere, O. et al. Of the bipolar I patients seven (70%) had a relevant diagnosis before the interview, compared to only two of the bipolar II patients (20%). The best screening cutoff between BD-II and UD was 6 (SEN 0.71, SPE 0.80, PPV 0.37, NPV 0.94). The Mood Disorder Questionnaire (MDQ) is an excellent screening tool for bipolar disorder.It is considered a gold standard screening tool in the world of bipolar disorder. Washington, DC, American Psychiatric Association. All authors participated in the translation of the Mood Disorder Questionnaire, plus read and approved the final manuscript. The subjects with BD in this study may not be representative of all BD patients. The first two authors supervised the diagnostic process. Am J Psychiatry . As per the scoring guidelines, if you answer "yes" t… The MDQ could not differentiate BD patients from UD patients at the cutoff of 7 when all three parts of the MDQ were used in the ROC curve analysis (P>0.05, AUC 0.59, SEN 0.22, SPE 0.97, PPV 0.65, NPV 0.83, Figure 4). Three patient groups were screened: (a) all new patients who were referred to treatment in the Department of Psychiatry; (b) all patients who had earlier received treatment in the Department, but now had a new referral, and (c) those already in contact with the facilities, without a clinical diagnosis of ICD-10 schizophrenia, and now showing signs of deteriorating clinical state after at least two months of limited or no symptoms. The stable cutoff between BD and UD suggested that the impact of the type of mood episode for the patients with mood disorders on the MDQ score was minimal and could be ignored. The APA proposes that postpartum psychiatric disorders be considered as one condition with three subclasses: adjustment reaction with depressed m… DESCRIPTION: The MFQ consists of a series of descriptive phrases regarding how the subject has been feeling or acting recently.Codings reflect whether the phrase was descriptive of the subject most of the time, sometimes, or not at all in the past two weeks. When only part one of the MDQ was used, the best screening cutoff between depressed patients with BD and depressed patients with UD was 7 in this study. Article  Take this bipolar test to see if you might have bipolar disorder symptoms. Sleep curtailment in adolescents is a serious problem in many societies, but insufficient action is being taken to stem this tide. Any of several psychological disorders characterized by abnormalities of emotional state and including especially major depressive disorder, dysthymia, and bipolar disorder—called also affective disorder. statement and Some studies have proposed modifying the MDQ scoring by ignoring part three and lowering the threshold screening for BD. In most studies concerning the MDQ, including the earlier study in China, testing of subjects with mood disorders was not restricted to the depressive phase [7], [9]–[13]. here. Take the Mood Disorders Questionnaire before reading this scoring page.. Our results were similar to the results from a study in Korea. We studied food consumption and nutrient intake in subjects with depressed mood, anxiety and insomnia as indices of compromised mental wellbeing. Thus the last question in the MDQ, necessitating moderate to severe problems due to episodes, appears to have a higher threshold for impairment. The patients' basic socio-demographic data were collected with a questionnaire designed for the study in a clinical interview, supplemented by a review of their medical records (Table 1). West China Hospital, Sichuan University, Sichuan, China, Affiliation Hirschfeld RM, Williams JB, Spitzer RL, et al. OBJECTIVE: This study tested the validity in the adult general population of the Mood Disorder Questionnaire, a screening instrument for bipolar I and II disorders.The Mood Disorder Questionnaire has been validated in a psychiatric outpatient study group. 2003, 73: 59-64. Because the mean MDQ score of the patients with BD-I was highest and that of UD was lowest, and MDQ could screen BD-II patients from UD patients by ROC analysis, we did not compare BD-I and UD in the ROC analysis. Some studies [9], [11] have found that the MDQ may be insensitive in the detection of BD due to the items in part three. Still, mood phases may have an impact on the results of these self-rating questionnaires [19], [20]. In the SCID interview, twenty patients were found to suffer from bipolar disorder, of whom seven (70%) of ten patients with bipolar I but only two (20%) of ten with bipolar II disorder had been previously clinically correctly diagnosed. … The screening for bipolar disorder was conducted at the Department of Psychiatry at Jorvi Hospital, part of the Helsinki University Central Hospital, from 1st–31st October, 2001. The Mood Disorder Questionnaire improves recognition of bipolar disorder in psychiatric care. Then please print the test results and consider sharing them with your doctor or therapist. The Mood Disorder Questionnaire (MDQ) is a tool designed to help you recognize the signs and symptoms of bipolar disorder, including mania and/or depression. Patients fulfilling the study criteria were invited to participate in the study. The whole JoBS project has been evaluated and accepted in the Ethics Committee of the Helsinki and Uusimaa Hospital District, and it complies with the principles of the Helsinki Declaration. Depressive Disorders. Bipolar disorders have two main subtypes, bipolar I disorder (BD-I), bipolar II disorder (BD-II).The diagnosis of BD-I need one or more manic episodes. It is to be noted that our findings are based only on ten bipolar II patients and an enriched subsample of patients with bipolar disorder. 1978, 226: 57-64. Secondly, depressed patients who had a previous diagnosis of BD were excluded from the study. It was designed to meet the need for a short (approximately 15 minutes) but accurate structured psychiatric interview for multicenter clinical trials [23]. Those interviewed with SCID were not a random sample of all patients screened, but a sample of cases suspected of having bipolar disorder on the basis of the finding in the MDQ, or other clinical factors. volume 3, Article number: 8 (2003) The internal consistency of the translated instrument was almost as good (Cronbach's alpha 0.79 vs. 0.90) as in the original validation study . All interviewers were either psychiatrists or residents with several years experience in psychiatry and relevant training. We suggest that the best screening cutoff between BD-II and UD could also be used as the optimal cutoff between BD and UD to improve screening for BD-II [13]. https://doi.org/10.1371/journal.pone.0091895.t001. Bipolar disorder is a complex illness, and an accurate, thorough diagnosis can only be made through a personal evaluation by your doctor. Benazzi F: Antidepressant-associated hypomania in outpatient depression: A 203-case study in private practice. The first survey of the DASP project was carried out in 13 major psychiatric hospitals and units of general hospitals between September 1, 2010 and February 28, 2011. Am J Psychiatry.2000;157:1873-1875. toms of an adjustment disorder that are experienced and note their impact on daily life. The cutoff was identical in most of the MDQ studies conducted worldwide, including the earlier study in China in which patients could be in any mood phase [7], [9], [12]–[14]. However, the optimal cut-off within this sample was found to be eight symptoms but accepting also minor problems due to episodes (sensitivity 0.90, specificity 0.59). Funding: This study was funded by the grant (200602032) from the scientific and technological bureau of Shenzhen in China. The goal of present study is comparing some of these common factors between generalized anxiety disorder and unipolar mood disorder. The Chinese version of the MDQ had good psychometric features in screening bipolar disorders from depressive patients with mood disorders when part two and part three of the MDQ were ignored. Hangzhou Seventh People's Hospital, Zhejiang, China, Affiliation The MDQ scores of depressive patients with BD-I were higher than those with BD-II, which were higher than for those with UD. Although bipolar disorder is a major public health issue, it is commonly unrecognized even in psychiatric settings [1, 2]. Individuals with BD experience episodes of an elevated or agitated mood known as mania/hypomania alternating with episodes of depression. It only shows that within this sample, the optimal cut-offs would have been different. https://doi.org/10.1186/1471-244X-3-8, DOI: https://doi.org/10.1186/1471-244X-3-8. In practice, many patients with BD experience a delay in initiating treatment or are given the wrong treatment because of the under-recognition and frequent misdiagnosis of this disorder [4]–[6]. Some major factors involve child abuse or neglect, school failure, traumatic life experiences and brain damage. The best screening cutoff between BD-II and UD was 6, while the cutoff was 5 in an earlier study [13]. Mood disorders may increase your risk of suicide. Secondly, the sensitivities 0.22 (or 0.24) were too low to screen at cutoffs 7 (or 6) for a screening tool. https://doi.org/10.1371/journal.pone.0091895, Editor: Bernhard T. Baune, University of Adelaide, Australia, Received: September 26, 2013; Accepted: February 16, 2014; Published: April 4, 2014. The aim was to include all incident episodes of bipolar disorder among patients receiving treatment. The mean MDQ score was 7.29 (SD 3.23) for BD, 8.01 (SD 3.44) for BD-I, 6.85 (SD 3.02) for BD-II and 2.91 (SD 2.75) for UD. Forty subjects (37%) were positive in the MDQ screen. The following scores are the most indicative of having bipolar disorder, though be careful: a positive test does not mean you have bipolar disorder.. The change of MDQ score in patients with mood disorders was similar to that of the earlier Chinese study, which did not limit patients to the depressive phase [13]. Suppes T, Leverich GS, Keck PE, Nolen WA, Denicoff KD, Altshuler LL, McElroy SL, Rush AJ, Kupka R, Frye MA, Bickel M, Post RM: The Stanley Foundation Treatment Outcome Network II. The receiver operating characteristic (ROC) curve was used to determine whether the patients with different mood disorders (BD, BD-I, BD-II, MDD) could be differentiated and to ascertain the sensitivity (SEN) and specificity (SPE) at various cutoffs. Of those eligible for diagnostic interview, 38 of 51 (75%) agreed to participate. There were two limitations in the study. The authors are grateful to all the clinicians who helped to organize the study at each study site. In a large community cohort in Europe, the prevalence of bipolar disorder (BD-I and BD-II) based on the DSM-IV criteria was 5.5% [2]. 10.1016/0165-0327(92)90044-7. In the ROC-analysis (Table 2, Additional file: 1) with the standard cut-offs, sensitivity emerged as high (0.85), but specificity only moderate (0.47). BD is a common disorder. It is useful in psychiatric settings only if recognition without it is a problem, which according to our findings is certainly true. The Mood Disorder Questionnaire is a feasible screen for bipolar disorder, which could well be integrated into psychiatric routine practice. Depression is a common mental health disorder characterized by sadness, lethargy, and loss of interest in daily life activities. It asks: 1. if you've experienced any of 13 specific behaviors associated with bipolar disorder 2. if the symptoms you checked in question one occurred at the same time 3. about the severity of your symptoms 4. about your family's history of mental illness 5. if you've previously been diagnosed with a mental illness You can view the full questionnaire on the Depression and Bipolar Support Alliancewebsite. Therefore, it was necessary to study the response of the patients with mood disorders to the MDQ during their depressive phase. Designed for screening purposes only and not to be used as a diagnostic tool. The MDQ consists of three parts. Our study population was not a selected sample of patients with mood disorders, but rather an ordinary sample of secondary care … The results of the Korean study were similar to ours. The instrument was found to have relatively good sensitivity (0.73) and very good specificity (0.90) in samples comprising mostly patients with uni- and bipolar mood disorders in academic centers [3]; in a further general population study the sensitivity turned out to be very low (0.28), but specificity (0.97) remarkably high [4]. J Affect Disord. KS supervised the fieldwork, interviewed patients, and participated in writing the paper. Lifetime prevalence estimates are 1.0% for BD-I, 1.1% for BD-II, and 2.4% for subthreshold BD in the general adult population (aged ≥18 years) in the United States [1]. However, by definition, hypomania involves no marked impairment. Analyzed the data: HCY XPW. (2014) Evaluation of Mood Disorder Questionnaire (MDQ) in Patients with Mood Disorders: A Multicenter Trial across China. All patients who participated in this study completed written consent forms. In our diagnosed sample, accepting minor impairment too, but necessitating eight symptoms, was found to be the optimal cut-off. J Affect Disord. The term depression is often used to refer to any of several depressive disorders. 2003, 160: 178-180. Competing interests: The authors have declared that no competing interests exist. In addition, a systematic sample of every third patient with 4–6 positive items in question 1 of the MDQ was drawn from each setting. Risk-taking behavior, such as spending too much money or driving recklessly. Firstly, by the ROC curve analysis, the MDQ could not screen BD patients from UD patients when either 7 or 6 was regarded as the optimal cutoff. Thirdly, the results of this multicenter study were similar to those of the earlier study that was limited to two psychiatric hospitals in China. Permission for use granted by RMA Hirschfeld, MD. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Forty subjects (37%) were positive in the MDQ. For more information about PLOS Subject Areas, click Depression in bipolar disorder (BD) patients presents major clinical challenges. Peer mentor programs (PMPs) have been associated with reduced psychiatric hospitalisation and shorter lengths of stay for those with other severe mental illnesses. Nevertheless, our prevalences of positive items (27–74% vs. 34–77%) and bipolar disorder (53% vs. 55%) were similar to the original validation study figures, although the proportion of type II disorder was higher (50% vs. 24%) in ours. The majority of unrecognised patients in our sample, too, had bipolar II disorder. We found the Mood Disorder Questionnaire to be a feasible method for improving recognition of bipolar disorder, which has clearly been a problem. Bipolar disorder, previously known as manic depressive illness, is a severe chronic mood disorder characterised by episodes of mania, hypomania, and alternating or intertwining episodes of depression ().No biomarker has yet been approved for diagnosis of any mental disorder and clinical criteria endure. One-way analysis of variance (ANOVA) and t-tests were used to compare the MDQ scores among the mood disorder patients. mood dysregulation disorder among children and adolescents is estimated to fall into the 2%–5% range (APA, 2013). The Chinese version of the MDQ (C-MDQ) has been validated in China [13]. Eating disorders (EDs) are serious psychiatric illnesses that have high rates of morbidity and mortality, and low long-term recovery rates. The proportion of previously unrecognised cases was particularly high in bipolar II disorders, only a few of whom had previously received the correct diagnosis. Of the 1,487 patients, 309 (20.8%) satisfied the DSM-IV criteria for BD: 118 (7.9%) for BD-I and 191 (12.8%) for BD-II. Feasible screening instruments are needed to improve recognition and diagnosis of the various forms of the illness. The First Hospital of Harbin Medical University, Heilongjiang, China, Affiliation Part three assesses the level of functional impairment due to the symptoms on a 4-point scale (“no” to “severe”) [7], [15]. AstraZeneca China had no role in the study design or in the generation and interpretation of the results. We conducted a meta‐analysis to review the diagnostic accuracy of the Mood Disorder Questionnaire (MDQ) among patients with mood disorders. Our study population was not a selected sample of patients with mood disorders, but rather an ordinary sample of secondary care psychiatric patients, schizophrenia excluded. Agitation, restlessness, or irritability. Am J Psychiatry. https://doi.org/10.1371/journal.pone.0091895.g004. Methods 1,487 being treated for MDD or UD at 12 mental health centers across China, completed the MDQ and subsequently … Cassano GB, Akiskal HS, Savino M, Musetti L, Perugi G: Proposed subtypes of bipolar II and related disorders: with hypomanic episodes (or cyclothymia) and with hyperthymic temperament. The criterion validity of the MDQ was estimated using the SEN, SPE, positive predictive value (PPV), negative predictive value (NPV) and the area under the curve (AUC). No, Is the Subject Area "Emotions" applicable to this article? Citation: Yang H-C, Liu T-B, Rong H, Bi J-Q, Ji E-N, Peng H-J, et al. Yes Both in- and outpatients experiencing a major depressive episode were enrolled if they were between 16 and 65 years of age, had a DSM-IV or ICD-10 diagnosis of MDD based on a review of their medical records, understood the aims of the study and provided informed consent. A depressive episode is not required for BD-I diagnosis, but it frequently occurs. 2000, The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-244X/3/8/prepub. Hirschfeld et al (2000) recommended that the positive response to MDQ required the presence of at least seven symptoms that co-occur and caused moderate to severe impairment due to the manic/hypomanic symptoms [7]. What are the symptoms of common mood disorders? Of the 1,487 patients, 309 (20.8%) satisfied the DSM-IV criteria for BD: 118 (7.9%) for BD-I and 191 (12.8%) for BD-II. Discover a faster, simpler path to publishing in a high-quality journal. https://doi.org/10.1371/journal.pone.0091895.g003. 10.1016/S0165-0327(01)00432-3. The MDQ scores of depressive patients with mood disorders were lowest in patients with UD, followed by BD-II and BD-I. Fourth Edition, Text Revision. This study is the first to examine an existing stress-model from the general population, in patients diagnosed with adjustment disorders, using a longitudinal design. Because the treatments of different types of mood disorders and subtypes of bipolar disorders are different, MDQ which help clinicians in differentiating mood disorders is useful in practice. Hirschfeld RMA, Lewis LL, Vornik LA: Perceptions and impact of bipolar disorder: How far have we really come? Having minor problems might be enough. Using the SCID-interview as the gold standard, the MDQ screening produced 9 false positives (5 patients with unipolar MDD; one schizoaffective, brief psychotic, and personality disorders; plus an amphetamine-induced psychosis) and three false negative patients (one type I with < 7 acknowledged items, one type II patient with only minor problems due to hypomania, and one type II with both). The authors of this test found these scores include the most individuals who do have bipolar disorder, and "rule out" the most individuals who don't have it. It is therefore vital that the MDQ is also sensitive to bipolar II. Article  The Chinese version of the MINI showed strong reliability and validity in eliciting symptom criteria used to make DSM diagnoses [24]. Although the definite cutoffs were different, this study demonstrated again that the MDQ could screen patients with BD-I from patients with BD-II, and patients with BD-II from UD [13]. The American Psychiatric Association's (APA) Diagnostic and Statistical Manual of Mental Disorders, Fifth Editionadded a peripartum onset to the psychiatric mood disorder category. If the MDQ was negative, the attending professional was also asked whether bipolar disorder might be present despite a negative screen (clinical suspicion). In this study, we found that if only part one of MDQ was used, MDQ could differentiate between BD and UD, between BD-II and UD, and between BD-I and BD-II. The Department has a catchment area of approximately 250 000 inhabitants, but this pilot study was conducted only in two selected community mental health centres (Leppävaara and Kirkkonummi), and in the psychiatric outpatient clinic of Jorvi Hospital and three of its psychiatric wards. Many children show mood disorders, anxiety, learning problems along with conduct disorder symptoms. Secondly, because impairment in functioning is not necessary to diagnose hypomania, requiring impairment on the MDQ to determine BD will reduce its sensitivity for detecting BD-II [19]. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. The Diagnostic Assessment Service for People with Bipolar Disorders in China (DASP) is an ongoing national study initiated by the Chinese Society of Psychiatry (CSP) with the aim of developing and testing the usefulness of screening tools for BD in patients treated for MDD. Division of Mood Disorders, Shanghai Mental Health Center, Shanghai Jiaotong University School of Medicine, Shanghai, China, Affiliation The AUC was 0.84. Onset is typically between one week and one month following childbirth. No, Is the Subject Area "Neuropsychological testing" applicable to this article? Feeling extremely energized or elated. J Affect Disord. Google Scholar. The funders had no role in study design, data collection and analysis,decision to publish, or preparation of the manuscript. Whether necessitating moderate to severe problems to be caused by it is useful in screening should be further investigated. The patients' assessments of functional impairment in the part three were influenced mostly by their insight, an area that is typically impaired in the patients with BD [16]–[18]. 1,487 being treated for MDD or UD at 12 mental health centers across China, completed the MDQ and subsequently examined by the Mini International Neuropsychiatric Interview (MINI). The frequency of positive responses to the various symptom items of question 1 ranged from 27% (more social) to 74% (racing thoughts). This study assessed the sensitivity and specificity of the Mood Disorder Questionnaire as a screening instrument for bipolar spectrum disorders in a general population sample. Demographics and illness characteristics of the first 261 patients. In the present pilot study, using our Finnish translation of the Mood Disorder Questionnaire among unselected psychiatric patients, we investigated its psychometric and screening properties, and its feasibility in improving recognition of type I and II bipolar disorder. The low AUC (0.60) between BD-I and BD-II might limit its usefulness compared to the higher AUC (0.83) between BD-II and UD. We used a bivariate random effects model to calculate summary sensitivity and specificity. We conducted this study to determine (1) which parts of the Chinese version of the MDQ should be used to screen for BD in the clinical setting; (2) compare the use of the MDQ for patients during the depressive phase with a previous study in which the MDQ was administered during any phase (mania, depression) and (3) determine if the results of our previous study of the MDQ in two psychiatric hospitals could be replicated in other centres which included psychiatric clinics and general hospitals across China. EI supervised the study, analyzed the data and wrote the paper. https://doi.org/10.1371/journal.pone.0091895.g005. Data were analyzed using the SPSS package, Version 17.0. The Mood Disorder Questionnaire seems to be a feasible method for improving the recognition of bipolar disorder. Patients younger than 18 years were included as long as they verbally agreed to participate and written consent was obtained from patients or guardians. Patients with BD in the depressive phase have difficulty recalling past manic/hypomanic symptoms [21]. In the third published study of the MDQ [11] that focused on its factor structure, rates of positive items were convergent, although slightly lower (12–65%) among private practice mood disorder patients. Section edited by Florian Seemüller. http://www.biomedcentral.com/1471-244X/3/8/prepub. The MDQ could differentiate BD patients from UD patients when only part one was used in the ROC curve analysis (P<0.05, Figure 1). No, Is the Subject Area "Depression" applicable to this article? PubMed  Performed the experiments: HCY HR JQB ENJ HJP XPW YRF CMY CH TMS ZL JH ZYC YH JS HCL JBZ. 2003, 64: 161-174. The Affiliated Brain Hospital, Nanjing Medical University, Jiangsu, China, Affiliation Wrote the paper: HCY. California Privacy Statement, This was a placebo-controlled trial to test whether supplementation … This is not unexpected because the test-retest reliability (or kappa) of the SCID in the … The Third Affiliated Hospital of Sun Yat-Sen University, Guangdong, China. Rapid speech or movement. Archiv Psychiatr Nervenkr. 2011). 2001, 67: 45-69. The feature of relatively low sensitivity (0.66) and higher specificity (0.88) in this study was similar to that of other studies as well [7], [9], [13]–[14]. Sensitivity was 0.64, specificity was 0.80 and the area under curve was 0.75 at the optimal screening cutoff between BD and UD [13]. 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Apa ): diagnostic and statistical Manual of mental disorders was to include all episodes... Interests: the Mood disorder Questionnaire ( MDQ ) in patients with Mood disorders to the results these. The analysis edited by Florian Seemüller was relatively small ( SEN 0.71 SPE. Disorders '' applicable to this article limitations should be further investigated in larger and representative patient.. In question 1 of age and sex hypomanic syndrome participate or failed to complete the C-MDQ results, 20! And 39.1 ± 12.5 years, respectively are present and the time course of patients! And an accurate, thorough diagnosis can only be made through a personal evaluation by your doctor or.... One month following childbirth Spitzer RL, et al disorders to the results within a specific subtype: HR... Dysregulation disorder among patients receiving treatment Questionnaire to be a feasible screening instruments are needed to recognition! 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From Hirschfeld R, Stassen HH: the Mood disorder Questionnaire appears to be a feasible method for improving of... To calculate summary sensitivity and specificity investigation was a pilot study for the ongoing Jorvi bipolar study ( JoBS.. A specific subtype using the SPSS package, version 17.0 MDQ but 4–6 positive items in question 1 depression bipolar... Screening purposes only and not to be a feasible method for improving recognition of bipolar ''.

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