Hypomania: a transcultural perspective.

This study examined the transcultural robustness of a screening instrument for hypomania, the Hypomania Checklist-32, first revised version (HCL-32 R1). It was carried out in 2606 patients from twelve countries in five geographic regions (Northern, Southern and Eastern Europe, South America and East Asia). In addition, GAMIAN Europe contributed data from its members. Exploratory and confirmatory factor analyses were used to examine the transregional stability of the measurement properties of the HCL-32 R1, including the influence of sex and age as covariates. Across cultures, a two-factor structure was confirmed: the first factor (F1) reflected the more positive aspects of hypomania (being more active, elated, self-confident, and cogni-tively enhanced); the second factor (F2) reflected the more negative aspects (being irritable, impulsive, careless, more substance use). The measurement properties of the HCL-32 R1 were largely invariant across cultures. Only few items showed transcultural differences in their relation to hypomania as measured by the test. F2 was higher among men and in more severe manic syndromes; F1 was highest in North and East Europe and lowest in South America. The scores decreased slightly with age. The frequency of the 32 items showed remarkable similarities across geographic areas, with two excep-tions: South Europeans had lower symptom frequencies in general and East Europeans higher rates of substance use. These findings support the interna-tional applicability of the HCL-32 R1 as a screening instrument for hypomania.

The Hypomania Checklist (HCL-32): its factorial structure and association to indices of impairment in German and Swedish nonclinical samples.

BACKGROUND: Bipolar disorders are often not recognized. Several instruments were developed but none primarily focused on hypomania. The Hypomania Checklist (HCL) is aimed at the identification of bipolarity in outpatients. Using a German and Swedish sample, we investigated if the factor structure in nonclinical samples is similar to the one reported for outpatient samples. Furthermore, we tested if people who probably had a lifetime history of hypomania report more depression or other signs of impairment and if current depression is associated with lifetime hypomania. METHOD: In the German study, participants completed the HCL-32 as an online questionnaire that also included questions about lifetime and current depression (n = 695), whereas the Swedish data relied on the paper-and-pencil version of the HCL-32 completed by a random sample from a representative population sample (n = 408). RESULTS: The factor structure of the HCL-32 was fairly similar in both samples and to the ones presented by Angst et al (J Affect Disord 2005;88:217-33). People reporting "highs" (> or =4 days and experiencing negative consequences) not only endorsed more HCL-32 symptoms but also had higher rates of current and former depression and psychotherapy. Level of current depression was also associated with lifetime hypomanic symptoms. DISCUSSION AND LIMITATION: An "active-elated" and "risk-taking/irritable" factor of hypomania can be distinguished with the HCL-32 in clinical and nonclinical samples. Based on our results, the HCL-32 might even be useful as screening tool in nonclinical samples and not only in depressed outpatients. However, our data do not allow estimating sensitivity and specificity of the HCL-32 because structured clinical interviews were not included.

Bipolar II and the bipolar spectrum.

In studies made in the last decade, patients consulting doctors because of depression and anxiety have very often turned out to suffer from bipolar type II and similar conditions with alternating depression and hypomania/mania (the bipolar spectrum disorders - BP). Specifically, about every second patient seeking consultation because of depression has been shown to suffer from BP, mainly bipolar type II. BP is often concealed by other psychiatric conditions, e.g. recurrent depression, psychosis, anxiety, addiction, personality disorder, attention-deficit hyperactivity disorder and eating disorder. BP shows strong heredity. Relatives of patients with BP also have a high frequency of the psychiatric conditions just mentioned. Conversion ("switching") from recurrent unipolar depressions (recurrent UP) to BP is common in very long longitudinal studies (over decades). Mood-stabilizing medicines are recommended to a great extent in the treatment of BP, since anti-depressive medicines are often not effective and involve a substantial risk of inducing mood swings. Particularly in the long-term pharmacological treatment of depression in BP anti-depressive medicines may worsen the condition, e.g. inducing a symptom triad of dysphoria, irritability and insomnia: ACID (antidepressant-associated chronic irritable dysphoria).

The HCL-32: towards a self-assessment tool for hypomanic symptoms in outpatients.

BACKGROUND: Bipolar disorders (BP) are frequently diagnosed and treated as pure depression initially; accurate diagnosis often being delayed by 8 to 10 years. In prospective studies, the presence of hypomanic symptoms in adolescence is strongly predictive of later bipolar disorders. As such, an instrument for self-assessment of hypomanic symptoms might increase the detection of suspected and of manifest, but under-treated, cases of bipolar disorders. METHODS: The multi-lingual hypomania checklist (HCL-32) has been developed and is being tested internationally. This preliminary paper reports the performance of the scale in distinguishing individuals with BP (N=266) from those with major depressive disorder (MDD; N=160). The samples were adult psychiatry patients recruited in Italy (N=186) and Sweden (N=240). RESULTS: The samples reported similar clinical profiles and the structure for the HCL-32 demonstrated two main factors identified as "active/elated" hypomania and "risk-taking/irritable" hypomania. The HCL-32 distinguished between BP and MDD with a sensitivity of 80% and a specificity of 51%. LIMITATIONS: Although the HCL-32 is a sensitive instrument for hypomanic symptoms, it does not distinguish between BP-I and BP-II disorders. CONCLUSIONS: Future studies should test if different combinations of items, possibly recording the consequences of hypomania, can distinguish between these BP subtypes.