Elsevier

Journal of Affective Disorders

Volume 178, 1 June 2015, Pages 112-120
Journal of Affective Disorders

Research report
Factor structure and reliability of the Italian adaptation of the Hypomania Check List-32, second revision (HCL-32-R2)

https://doi.org/10.1016/j.jad.2015.03.001Get rights and content

Abstract

Objective

To assess the psychometric properties of the Italian adaptation of the Hypomania-Check-List 32-item, second revision (HCL-32-R2) for the detection of bipolarity in major depressive disorder (MDD) treatment-seeking outpatients.

Methods

A back-to-back Italian adaption of the “Bipolar Disorders: Improving Diagnosis, Guidance, and Education” English module of the HCL-32-R2 was administered between March 2013 and October 2014 across twelve collaborating sites in Italy. Diagnostic and Statistical Manual Fourth edition (DSM-IV) diagnoses were made adopting the mini-international neuropsychiatric interview, using bipolar disorder (BD) patients as controls.

Results

In our sample (n=441, of whom, BD-I=68; BD-II=117; MDD=256), using a cut-off of 14 allowed the HCL-32-R2 to discriminate DSM-IV-defined MDD patients between “true unipolar” (HCL-32-R2) and “sub-threshold bipolar depression” (HCL-32-R2+) with sensitivity=89% and specificity=79%. Area under the curve was .888; positive and negative predictive values were 75.34% and 90.99% respectively. Owing to clinical interpretability considerations and consistency with previous adaptations of the HCL-32, a two-factor solution (F1=“hyperactive/elated” vs. F2=“irritable/distractible/impulsive”) was preferred using exploratory and confirmatory factor analyses, whereas items n.33 (“I gamble more”) and n.34 (“I eat more”) introduced in the R2 version of the scale slightly loaded onto F2 and F1 respectively. Cronbach׳s α=.88 for F1 and .71 for F2.

Limitations

No cross-validation with any additional validated screening tool; treatment-seeking outpatient sample; recall bias; no systematic evaluation of eventual medical/psychiatric comorbidities, current/lifetime pharmacological history, neither record of severity of current MDE.

Conclusions

Our results seem to indicate fair accuracy of HCL-32 as a screening instrument for BD, though replication studies are warranted.

Introduction

The onset of bipolar disorder (BD) involves a major depressive episode (MDE) in approximately half of type-I (BD-I) patients, and three-quarters of those diagnosed type-II (BD-II) (Baldessarini et al., 2013, Goodwin and Jamison, 2007, Koukopoulos et al., 2013, Tondo et al., 2014). Nonetheless, studies carried out in psychiatric and primary care settings have found that BD is sometimes under-recognized, particularly in patients presenting for treatment of depression (Ghaemi et al., 2000, Ghaemi et al., 2002, Hantouche et al., 1998, Zimmerman et al., 2008). Even for those patients diagnosed with BD, the time lag between initial treatment seeking and correct diagnosis often exceeds 10 years (Coryell et al., 1995, Hirschfeld et al., 2000, Lish et al., 1994). Yet, the treatment implications of the failure to promptly recognize BD in depressed patients include the under-prescription of mood-stabilizers, an increased risk of rapid cycling, increased cost of care due to ineffective treatment and increased risk for suicide (Baldessarini et al., 2013, Coryell et al., 1995, Dunner, 2003, Fiedorowicz et al., 2011, Ghaemi et al., 2001, Phillips and Kupfer, 2013). When symptomatic, patients with BD are much more likely to experience symptoms of depression and anxiety rather than symptoms of mania or hypomania (Judd et al., 2002). It is therefore often that, when presenting for treatment, patients with BD are not in the manic or hypomanic phases of the illness. This suggests that manic phases, especially when brief or not characterized by impulse dyscontrol, need to be elicited with retrospective assessment. This is done, despite the substantial risk for spontaneous recall bias, essentially due to the frequent lack of subjective suffering, enhanced productivity, ego-syntonicity and diurnal or seasonal rhythmicity associated with several manic/hypomanic symptoms (Cassano et al., 1999). To date, several factors have been proposed as possible predictors for the diagnosis of BD, essentially by comparing early clinical characteristics of patients eventually meeting diagnostic criteria for a bipolar vs. unipolar depressive disorder worldwide (Gilman et al., 2012, Takeshima and Oka, 2013, Tondo et al., 2014). Among other approaches, recommendations for improving the detection of BD include careful clinical evaluations inquiring about a history of mania and hypomania and the use of screening questionnaires (Rucci et al., 2013) aimed at identifying some of the most clinically sound predictive factors of eventual sub-threshold bipolarity (Nusslock and Frank, 2011). The Hypomania-Check-List 32-item (Angst et al., 2005), and its subsequent revisions/translations up to the latest (final 2008 module: CRF 05FEB08) 34-item second revision (HCL-32-R2) (Gamma et al., 2013) have been broadly adopted across different languages and cultural settings as part of the “Bipolar Disorders: Improving Diagnosis, Guidance, and Education” (BRIDGE) worldwide study (Angst et al., 2011). Yet no Italian adaptation of the HCL-32-R2 has been made available to date despite adaptations of the previous versions being available in Italian (Carta et al., 2006, Perugi et al., 2012, Sasdelli et al., 2013).

Therefore, the present study aims at testing the psychometric properties of the Italian adaptation of the HCL-32-R2 based in a representative outpatients׳ sample.

Section snippets

Design

The present observational study was conducted across 12 outpatient facilities through Italy (Catania, Pisa, Genoa, Novara, Naples, Foggia, Teramo, and Bressanone) between March 2013 and October 2014; participants were adult, treatment-seeking outpatients for current depression. After a full description of the study to potential subjects by the appointed investigators, (boarded psychiatrists and/or psychologists with at least five-year post-doctoral clinical and research experience) a written

Essential description of the sample

Four hundred and forty one outpatients accepted to participate to the study. According to literature guidelines, this is considered a representative sample size (Field, 2009). Substantially proportional number of subjects was screened at each participating center. Only two subjects declined the invite to participate to the study, due to privacy concerns. Essential demographic and clinical data of the sample have been outlined in Table 1.

ROC curve analysis and predictive values

Receiver operating characteristics (ROC) curve analysis

Limitations of the study

A number of limitations should be acknowledged in the interpretation of the results from the present study. Specifically, no cross-validation was made with any alternative screening instrument, as the classification of positive vs. negative cases relied just on the DSM-IV diagnoses, no within-groups or healthy-control group comparison was performed distinguishing cases based on their geographical origin or other demographic or clinical features, including severity of current MDE and/or the

Role of founding source

Nothing declared.

Conflict of interest

No conflict declared.

Acknowledgment

None to state.

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