Brief Screening for Mood Instability: Improving the Activation Scale of the Multidimensional Behavioral Health Screen

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Hicks, Matthew C. Dodge, Rachel S. Faulkenberry, David M. McCord This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7924366/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract The Multidimensional Behavioral Health Screen (MBHS; McCord, 2020 ) is a brief, 29-item self-administered instrument designed for use in high-volume primary medical care settings. It includes nine 3-item scales tapping major core constructs of psychological dysfunction using a hierarchical-dimensional framework, with initial validation based on associations with related, primarily mid-level, scales of the Minnesota Multiphasic Personality Inventory-3 (MMPI-3; Ben-Porath & Tellegen, 2020 ). A frequent challenge in primary medical care is evaluating for possible mood instability, including underlying hypomania or mania, in cases that present with primarily depressive symptomatology. For this reason, an Activation scale was included on the MBHS. Although the basic psychometric properties of the most recent version of the Activation scale were acceptable, convergent correlation with its target variable on the MMPI-3 (Activation) was the lowest amongst the nine MBHS scales, and discriminant validity was poor. In this paper we describe an effort to address these weaknesses in the development of a revised version of the 3-item Activation scale. Participants in this project were 288 college students with valid MMPI-3 protocols. The revised Activation scale exhibits substantially improved discriminant validity that should support a more precise screening-level indication of the possible presence of mood instability. depression screening Multidimensional Behavioral Health Screen mental health screening in primary care Introduction The Multidimensional Behavioral Health Screen (MBHS; Dodge et al., 2024 ; McCord, 2020 ) is a brief screening tool (29 items, 9 dimensional scales) designed specifically for routine surveillance and progress monitoring (every patient, every visit) in primary medical care outpatient settings. It was developed based on new and emerging models of psychological dysfunction (e.g., HiTOP; Krueger et al., 2021) and hierarchical-dimensional models of assessment (e.g., MMPI-3; Ben-Porath & Tellegen, 2020 ) to replace widely used measures that are based on the categorical diagnostic paradigm tools, such as the PHQ-9 (Kroenke & Spitzer, 2002 ) and GAD-7 (Spitzer et al., 2006 ). An updated version of the original MBHS, labeled MBHS 2.0, added a suicide-risk algorithm and re-aligned the MBHS with the MMPI-3 (see Dodge, 2022 ; Dodge et al., 2024 ). In this paper we describe the rationale and procedures involved in a major revision of the MBHS Activation scale, resulting in the MBHS 3.0 update. The original version of the MBHS was specifically linked to the assessment model reflected in the MMPI-2-RF (Ben-Porath & Tellegen, 2008/2011), and the key target criterion for the MBHS Activation scale was Activation, a Specific Problems facet scale of the Restructured Clinical (RC) Scale 9 – Hypomanic Activation, on the MMPI-2-RF. Sellbom et al. ( 2012 ) conducted a study designed to evaluate the ability of the MMPI-2-RF to differentiate patients within three major diagnostic groupings, major depression (n = 407), bipolar disorder (n = 67), and schizophrenia (n = 70). Results demonstrated that the three Higher-Order scales (Emotional/Internalizing Dysfunction, Thought Dysfunction, Behavioral/Externalizing Dysfunction) were most useful in differentiating between patient groups overall, and the Activation scale was most useful in specifically differentiating bipolar disorder patients from the other groups. Watson et al. ( 2011 ) also used the MMPI-2-RF to differentiate between patients with major depression (n = 381) and those with bipolar disorder (61), and, secondarily, to compare a subgroup of 29 bipolar patients who were currently depressed with a randomly selected group of 29 patients with major (unipolar) depression. Using ROC analyses, they found that the Activation scale on the MMPI-2-RF was the best differentiator in both comparisons, with an AUC of .74 for separating patients with major depression from those with bipolar disorder, and an AUC of .75 for separating currently depressed patients with major depression from currently depressed patients with bipolar disorder. More recently, Whitman and Sellbom ( 2023 ) examined correlates of the substantive scales of the MMPI-3 (Ben-Porath & Tellegen, 2020 ) and the Hypomanic Personality Scale – Short Form (HPS-SF; Meads & Bentall, 2008 ) in a large sample of New Zealand college students. As hypothesized, they found that the highest MMPI-3 scale correlations with the HPS-SF Total score were with RC9-Hypomanic Activation and Activation ( r ’s of .70 and .66, respectively). In the high-volume, fast-paced environment of primary medical care outpatient clinics, efficiency is essential. Though it would be desirable to carefully screen for a wide range of dysfunctional psychological characteristics, increased response burden quickly overloads the system. Thus, routine surveillance screening must, by necessity, focus on those symptoms that are most frequent and most salient in primary care. Specifically, anxiety and depressive-related issues are the most frequently reported symptom types and assigned diagnostic categories within primary care settings (Beck, 2019; Schiller & Norris, 2023). Federal guidelines also encourage routine screening for suicidal ideation and risk, maladaptive substance use, and cognitive problems (Jacques et al., 2011). Accordingly, the MBHS scales include Somatization, Cognitive Issues, Demoralization, Anhedonia, Anxiety, Suicidal Ideation, and Substance Misuse. Additionally, Disconstraint was included largely as a case-management informant, as high scores may indicate a patient who, for example, is more likely to not take medication as prescribed, and Activation was included as an adjunctive scale to inform physicians who may be prescribing anti-depressant medication (Magallón-Neri et al., 2015 ). Specifically, approximately 25% of patients with anxiety and/or depressive presentation have also had a previous diagnosis of bipolar disorder (Marzani & Neff, 2021). Furthermore, hypomanic and manic episodes typically have a shorter duration than depressive and anxious episodes (American Psychiatric Association, 2013 ); for this and other reasons, patients are more likely to present with depressive/anxious symptoms rather than hypomanic/manic symptoms (Marzani & Neff, 2021). Thus, general screening for depressive and anxious symptoms combined with patient presentation may lead physicians to initially prescribe anti-depressant medications, many of which can cause exacerbated hypomanic/manic episodes in patients who experience underlying cyclical mood dysfunction as opposed to unipolar depression (see, for example, Patel et al., 2015 ). As such, it would be useful for physicians to have access to screeners that, in addition to measuring depressive and anxious symptoms, would indicate the possibility that a patient may have an underlying cyclical mood disorder and thus better inform the physician’s choice of treatment and/or referral. Currently, physicians would need to add an additional screener to their battery as the most widely used screeners (e.g., PHQ-9, GAD-7) do not include items that assess manic/hypomanic symptoms. (Note: We acknowledge that PHQ-9 question #8 purports to tap manic/hypomanic tendencies, but the item construction is so astonishingly poor that it provides little useful information, particularly when simply added to a total score of 9 symptoms.) To address this issue, the Activation scale was included on the MBHS as a means of providing clinicians with a single brief, automated instrument that screens for treatment-relevant core components of mood dysfunction, including demoralization (unhappiness, dissatisfaction), anhedonia, anxiety, and manic/hypomanic symptoms. Development and Initial Revisions of the Activation Scale In developing the MBHS 1.0 (McCord, 2020 ), an initial pool of 115 potential items were generated rationally by a small team focusing on targeted constructs on the MMPI-2-RF. The goals were to use correlations to identify the four best items to screen for each of the nine core constructs of the MBHS. For the Activation scale (originally named the Manic scale), item generation was based on a conceptual analysis of the mid-level RC9-Hypomanic Activation scale and the more narrowly focused Activation scale of the MMPI-2-RF. A key difference between the Activation scale and RC9 is that RC9 includes an aggression component in addition to an over-activation/excitation component; thus, we considered the broader concepts of RC9 but intentionally excluded potential items with aggressive content. All experimental items were then correlated with all target scales on the MMPI-2-RF, and four items were selected for Activation based on the correlations between new items and both RC9 and Activation MMPI-2-RF scales. The four items were: “I get bored easily,” “My thoughts race through my head very fast”, “My mind is so active that at times I cannot sleep,” “I do dangerous things for thrills.” As test development moved into actual applied medical settings, practical issues resulted in shortening all scales from 4 items to 3 items, removing a psychosis scale, adding a cognitive problems scale, and re-calibrating the new 9-scale, 27-item MBHS instrument with the MMPI-2-RF criterion scales. This resulted in the initial deployed version of the Activation scale with 3 items: “I get bored easily”, “My thoughts race through my head very fast”, and “I do dangerous things for thrills.” This scale achieved a marginally acceptable correlation of .38 with the criterion scale (MMPI-2-RF Activation scale), but it was the lowest convergent correlation amongst the nine MBHS scales, and discriminant validity was poor (e.g., its correlations with both RCd-Demoralization and RC7-Dysfunctional Negative Emotions were .45). IRT analyses in medical samples indicated that one of these three items (“I do dangerous things for thrills”), while contributing positively to convergent validity and internal consistency, produced essentially a flat line, indicating poor item discrimination. As data collection was ongoing, we added a potential replacement item, “My mood has very severe changes.” This item yielded better IRT results and thus replaced the “dangerous things for thrills” item in the MBHS 2.0 revision (Dodge, 2022 ). Though some improvement in convergent validity was found, it was still the lowest of the nine screening scales, and discriminant validity remained quite poor. Thus, the purpose of the current study was to achieve psychometric improvement in the Activation scale of the MBHS by generating a new pool of potential items, obtaining data from a large participant sample, and re-aligning the new scale with the MMPI-3 Activation scale. Method Participants Data for this study were collected from college students attending a midlevel university in the southeastern United States. Participants were required to be at least 18 years-old and be fluent in English; they received class credit for participating in this study. The method and procedures for this study were approved by the university IRB. There were a total of 309 participants who provided data for this study, with 288 providing responses to the Activation items as well as valid MMPI-3 protocols based on the criteria listed in the manual (Ben-Porath & Tellegen, 2020 ). This sample was randomly split in two to provide one sample that was used to construct the updated MBHS Activation scale, and the second sample to assess the new scale’s psychometric properties. The construction sample consisted of 137 participants, with a mean age of 19.35 (SD = 2.58), gender identities of 39.4% male, 56.9% female, and 3.6% other, and ethnic identities of 83.2% White, 12.4% African American, 10.9% Hispanic, 2.9% Asian, and 2.2% Native American. The psychometric analysis sample consisted of 151 participants with a mean age of 19.36 (SD = 3.76), gender identities of 44.4% male, 53.6% female, and 2.0% other, and ethnic identities of 86.1% White, 9.9% African American, 6.6% Hispanic, 2% Asian, 3.3% Native American, and 0.7% Other. Participants were recruited via a university subject pool. This study was not pre-registered. Data and analysis code can be made available for replication purposes providing appropriate institutional agreements are met. Measures Multidimensional Behavioral Health Screen (MBHS; McCord, 2020 ). The MBHS is a psychological instrument used to screen for nine core behavioral health dimensions for use in primary medical care settings. The revised version of the MBHS (2.0) consists of 29 items; the nine dimensional scales have three items each, and two additional items contribute specific information to the suicide risk algorithm. The dimensional scales include: Somatization, Cognitive Issues, Demoralization, Anhedonia, Anxiety, Suicidal Ideation, Disconstraint, Substance Abuse problems, and Activation – the focus of this report. Items are rated on a 4-point scale, 0–3, with labels of “definitely false,” “mostly false,” “mostly true,” and “definitely true,” respectively. Cronbach’s alphas for the first version of the MBHS ranged from .61 to .84 in the primary developmental sample (McCord, 2020 ). Minnesota Multiphasic Personality Inventory-3 (MMPI-3; Ben-Porath & Tellegen, 2020 ). The MMPI-3 is the current revision of the MMPI assessment that measures a multitude of important facets of personality and psychopathology. In addition, the MMPI-3 is a self-report instrument and has protocol validity scales which assess the test takers response style, as well as any threats to validity of their profile, including over- or under-reporting. This is important for data collection purposes to ensure that only valid data is analyzed. The MMPI-3 exhibits excellent psychometric properties in a wide range of clinical, forensic, and medical settings. It has 335, true-false items, measuring 42 content scales which are organized in a hierarchical framework and measure various personality traits and psychopathological symptoms. Using these scales on the MMPI-3, a comprehensive understanding of psychological dysfunction is assessed and understood for use in a wide range of mental health settings. Procedure Due to COVID-19, data were collected in two distinct phases. In both cases, participants signed up using SONA (web-based participant pool management system) to participate in the study in exchange for credit associated with their general psychology class. The first phase was utilized prior to the COVID-19 pandemic – participantsattended a session in a common room, received and signed informed consent forms, and then completed a number of questionnaires presented on Qualtrics, including those in this study. The second phase was utilized throughout the COVID-19 pandemic, which led the university to stop in-person data collection. Participants still signed up for the study via SONA and continued to receive course credit, however, all data collection was completed over Zoom with HIPAA protections. Specifically, participants were emailed a Zoom link and a copy of the informed consent the day before their scheduled session. Once the session began, participants verbally consented to providing information about their current location and contact information that would be used in case of emergency. Participants then electronically consented and completed all questionnaires on Qualtrics. Throughout the course of the study, some measures changed as specific samples were obtained for other studies. Both procedures and subsequent changes in instrumentation were approved by the university's IRB. The co-authors of this paper worked separately and then collaborated to generate a pool of additional items, beyond the current three, to evaluate for possible inclusion in a revised Activation scale. After combining the three separate lists, removing redundancies, and reviewing each item for construct congruence, a set of 10 new items was constructed. These items are listed in Table 1 , with the three existing three items bolded. Bivariate (Pearson) correlations were computed between each of the 13 potential items and the MMPI-3 Activation and RC9-Hypomanic Activation scales. Additionally, all 13 items were entered into stepwise multiple regression analyses, with the MMPI-3 Activation and RC9-Hypomanic Activation scales as the criterion variables. The goal was to establish a new 3-item MBHS Activation scale that exhibited the optimal combination of psychometric properties, with an emphasis on convergent validity with the criterion and secondarily discriminant validity. Table 1 Correlations Between Potential Activation Items and MMPI-3 Target Scales Potential Activation Items ACT RC9 1. My mood has very severe changes. .38 .40 2. I get bored easily. .30 .38 3. My thoughts race through my head very fast. .33 .34 4. Some days I’m so full of energy I can’t sit still. .58 .51 5. Sometimes I do not need sleep to feel lively or energetic. .36 .36 6. Sometimes I’m very happy or excited even when things are not going well. .23 .21 7. At times I feel uncontrollable excitement. .51 .45 8. I often find myself talking very rapidly. .47 .44 9. I have racing thoughts I cannot control .34 .39 10. My mood severely changes regardless of what is going on around me. .36 .41 11. I often feel overconfident. .15 .25 12. At times I’ve thought I was better than others. .17 .30 13. I frequently engage in dangerous behavior. − .04 .12 Note . The three current Activation scale items are bolded. Results Bivariate correlations between each of the 13 potential scale items and the two MMPI-3 criterion variables are shown in Table 1 . The results of the stepwise multiple regressions are presented in Table 2 (for MMPI-3 Activation) and Table 3 (for MMPI-3 RC9). In making the final selection of three items for the new MBHS Activation scale, bivariate correlations and both regressions were considered, along with item content and qualitative issues. Referring to Table 1 , items numbered 4 (“Some days I’m so full of energy I can’t sit still”), 7 (“At times I feel uncontrollable excitement”), and 10 (“My mood severely changes regardless of what is going on around me”) were selected for the revised Activation scale. Item 4 had the highest bivariate correlation with each target scale, and it was also the first item selected in each of the stepwise multiple regressions. Item 7 was in 4th position in both regressions but in the top three in terms of beta weight in the final model. So, in the end, it was actually one of the top three predictors even though it was not chosen until the 4th model. Item 10 was the second best predictor for RC9 but did not appear in the ACT regression. However, this item was a revision of the original item1 about severe mood changes, and the original item does appear (selected 3rd ) in the ACT regression; further, both the original item 1 and new item 10 are among the 3 strongest predictors based on beta weights. Considering the bivariate correlations in Table 1 , new item 10 and the original item 1 did not differ significantly, and item 10 is more specific about the type of mood changes we are targeting. Thus, the decision was to use the new wording for the mood change item. Table 2 Stepwise Regression for MMPI-3 Activation Scale Item R Squared Standard B 4. Some days I'm so full of energy I can't sit still 0.32 0.3 8. I often find myself talking very rapidly 0.38 0.17 1. My mood has very severe changes 0.41 0.19 7. At times I feel uncontrollable excitement 0.44 0.22 13. I frequently engage in dangerous behavior 0.46 -0.2 5. Sometimes I do not need sleep to feel lively or energetic 0.48 0.15 Table 3 Stepwise Regression for MMPI-3 RC9-Hypomanic Activation Scale Item R Squared Standard B 4. Some days I'm so full of energy I can't sit still 0.26 0.24 10. My mood severely changes regardless of what is going on around me 0.34 0.24 9. I have racing thoughts I cannot control 0.37 0.17 7. At times I feel uncontrollable excitement 0.4 0.19 5. Sometimes I do not need sleep to feel lively or energetic 0.42 0.17 To clarify the use of the two subsamples, the developmental sample was used to produce findings displayed in Tables 1 , 2 , and 3 , described above. The psychometric analyses sample was used to produce findings described below and displayed in Tables 4 and 5 . Table 5 Correlations Between MBHS Screening Scales and MMPI-3 Target Scales MBHS Screening Scales MMPI-3 Target Criteria RC1 COG RCd RC2 RC7 SUI ACT DISC SUB Somatization .63 .54 .71 .48 .59 .35 .24 .23 .18 Cognitive Issues .51 .83 .66 .47 .62 .37 .31 .36 .28 Demoralization .55 .60 .81 .68 .63 .43 .12 .24 .19 Anhedonia .46 .58 .73 .67 .53 .35 .05 .26 .16 Anxiety .55 .60 .72 .52 .77 .45 .27 .22 .15 Suicidal Ideation .44 .55 .70 .59 .54 .59 .16 .32 .24 Activation - revised (Previous version of Activation) .39 (.61) .34 (.69) .33 (.66) .12 (.42) .38 (.64) .26 (.47) .47 (.44) .20 (.42) .13 (.23) Disconstraint .27 .43 .31 .21 .31 .22 .33 .52 .27 Substance Misuse .23 .27 .23 .13 .23 .23 .23 .63 .67 Note . Values in cells are Pearson correlations. Convergent correlation coefficients are bolded. RC1-Somatic Concerns; COG-Cognitive Concerns; RCd-Demoralization; RC2-Low Positive Emotions; RC7-Dysfunctional Negative Emotions; SUI-Suicidal/Death Ideation; ACT-Activation; DISC-Disconstraint; SUB-Substance Abuse. The MBHS Activation scale was designed to estimate the probability that an individual would achieve a score in the clinical range (T ≥ 65) on the ACT scale of the MMPI-3. Given this binary outcome, ROC analysis provides a relevant perspective. As shown in Table 4 , the revised Activation scale exhibited an increase in AUC from .69 (original) to .80 (revised) in predicting an elevation on ACT. Similarly, the revised Activation scale exhibited an increase in AUC from .77 (original) to .85 (revised) in predicting an elevation on RC9. Table 5 presents bivariate correlations between each of the MBHS predictor scales and the nine target criteria on the MMPI-3. Values for the original Activation scale are included in parentheses for comparison purposes. With regard to convergent correlation with the primary criterion (MMPI-3 ACT scale), marginal improvement is evident (.44 to .47). However, broad-based and meaningful improvement was achieved with regard to discriminant validity. The older Activation scale exhibited an average correlation of .52 with non-target criteria; this dropped to .27 with the revised scale. With the new version, no discriminant correlation coefficient reached .40, whereas with the older scale only one off-target comparison did not reach that level. Discussion Precise characterization of manic/hypomanic symptomatology in the context of a single-point-in-time psychological evaluation is historically challenging, due largely to the transitory nature of the key phenomena (Ben-Porath, 2012 ). We acknowledge that using a brief screening device exacerbates the challenge. That said, given the significant treatment relevance in distinguishing between depressed primary care patients with or without underlying cyclical mood, we argue that the primary care provider should routinely consider this distinction. Indeed, numerous sources have suggested that the misdiagnosing cyclical mood disturbance as “simple depression” is the most common mental health diagnostic error in primary care settings (Bowden, 2001 ; Hirschfield et al., 2003). A screening-level activation indicator used in conjunction with dimensional depressive indicators can inform that process. This project was designed to improve the accuracy of the Activation scale, one of the nine scales comprising the Multidimensional Behavioral Health Screen (MBHS). The slightly improved convergent correlation with the key criterion (from .44 to .47) is noted; even so, this is still the lowest convergent correlation amongst the nine scales of the MBHS. This limitation is generally consistent with other psychological tests measuring mania/hypomania, likely attributable to the cyclical nature of the key symptoms. The much larger improvements in discriminant validity suggests that the new scale is significantly more precise than the original, likely yielding fewer false positives. The meaningful improvement in predictive accuracy as measured by ROC analyses support this conclusion. Though these improvements are noteworthy and have real implications for use in healthcare screening, it is important to acknowledge some l imitations, foremost being that this studyrelied on data collected from college student participants. Though this demographic is perhaps more likely to display higher rates of mood disorders (CITE) than other populations and therefore a key young adult population, the ideal sample for a study of this nature would utilize data from primary medical care outpatients. In order to facilitate and continue this important research, we would certainly recommend that future studiesthat use the MMPI-3 with primary care patients add the 29 items of the MBHS to the data collection protocol and repeat the ROC analyses described here for all nine MBHS screening scales.This will enable continued improvements in generalizability and diagnostic accuracy. Similarly, because the data were collected in a regional university setting, this sample has a larger percentage of both female (53.6%) and white (86.1%) participants, and thus lacks diversity. As a result, it may not well represent significant minority populations and the ability of the MBHS to capture and screen for mental health symptom presentations that may be most relevant to those groups. Further research is needed to ensure this screener is as accurate and inclusive to all groups as possible, with a further focus on male populations, gender diverse, and culturally and ethnically diverse groups. In conclusion, because primary health screeners are such a broad, wide reaching mental health tool it is vital that the screeners used in these settings are continually updated and evaluated for accuracy. This study offers an important update and improvement to the current MBHS Activation scale, and a notable advancement in the ability of primary care providers to accurately measure a historically difficult mental health concern to capture. Particularly, the improvements to discriminant validity are a significant development to the accuracy of this important MBHS scale. With fewer instances of misdiagnosis and greater ability to differentiate between unipolar depression and cyclical mood disorders, primary health screenings are more likely to facilitate timely and effective treatment, which may have drastic impacts on a patient’s health and reduce the occurrence of ineffective/misprescriptions. Improving the way we measure and screen for these mental health concerns is a vital step towards better patient and treatment outcomes and better primary care screening, a fundamental goal of the MBHS. Declarations This study was not pre-registered. Data and analysis code can be made available for replication purposes providing appropriate institutional agreements are met. No external funding was provided for this research. None of the authors have conflicts of interest wit regard to this research. Author Contribution A.H. played a lead role in conceptualization, methodology, data collection, statistical analyses, and writing. M.D. played a supporting role in conceptualization, methodology, data collection, writing, review, and editing. R. F. participated in data collection and played a supporting role in writing, review, and editing. D. M. played a lead role in conceptualization, supervision, and resources, with a supporting role in writing, review, and editing. 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The PHQ-9 Item 9 based screening for suicide risk: a validation study of the Patient Health Questionnaire (PHQ)− 9 Item 9 with the Columbia Suicide Severity Rating Scale (C-SSRS). Journal of Affective Disorders , 232 , 34-40. Park, L. T., & Zarate Jr, C. A. (2019). Depression in the primary care setting. New England Journal of Medicine , 380 (6), 559-568. Patel, R., Reiss, P., Shetty, H., Broadbent, M., Stewart, R., McGuire, P., & Taylor, M. (2015). Do antidepressants increase the risk of mania and bipolar disorder in people with depression? A retrospective electronic case register cohort study. BMJ open , 5 (12), e008341. https:// Posner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova, K. V., Oquendo, M. A., ... & Mann, J. J. (2011). The Columbia–Suicide Severity Rating Scale: Initial validity and internal consistency findings from three multisite studies with adolescents and adults. American Journal of Psychiatry , 168 (12), 1266-1277. Rural Health Information Hub (2022). Screening for addressing suicide risk in clinical settings. https://www.ruralhealthinfo.org/toolkits/suicide/2/screening-tools Rui, P., & Okeyode, T. (2015). National Ambulatory Medical Care Survey 2015. State and national summary tables. Available at http:// www.cdc.gov/nchs/ahcd/ahcd_products.htm Schiller, J. S., & Norris, T. (2023, April). National Health Interview Survey Early Release Program. National Center for Health Statistics. https://www.cdc.gov/nchs/data/nhis/earlyrelease/earlyrelease202304.pdf Sellbom, M., Bagby, R. M., Kushner, S., Quilty, L. C., & Ayearst, L. E. (2012). Diagnostic construct validity of MMPI-2 Restructured Form (MMPI-2-RF) scale scores. Assessment , 19 (2), 176-186. https://doi.org/10.1177/1073191111428763 Spitzer, R. L., Kroenke, K., Williams, J. B., & Löwe, B. (2006). A brief measure for assessing generalized anxiety disorder: the GAD-7. Archives of Internal Medicine , 166 (10), 1092-1097. Vahratian, A., Blumberg, S. J., Terlizzi, E. P., & Schiller, J. S. (2021). Symptoms of anxiety or depressive disorder and use of mental health care among adults during the COVID-19 pandemic — United States, August 2020–February 2021. MMWR. Morbidity and Mortality Weekly Report, 70(13), 490–494. https://doi.org/10.15585/mmwr.mm7013e2 Van Orden, K. A., Witte, T. K., Cukrowicz, K. C., Braithwaite, S. R., Selby, E. A., & Joiner, T. E., Jr. (2010). The interpersonal theory of suicide. Psychological Review , 117 (2), 575–600. https://doi-org.proxy195.nclive.org/10.1037/a0018697 Van Orden, K. A., Cukrowicz, K. C., Witte, T. K., & Joiner, T. E. (2012). Thwarted belongingness and perceived burdensomeness: Construct validity and psychometric properties of the Interpersonal Needs Questionnaire. Psychological Assessment , 24 (1), 197-215. Villanueva van den Hurk, A. W., McCord, D. M., Görner, K. J., Jowers, C. E., & Mihura, J. L. (in press). New versions of the MMPI and Rorschach: How have training programs responded? Journal of Personality Assessment . Watson, C., Quilty, L. C., & Bagby, R. M. (2011). Differentiating bipolar disorder from major depressive disorder using the MMPI-2-RF: A receiver operating characteristics (ROC) analysis. Journal of Psychopathology and Behavioral Assessment , 33 , 368-374. Whitman, M. R., & Sellbom, M. (2023). Construct validation of Minnesota Multiphasic Personality Inventory-3 (MMPI-3) scales relevant to the assessment of bipolar spectrum disorders. Journal of Clinical Psychology , 79 (11), 2583-2601. Table 4 Table 4 is available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Table4ReliabilityandROCAnalysesBetweenMBHSScreeningScalesandMMPI.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7924366","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":544055808,"identity":"daf56012-f057-462f-b4e9-f17e6820c59b","order_by":0,"name":"Adam D. 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It was developed based on new and emerging models of psychological dysfunction (e.g., HiTOP; Krueger et al., 2021) and hierarchical-dimensional models of assessment (e.g., MMPI-3; Ben-Porath \u0026amp; Tellegen, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) to replace widely used measures that are based on the categorical diagnostic paradigm tools, such as the PHQ-9 (Kroenke \u0026amp; Spitzer, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2002\u003c/span\u003e) and GAD-7 (Spitzer et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). An updated version of the original MBHS, labeled MBHS 2.0, added a suicide-risk algorithm and re-aligned the MBHS with the MMPI-3 (see Dodge, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Dodge et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). In this paper we describe the rationale and procedures involved in a major revision of the MBHS Activation scale, resulting in the MBHS 3.0 update.\u003c/p\u003e\u003cp\u003eThe original version of the MBHS was specifically linked to the assessment model reflected in the MMPI-2-RF (Ben-Porath \u0026amp; Tellegen, 2008/2011), and the key target criterion for the MBHS Activation scale was Activation, a Specific Problems facet scale of the Restructured Clinical (RC) Scale 9 \u0026ndash; Hypomanic Activation, on the MMPI-2-RF. Sellbom et al. (\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2012\u003c/span\u003e) conducted a study designed to evaluate the ability of the MMPI-2-RF to differentiate patients within three major diagnostic groupings, major depression (n\u0026thinsp;=\u0026thinsp;407), bipolar disorder (n\u0026thinsp;=\u0026thinsp;67), and schizophrenia (n\u0026thinsp;=\u0026thinsp;70). Results demonstrated that the three Higher-Order scales (Emotional/Internalizing Dysfunction, Thought Dysfunction, Behavioral/Externalizing Dysfunction) were most useful in differentiating between patient groups overall, and the Activation scale was most useful in specifically differentiating bipolar disorder patients from the other groups. Watson et al. (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) also used the MMPI-2-RF to differentiate between patients with major depression (n\u0026thinsp;=\u0026thinsp;381) and those with bipolar disorder (61), and, secondarily, to compare a subgroup of 29 bipolar patients who were currently depressed with a randomly selected group of 29 patients with major (unipolar) depression. Using ROC analyses, they found that the Activation scale on the MMPI-2-RF was the best differentiator in both comparisons, with an AUC of .74 for separating patients with major depression from those with bipolar disorder, and an AUC of .75 for separating currently depressed patients with major depression from currently depressed patients with bipolar disorder. More recently, Whitman and Sellbom (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) examined correlates of the substantive scales of the MMPI-3 (Ben-Porath \u0026amp; Tellegen, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) and the Hypomanic Personality Scale \u0026ndash; Short Form (HPS-SF; Meads \u0026amp; Bentall, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2008\u003c/span\u003e) in a large sample of New Zealand college students. As hypothesized, they found that the highest MMPI-3 scale correlations with the HPS-SF Total score were with RC9-Hypomanic Activation and Activation (\u003cem\u003er\u003c/em\u003e\u0026rsquo;s of .70 and .66, respectively).\u003c/p\u003e\u003cp\u003eIn the high-volume, fast-paced environment of primary medical care outpatient clinics, efficiency is essential. Though it would be desirable to carefully screen for a wide range of dysfunctional psychological characteristics, increased response burden quickly overloads the system. Thus, routine surveillance screening must, by necessity, focus on those symptoms that are most frequent and most salient in primary care. Specifically, anxiety and depressive-related issues are the most frequently reported symptom types and assigned diagnostic categories within primary care settings (Beck, 2019; Schiller \u0026amp; Norris, 2023). Federal guidelines also encourage routine screening for suicidal ideation and risk, maladaptive substance use, and cognitive problems (Jacques et al., 2011). Accordingly, the MBHS scales include Somatization, Cognitive Issues, Demoralization, Anhedonia, Anxiety, Suicidal Ideation, and Substance Misuse. Additionally, Disconstraint was included largely as a case-management informant, as high scores may indicate a patient who, for example, is more likely to not take medication as prescribed, and Activation was included as an adjunctive scale to inform physicians who may be prescribing anti-depressant medication (Magall\u0026oacute;n-Neri et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). Specifically, approximately 25% of patients with anxiety and/or depressive presentation have also had a previous diagnosis of bipolar disorder (Marzani \u0026amp; Neff, 2021). Furthermore, hypomanic and manic episodes typically have a shorter duration than depressive and anxious episodes (American Psychiatric Association, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2013\u003c/span\u003e); for this and other reasons, patients are more likely to present with depressive/anxious symptoms rather than hypomanic/manic symptoms (Marzani \u0026amp; Neff, 2021). Thus, general screening for depressive and anxious symptoms combined with patient presentation may lead physicians to initially prescribe anti-depressant medications, many of which can cause exacerbated hypomanic/manic episodes in patients who experience underlying cyclical mood dysfunction as opposed to unipolar depression (see, for example, Patel et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). As such, it would be useful for physicians to have access to screeners that, in addition to measuring depressive and anxious symptoms, would indicate the possibility that a patient may have an underlying cyclical mood disorder and thus better inform the physician\u0026rsquo;s choice of treatment and/or referral. Currently, physicians would need to add an additional screener to their battery as the most widely used screeners (e.g., PHQ-9, GAD-7) do not include items that assess manic/hypomanic symptoms. (Note: We acknowledge that PHQ-9 question #8 purports to tap manic/hypomanic tendencies, but the item construction is so astonishingly poor that it provides little useful information, particularly when simply added to a total score of 9 symptoms.) To address this issue, the Activation scale was included on the MBHS as a means of providing clinicians with a single brief, automated instrument that screens for treatment-relevant core components of mood dysfunction, including demoralization (unhappiness, dissatisfaction), anhedonia, anxiety, and manic/hypomanic symptoms.\u003c/p\u003e\n\u003ch3\u003eDevelopment and Initial Revisions of the Activation Scale\u003c/h3\u003e\n\u003cp\u003eIn developing the MBHS 1.0 (McCord, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2020\u003c/span\u003e), an initial pool of 115 potential items were generated rationally by a small team focusing on targeted constructs on the MMPI-2-RF. The goals were to use correlations to identify the four best items to screen for each of the nine core constructs of the MBHS. For the Activation scale (originally named the Manic scale), item generation was based on a conceptual analysis of the mid-level RC9-Hypomanic Activation scale and the more narrowly focused Activation scale of the MMPI-2-RF. A key difference between the Activation scale and RC9 is that RC9 includes an aggression component in addition to an over-activation/excitation component; thus, we considered the broader concepts of RC9 but intentionally excluded potential items with aggressive content. All experimental items were then correlated with all target scales on the MMPI-2-RF, and four items were selected for Activation based on the correlations between new items and both RC9 and Activation MMPI-2-RF scales. The four items were: \u0026ldquo;I get bored easily,\u0026rdquo; \u0026ldquo;My thoughts race through my head very fast\u0026rdquo;, \u0026ldquo;My mind is so active that at times I cannot sleep,\u0026rdquo; \u0026ldquo;I do dangerous things for thrills.\u0026rdquo; As test development moved into actual applied medical settings, practical issues resulted in shortening all scales from 4 items to 3 items, removing a psychosis scale, adding a cognitive problems scale, and re-calibrating the new 9-scale, 27-item MBHS instrument with the MMPI-2-RF criterion scales. This resulted in the initial deployed version of the Activation scale with 3 items: \u0026ldquo;I get bored easily\u0026rdquo;, \u0026ldquo;My thoughts race through my head very fast\u0026rdquo;, and \u0026ldquo;I do dangerous things for thrills.\u0026rdquo; This scale achieved a marginally acceptable correlation of .38 with the criterion scale (MMPI-2-RF Activation scale), but it was the lowest convergent correlation amongst the nine MBHS scales, and discriminant validity was poor (e.g., its correlations with both RCd-Demoralization and RC7-Dysfunctional Negative Emotions were .45). IRT analyses in medical samples indicated that one of these three items (\u0026ldquo;I do dangerous things for thrills\u0026rdquo;), while contributing positively to convergent validity and internal consistency, produced essentially a flat line, indicating poor item discrimination. As data collection was ongoing, we added a potential replacement item, \u0026ldquo;My mood has very severe changes.\u0026rdquo; This item yielded better IRT results and thus replaced the \u0026ldquo;dangerous things for thrills\u0026rdquo; item in the MBHS 2.0 revision (Dodge, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Though some improvement in convergent validity was found, it was still the lowest of the nine screening scales, and discriminant validity remained quite poor. Thus, the purpose of the current study was to achieve psychometric improvement in the Activation scale of the MBHS by generating a new pool of potential items, obtaining data from a large participant sample, and re-aligning the new scale with the MMPI-3 Activation scale.\u003c/p\u003e\u003c/div\u003e"},{"header":"Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003cdiv id=\"Sec4\" class=\"Section3\"\u003e\u003ch2\u003eParticipants\u003c/h2\u003e\u003cp\u003eData for this study were collected from college students attending a midlevel university in the southeastern United States. Participants were required to be at least 18 years-old and be fluent in English; they received class credit for participating in this study. The method and procedures for this study were approved by the university IRB. There were a total of 309 participants who provided data for this study, with 288 providing responses to the Activation items as well as valid MMPI-3 protocols based on the criteria listed in the manual (Ben-Porath \u0026amp; Tellegen, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). This sample was randomly split in two to provide one sample that was used to construct the updated MBHS Activation scale, and the second sample to assess the new scale\u0026rsquo;s psychometric properties. The construction sample consisted of 137 participants, with a mean age of 19.35 (SD\u0026thinsp;=\u0026thinsp;2.58), gender identities of 39.4% male, 56.9% female, and 3.6% other, and ethnic identities of 83.2% White, 12.4% African American, 10.9% Hispanic, 2.9% Asian, and 2.2% Native American. The psychometric analysis sample consisted of 151 participants with a mean age of 19.36 (SD\u0026thinsp;=\u0026thinsp;3.76), gender identities of 44.4% male, 53.6% female, and 2.0% other, and ethnic identities of 86.1% White, 9.9% African American, 6.6% Hispanic, 2% Asian, 3.3% Native American, and 0.7% Other. Participants were recruited via a university subject pool. This study was not pre-registered. Data and analysis code can be made available for replication purposes providing appropriate institutional agreements are met.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eMultidimensional Behavioral Health Screen (MBHS;\u003c/span\u003e McCord, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2020\u003c/span\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e).\u003c/span\u003e The MBHS is a psychological instrument used to screen for nine core behavioral health dimensions for use in primary medical care settings. The revised version of the MBHS (2.0) consists of 29 items; the nine dimensional scales have three items each, and two additional items contribute specific information to the suicide risk algorithm. The dimensional scales include: Somatization, Cognitive Issues, Demoralization, Anhedonia, Anxiety, Suicidal Ideation, Disconstraint, Substance Abuse problems, and Activation \u0026ndash; the focus of this report. Items are rated on a 4-point scale, 0\u0026ndash;3, with labels of \u0026ldquo;definitely false,\u0026rdquo; \u0026ldquo;mostly false,\u0026rdquo; \u0026ldquo;mostly true,\u0026rdquo; and \u0026ldquo;definitely true,\u0026rdquo; respectively. Cronbach\u0026rsquo;s alphas for the first version of the MBHS ranged from .61 to .84 in the primary developmental sample (McCord, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2020\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eMinnesota Multiphasic Personality Inventory-3 (MMPI-3;\u003c/span\u003e Ben-Porath \u0026amp; Tellegen, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2020\u003c/span\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e).\u003c/span\u003e The MMPI-3 is the current revision of the MMPI assessment that measures a multitude of important facets of personality and psychopathology. In addition, the MMPI-3 is a self-report instrument and has protocol validity scales which assess the test takers response style, as well as any threats to validity of their profile, including over- or under-reporting. This is important for data collection purposes to ensure that only valid data is analyzed. The MMPI-3 exhibits excellent psychometric properties in a wide range of clinical, forensic, and medical settings. It has 335, true-false items, measuring 42 content scales which are organized in a hierarchical framework and measure various personality traits and psychopathological symptoms. Using these scales on the MMPI-3, a comprehensive understanding of psychological dysfunction is assessed and understood for use in a wide range of mental health settings.\u003c/p\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cp\u003eDue to COVID-19, data were collected in two distinct phases. In both cases, participants signed up using SONA (web-based participant pool management system) to participate in the study in exchange for credit associated with their general psychology class. The first phase was utilized prior to the COVID-19 pandemic \u0026ndash; participantsattended a session in a common room, received and signed informed consent forms, and then completed a number of questionnaires presented on Qualtrics, including those in this study.\u003c/p\u003e\u003cp\u003eThe second phase was utilized throughout the COVID-19 pandemic, which led the university to stop in-person data collection. Participants still signed up for the study via SONA and continued to receive course credit, however, all data collection was completed over Zoom with HIPAA protections. Specifically, participants were emailed a Zoom link and a copy of the informed consent the day before their scheduled session. Once the session began, participants verbally consented to providing information about their current location and contact information that would be used in case of emergency. Participants then electronically consented and completed all questionnaires on Qualtrics. Throughout the course of the study, some measures changed as specific samples were obtained for other studies. Both procedures and subsequent changes in instrumentation were approved by the university's IRB.\u003c/p\u003e\u003cp\u003eThe co-authors of this paper worked separately and then collaborated to generate a pool of additional items, beyond the current three, to evaluate for possible inclusion in a revised Activation scale. After combining the three separate lists, removing redundancies, and reviewing each item for construct congruence, a set of 10 new items was constructed. These items are listed in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, with the three existing three items bolded. Bivariate (Pearson) correlations were computed between each of the 13 potential items and the MMPI-3 Activation and RC9-Hypomanic Activation scales. Additionally, all 13 items were entered into stepwise multiple regression analyses, with the MMPI-3 Activation and RC9-Hypomanic Activation scales as the criterion variables. The goal was to establish a new 3-item MBHS Activation scale that exhibited the optimal combination of psychometric properties, with an emphasis on convergent validity with the criterion and secondarily discriminant validity.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eCorrelations Between Potential Activation Items and MMPI-3 Target Scales\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePotential Activation Items\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eACT\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eRC9\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1. \u003cb\u003eMy mood has very severe changes.\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.40\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2. \u003cb\u003eI get bored easily.\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.30\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.38\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3. \u003cb\u003eMy thoughts race through my head very fast.\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.34\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4. Some days I\u0026rsquo;m so full of energy I can\u0026rsquo;t sit still.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.51\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5. Sometimes I do not need sleep to feel lively or energetic.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.36\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6. Sometimes I\u0026rsquo;m very happy or excited even when things are not going well.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.21\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7. At times I feel uncontrollable excitement.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.45\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8. I often find myself talking very rapidly.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.44\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9. I have racing thoughts I cannot control\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.39\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10. My mood severely changes regardless of what is going on around me.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.41\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e11. I often feel overconfident.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.25\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12. At times I\u0026rsquo;ve thought I was better than others.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.30\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13. I frequently engage in dangerous behavior.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.04\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.12\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003cem\u003eNote\u003c/em\u003e. The three current Activation scale items are bolded.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eBivariate correlations between each of the 13 potential scale items and the two MMPI-3 criterion variables are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The results of the stepwise multiple regressions are presented in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e (for MMPI-3 Activation) and Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e (for MMPI-3 RC9). In making the final selection of three items for the new MBHS Activation scale, bivariate correlations and both regressions were considered, along with item content and qualitative issues. Referring to Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, items numbered 4 (\u0026ldquo;Some days I\u0026rsquo;m so full of energy I can\u0026rsquo;t sit still\u0026rdquo;), 7 (\u0026ldquo;At times I feel uncontrollable excitement\u0026rdquo;), and 10 (\u0026ldquo;My mood severely changes regardless of what is going on around me\u0026rdquo;) were selected for the revised Activation scale. Item 4 had the highest bivariate correlation with each target scale, and it was also the first item selected in each of the stepwise multiple regressions. Item 7 was in 4th position in both regressions but in the top three in terms of beta weight in the final model. So, in the end, it was actually one of the top three predictors even though it was not chosen until the 4th model. Item 10 was the second best predictor for RC9 but did not appear in the ACT regression. However, this item was a revision of the original item1 about severe mood changes, and the original item does appear (selected 3rd ) in the ACT regression; further, both the original item 1 and new item 10 are among the 3 strongest predictors based on beta weights. Considering the bivariate correlations in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, new item 10 and the original item 1 did not differ significantly, and item 10 is more specific about the type of mood changes we are targeting. Thus, the decision was to use the new wording for the mood change item.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eStepwise Regression for MMPI-3 Activation Scale\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eItem\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eR Squared\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStandard B\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4. Some days I'm so full of energy I can't sit still\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8. I often find myself talking very rapidly\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.38\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.17\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1. My mood has very severe changes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.19\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7. At times I feel uncontrollable excitement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.22\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13. I frequently engage in dangerous behavior\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5. Sometimes I do not need sleep to feel lively or energetic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eStepwise Regression for MMPI-3 RC9-Hypomanic Activation Scale\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eItem\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eR Squared\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStandard B\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4. Some days I'm so full of energy I can't sit still\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.24\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10. My mood severely changes regardless of what is going on around me\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.24\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9. I have racing thoughts I cannot control\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.17\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7. At times I feel uncontrollable excitement\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.19\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5. Sometimes I do not need sleep to feel lively or energetic\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.42\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.17\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTo clarify the use of the two subsamples, the developmental sample was used to produce findings displayed in Tables\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e, and \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e, described above. The psychometric analyses sample was used to produce findings described below and displayed in Tables\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e and \u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003e\u003cem\u003eCorrelations Between MBHS Screening Scales and MMPI-3 Target Scales\u003c/em\u003e\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"10\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMBHS Screening Scales\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"9\" nameend=\"c10\" namest=\"c2\"\u003e\u003cp\u003eMMPI-3 Target Criteria\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRC1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCOG\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRCd\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eRC2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003eRC7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003eSUI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eACT\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eDISC\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003eSUB\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSomatization\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e.63\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.71\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.48\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e.18\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCognitive Issues\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e.83\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.66\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.37\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.36\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e.28\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDemoralization\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e.81\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.68\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e.19\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnhedonia\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.46\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.58\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e.67\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.53\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.35\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e.16\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.60\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.72\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.52\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e.77\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e.15\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSuicidal Ideation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.44\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.55\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.70\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.54\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e.59\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.32\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e.24\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eActivation - revised\u003c/p\u003e\u003cp\u003e(Previous version of Activation)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.39\u003c/p\u003e\u003cp\u003e(.61)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.34\u003c/p\u003e\u003cp\u003e(.69)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.33\u003c/p\u003e\u003cp\u003e(.66)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.12\u003c/p\u003e\u003cp\u003e(.42)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.38\u003c/p\u003e\u003cp\u003e(.64)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.26\u003c/p\u003e\u003cp\u003e(.47)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003e.47 (.44)\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.20\u003c/p\u003e\u003cp\u003e(.42)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e.13\u003c/p\u003e\u003cp\u003e(.23)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDisconstraint\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.31\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.33\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cb\u003e.52\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e.27\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSubstance Misuse\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.27\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e.23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e.63\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u003cb\u003e.67\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"10\"\u003e\u003cem\u003eNote\u003c/em\u003e. Values in cells are Pearson correlations. Convergent correlation coefficients are bolded. RC1-Somatic Concerns; COG-Cognitive Concerns; RCd-Demoralization; RC2-Low Positive Emotions; RC7-Dysfunctional Negative Emotions; SUI-Suicidal/Death Ideation; ACT-Activation; DISC-Disconstraint; SUB-Substance Abuse.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe MBHS Activation scale was designed to estimate the probability that an individual would achieve a score in the clinical range (T\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026ge;\u003c/span\u003e\u0026thinsp;65) on the ACT scale of the MMPI-3. Given this binary outcome, ROC analysis provides a relevant perspective. As shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, the revised Activation scale exhibited an increase in AUC from .69 (original) to .80 (revised) in predicting an elevation on ACT. Similarly, the revised Activation scale exhibited an increase in AUC from .77 (original) to .85 (revised) in predicting an elevation on RC9.\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e presents bivariate correlations between each of the MBHS predictor scales and the nine target criteria on the MMPI-3. Values for the original Activation scale are included in parentheses for comparison purposes. With regard to convergent correlation with the primary criterion (MMPI-3 ACT scale), marginal improvement is evident (.44 to .47). However, broad-based and meaningful improvement was achieved with regard to discriminant validity. The older Activation scale exhibited an average correlation of .52 with non-target criteria; this dropped to .27 with the revised scale. With the new version, no discriminant correlation coefficient reached .40, whereas with the older scale only one off-target comparison did \u003cem\u003enot\u003c/em\u003e reach that level.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003ePrecise characterization of manic/hypomanic symptomatology in the context of a single-point-in-time psychological evaluation is historically challenging, due largely to the transitory nature of the key phenomena (Ben-Porath, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). We acknowledge that using a brief screening device exacerbates the challenge. That said, given the significant treatment relevance in distinguishing between depressed primary care patients with or without underlying cyclical mood, we argue that the primary care provider should routinely consider this distinction. Indeed, numerous sources have suggested that the misdiagnosing cyclical mood disturbance as \u0026ldquo;simple depression\u0026rdquo; is the most common mental health diagnostic error in primary care settings (Bowden, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2001\u003c/span\u003e; Hirschfield et al., 2003). A screening-level activation indicator used in conjunction with dimensional depressive indicators can inform that process.\u003c/p\u003e\u003cp\u003eThis project was designed to improve the accuracy of the Activation scale, one of the nine scales comprising the Multidimensional Behavioral Health Screen (MBHS). The slightly improved convergent correlation with the key criterion (from .44 to .47) is noted; even so, this is still the lowest convergent correlation amongst the nine scales of the MBHS. This limitation is generally consistent with other psychological tests measuring mania/hypomania, likely attributable to the cyclical nature of the key symptoms. The much larger improvements in discriminant validity suggests that the new scale is significantly more precise than the original, likely yielding fewer false positives. The meaningful improvement in predictive accuracy as measured by ROC analyses support this conclusion.\u003c/p\u003e\u003cp\u003eThough these improvements are noteworthy and have real implications for use in healthcare screening, it is important to acknowledge some l imitations, foremost being that this studyrelied on data collected from college student participants. Though this demographic is perhaps more likely to display higher rates of mood disorders (CITE) than other populations and therefore a key young adult population, the ideal sample for a study of this nature would utilize data from primary medical care outpatients. In order to facilitate and continue this important research, we would certainly recommend that future studiesthat use the MMPI-3 with primary care patients add the 29 items of the MBHS to the data collection protocol and repeat the ROC analyses described here for all nine MBHS screening scales.This will enable continued improvements in generalizability and diagnostic accuracy.\u003c/p\u003e\u003cp\u003eSimilarly, because the data were collected in a regional university setting, this sample has a larger percentage of both female (53.6%) and white (86.1%) participants, and thus lacks diversity. As a result, it may not well represent significant minority populations and the ability of the MBHS to capture and screen for mental health symptom presentations that may be most relevant to those groups. Further research is needed to ensure this screener is as accurate and inclusive to all groups as possible, with a further focus on male populations, gender diverse, and culturally and ethnically diverse groups.\u003c/p\u003e\u003cp\u003eIn conclusion, because primary health screeners are such a broad, wide reaching mental health tool it is vital that the screeners used in these settings are continually updated and evaluated for accuracy. This study offers an important update and improvement to the current MBHS Activation scale, and a notable advancement in the ability of primary care providers to accurately measure a historically difficult mental health concern to capture. Particularly, the improvements to discriminant validity are a significant development to the accuracy of this important MBHS scale. With fewer instances of misdiagnosis and greater ability to differentiate between unipolar depression and cyclical mood disorders, primary health screenings are more likely to facilitate timely and effective treatment, which may have drastic impacts on a patient\u0026rsquo;s health and reduce the occurrence of ineffective/misprescriptions. Improving the way we measure and screen for these mental health concerns is a vital step towards better patient and treatment outcomes and better primary care screening, a fundamental goal of the MBHS.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003eThis study was not pre-registered. Data and analysis code can be made available for replication purposes providing appropriate institutional agreements are met. No external funding was provided for this research. None of the authors have conflicts of interest wit regard to this research.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eA.H. played a lead role in conceptualization, methodology, data collection, statistical analyses, and writing. M.D. played a supporting role in conceptualization, methodology, data collection, writing, review, and editing. R. F. participated in data collection and played a supporting role in writing, review, and editing. D. M. played a lead role in conceptualization, supervision, and resources, with a supporting role in writing, review, and editing.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThis study was not pre-registered. Data and analysis code can be made available for replication purposes providing appropriate institutional agreements are met.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eAguinaldo, L. D., Sullivant, S., Lanzillo, E. C., Ross, A., He, J. 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Personality psychopathology, drug use and psychological symptoms in adolescents with substance use disorders and community controls. PeerJ, 3. https://doi.org/10.7717/peerj.992\u003c/li\u003e\n \u003cli\u003eMcCord, D. M. (2020) The Multidimensional Behavioral Health Screen 1.0: A Translational Tool for Primary Medical Care. \u003cem\u003eJournal of Personality Assessment\u003c/em\u003e, \u003cem\u003e102\u003c/em\u003e(2), 164-174. DOI: 10.1080/00223891.2019.1683019\u003c/li\u003e\n \u003cli\u003eMeads, D. M., \u0026amp; Bentall, R. P. (2008). Rasch analysis and item reduction of the Hypomanic Personality Scale. \u003cem\u003ePersonality and Individual Differences\u003c/em\u003e, \u003cstrong\u003e44\u003c/strong\u003e(8), 1772\u0026ndash;1783. https://doi.org/10.1016/j.paid.2008.02.009\u003c/li\u003e\n \u003cli\u003eNa, P. J., Yaramala, S. R., Kim, J. A., Kim, H., Goes, F. S., Zandi, P. P., ... \u0026amp; Bobo, W. V. (2018). The PHQ-9 Item 9 based screening for suicide risk: a validation study of the Patient Health Questionnaire (PHQ)\u0026minus; 9 Item 9 with the Columbia Suicide Severity Rating Scale (C-SSRS). \u003cem\u003eJournal of Affective Disorders\u003c/em\u003e, \u003cem\u003e232\u003c/em\u003e, 34-40.\u003c/li\u003e\n \u003cli\u003ePark, L. T., \u0026amp; Zarate Jr, C. A. (2019). Depression in the primary care setting. \u003cem\u003eNew England Journal of Medicine\u003c/em\u003e, \u003cem\u003e380\u003c/em\u003e(6), 559-568.\u003c/li\u003e\n \u003cli\u003ePatel, R., Reiss, P., Shetty, H., Broadbent, M., Stewart, R., McGuire, P., \u0026amp; Taylor, M. (2015). Do antidepressants increase the risk of mania and bipolar disorder in people with depression? A retrospective electronic case register cohort study. \u003cem\u003eBMJ open\u003c/em\u003e, \u003cem\u003e5\u003c/em\u003e(12), e008341. \u003cu\u003ehttps://\u003c/u\u003e\u003c/li\u003e\n \u003cli\u003ePosner, K., Brown, G. K., Stanley, B., Brent, D. A., Yershova, K. V., Oquendo, M. A., ... \u0026amp; Mann, J. J. (2011). The Columbia\u0026ndash;Suicide Severity Rating Scale: Initial validity and internal consistency findings from three multisite studies with adolescents and adults. \u003cem\u003eAmerican Journal of Psychiatry\u003c/em\u003e, \u003cem\u003e168\u003c/em\u003e(12), 1266-1277.\u003c/li\u003e\n \u003cli\u003eRural Health Information Hub (2022). Screening for addressing suicide risk in clinical settings. https://www.ruralhealthinfo.org/toolkits/suicide/2/screening-tools\u003c/li\u003e\n \u003cli\u003eRui, P., \u0026amp; Okeyode, T. (2015). National Ambulatory Medical Care Survey 2015. State and national summary tables. Available at http:// www.cdc.gov/nchs/ahcd/ahcd_products.htm\u003c/li\u003e\n \u003cli\u003eSchiller, J. S., \u0026amp; Norris, T. (2023, April). National Health Interview Survey Early Release Program. National Center for Health Statistics. https://www.cdc.gov/nchs/data/nhis/earlyrelease/earlyrelease202304.pdf\u003c/li\u003e\n \u003cli\u003eSellbom, M., Bagby, R. M., Kushner, S., Quilty, L. C., \u0026amp; Ayearst, L. E. (2012). Diagnostic construct validity of MMPI-2 Restructured Form (MMPI-2-RF) scale scores. \u003cem\u003eAssessment\u003c/em\u003e, \u003cem\u003e19\u003c/em\u003e(2), 176-186. https://doi.org/10.1177/1073191111428763\u003c/li\u003e\n \u003cli\u003eSpitzer, R. L., Kroenke, K., Williams, J. B., \u0026amp; L\u0026ouml;we, B. (2006). A brief measure for assessing generalized anxiety disorder: the GAD-7. \u003cem\u003eArchives of Internal Medicine\u003c/em\u003e, \u003cem\u003e166\u003c/em\u003e(10), 1092-1097.\u003c/li\u003e\n \u003cli\u003eVahratian, A., Blumberg, S. J., Terlizzi, E. P., \u0026amp; Schiller, J. S. (2021). Symptoms of anxiety or depressive disorder and use of mental health care among adults during the COVID-19 pandemic \u0026mdash; United States, August 2020\u0026ndash;February 2021. MMWR. Morbidity and Mortality Weekly Report, 70(13), 490\u0026ndash;494. https://doi.org/10.15585/mmwr.mm7013e2\u003c/li\u003e\n \u003cli\u003eVan Orden, K. A., Witte, T. K., Cukrowicz, K. C., Braithwaite, S. R., Selby, E. A., \u0026amp; Joiner, T. E., Jr. (2010). The interpersonal theory of suicide. \u003cem\u003ePsychological Review\u003c/em\u003e, \u003cem\u003e117\u003c/em\u003e(2), 575\u0026ndash;600. https://doi-org.proxy195.nclive.org/10.1037/a0018697\u003c/li\u003e\n \u003cli\u003eVan Orden, K. A., Cukrowicz, K. C., Witte, T. K., \u0026amp; Joiner, T. E. (2012). Thwarted belongingness and perceived burdensomeness: Construct validity and psychometric properties of the Interpersonal Needs Questionnaire. \u003cem\u003ePsychological Assessment\u003c/em\u003e, \u003cem\u003e24\u003c/em\u003e(1), 197-215.\u003c/li\u003e\n \u003cli\u003eVillanueva van den Hurk, A. W., McCord, D. M., G\u0026ouml;rner, K. J., Jowers, C. E., \u0026amp; Mihura, J. L. (in press). New versions of the MMPI and Rorschach: How have training programs responded? \u003cem\u003eJournal of Personality Assessment\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eWatson, C., Quilty, L. C., \u0026amp; Bagby, R. M. (2011). Differentiating bipolar disorder from major depressive disorder using the MMPI-2-RF: A receiver operating characteristics (ROC) analysis. \u003cem\u003eJournal of Psychopathology and Behavioral Assessment\u003c/em\u003e, \u003cem\u003e33\u003c/em\u003e, 368-374.\u003c/li\u003e\n \u003cli\u003eWhitman, M. R., \u0026amp; Sellbom, M. (2023). Construct validation of Minnesota Multiphasic Personality Inventory-3 (MMPI-3) scales relevant to the assessment of bipolar spectrum disorders. \u003cem\u003eJournal of Clinical Psychology\u003c/em\u003e, \u003cem\u003e79\u003c/em\u003e(11), 2583-2601.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Table 4","content":"\u003cp\u003eTable 4 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":true,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"depression screening, Multidimensional Behavioral Health Screen, mental health screening in primary care","lastPublishedDoi":"10.21203/rs.3.rs-7924366/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7924366/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe Multidimensional Behavioral Health Screen (MBHS; McCord, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2020\u003c/span\u003e) is a brief, 29-item self-administered instrument designed for use in high-volume primary medical care settings. It includes nine 3-item scales tapping major core constructs of psychological dysfunction using a hierarchical-dimensional framework, with initial validation based on associations with related, primarily mid-level, scales of the Minnesota Multiphasic Personality Inventory-3 (MMPI-3; Ben-Porath \u0026amp; Tellegen, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). A frequent challenge in primary medical care is evaluating for possible mood instability, including underlying hypomania or mania, in cases that present with primarily depressive symptomatology. For this reason, an Activation scale was included on the MBHS. Although the basic psychometric properties of the most recent version of the Activation scale were acceptable, convergent correlation with its target variable on the MMPI-3 (Activation) was the lowest amongst the nine MBHS scales, and discriminant validity was poor. In this paper we describe an effort to address these weaknesses in the development of a revised version of the 3-item Activation scale. Participants in this project were 288 college students with valid MMPI-3 protocols. The revised Activation scale exhibits substantially improved discriminant validity that should support a more precise screening-level indication of the possible presence of mood instability.\u003c/p\u003e","manuscriptTitle":"Brief Screening for Mood Instability: Improving the Activation Scale of the Multidimensional Behavioral Health Screen","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-11-13 15:09:45","doi":"10.21203/rs.3.rs-7924366/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"232bca66-811a-4c13-b365-22e40b7eaf71","owner":[],"postedDate":"November 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-09T22:39:12+00:00","versionOfRecord":[],"versionCreatedAt":"2025-11-13 15:09:45","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7924366","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7924366","identity":"rs-7924366","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}