Bipolarity Questionnaire: Preliminary Construction of a Screening Questionnaire for Bipolar Disorder

Bipolarity Questionnaire: Preliminary Construction of a Screening Questionnaire for Bipolar Disorder | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Bipolarity Questionnaire: Preliminary Construction of a Screening Questionnaire for Bipolar Disorder Zhaoyu Gan, Ting Yang, Yu Chen Lin, Xiuhua Wu, Qi Zhu This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7685744/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 Background Bipolar disorder (BD) is often underdiagnosed or misdiagnosed due to limitations in current diagnostic tools, which may not adequately capture the disorder’s defining characteristics, such as symptom polarity and instability. Existing self-report scales, like the MDQ and HCL-32, have limited sensitivity and are not culturally tailored to Chinese populations. To address this gap, a new self-report questionnaire was developed to aid in the differentiation between unipolar and bipolar depression, with an emphasis on broader symptom coverage. Methods A 21-item self-rated questionnaire was drafted and administered to 445 patients with Major Depressive Disorder (MDD) or Bipolar Disorder (BD) confirmed by structural diagnostical interview according to DSM-5 and a at least 6-month follow-up. The internal consistency was assessed using Cronbach's alpha, structural validity was evaluated through confirmatory factor analysis, and the screening performance was determined using an ROC curve analysis. Results The Cronbach's coefficient for the entire questionnaire was 0.872. Exploratory factor analysis revealed four factors with a cumulative variance contribution of 46.22%. The questionnaire demonstrated good sensitivity (0.66-0.84) and specificity (0.58-0.71) for different BD subtypes, with AUC values ranging from 0.689 to 0.741. Conclusion The Bipolarity Questionnaire is a reliable and valid tool for differentiating unipolar and bipolar depression, with a broader symptom assessment compared to existing tools. Bipolar disorder diagnosis self-report questionnaire questionnaire properties Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Bipolar disorder (BD) is a prevalent mental health condition with a global lifetime prevalence of 2.4% [ 1 ]. Despite its prevalence, clinical management of BD is impeded by high incidence of misdiagnosis, underdiagnosis and delayed diagnosis. The current gold standard for diagnosing bipolar disorder relies on structured interviews to ascertain the history of manic or hypomanic episodes, which exhibit high specificity but a low sensitivity [ 2 , 3 ]. To address these limitations, researchers have developed screening tools such as the Mood Disorder Questionnaire (MDQ) [ 4 ] and the 32-item Hypomania Checklist (HCL-32) [ 5 ]. However, initial studies found that the sensitivity of these scales was significantly reduced by items related to the course and severity of the disease. Both scales have since been revised to screen for BD by assessing whether there have been sufficient number of manic symptoms in the past[ 6 , 7 ]. Although the revised versions are of good reliability and validity in BD screening, they do not fully capture the essential characteristics of the disorder as originally intended. In addition, screening tools developed specifically for and by Chinese populations are not yet available and are appropriate for use in China. The aim of this study is to develop a screening questionnaire for BD based on the Chinese population which will focus on the key features of polarity and symptom instability. Methods Subjects All of the participants in this study were recruited from a clinical research project (Project No.: YHJH201805) under the "Yuanhang Plan" at the Third Affiliated Hospital of Sun Yat-sen University. The participants were patients who visited the psychiatric outpatient or inpatient department of the Third Affiliated Hospital of Sun Yat-sen University between October 17, 2018 and June 30, 2020, and who met the following criteria: (1) are currently meet the DSM-5 criteria for major depressive episode; (2) are between the age of 18 and 65; (3) have at least a middle school education and are able to complete the questionnaire; (4) have signed informed consent. The study protocol was approved by the Ethics Committee of the Third Affiliated Hospital of Sun Yat-sen University (Ethics Approval No.: 2018-02-207-01). All participants provided written informed consent and agreed to participate in the study. Theoretical Framework of the Questionnaire Bipolar disorder, also known as manic depression, is a mental illness characterized by extreme mood swings, including emotional highs (mania or hypomania) and lows (depression). Although there is no universally accepted definition, the most widely recognized features are the bipolarity and instability of symptoms. Bipolarity refers to two contrasting symptoms experienced by people with bipolar disorder: mania and depression. Instability describes the variability and unpredictability of symptoms. Moreover, the timing of mood episodes in bipolar disorder is not in a linear pattern, meaning that there is no predictable pattern to when a person may move from a depressive episode to a manic episode, or vice versa [ 8 , 9 ]. Finally, from a cross-sectional perspective, symptoms of bipolar disorder are not always present in parallel, which means that not all symptoms occur at the same time and that severity may vary [ 10 ]. Therefore, the screening tool for bipolar disorder should be capable of reflecting the above-mentioned features of this disorder. Items Pool and Draft Construction of the Scale Drawing from previous mania and depression scales, as well as the diagnostic criteria for depressive and manic episodes, the items in this scale consist of 21 pairs of corresponding symptoms of mania and depression. The scale emphasizes the inter-temporal alternation of these symptoms, but does not specify the length or frequency of the cycles of manic and depressive symptoms. Research Procedure First, an initial evaluation of the patient is performed by an outpatient physician to determine if the patient meets the inclusion criteria for the study. If a patient is eligible, the physician refers him/her to the staff of the research team, who then verify that the patient meets the inclusion and exclusion criteria. Patients meeting these criteria are given written informed consent is obtained, and a questionnaire is distributed. After the patient completes the self-assessment questionnaire, the researchers conduct a structured interview using the Chinese version of SCID-P, focusing on sections relating to manic or hypomanic episodes, depressive episodes, and atypical depressive symptoms. In addition, a custom questionnaire is used to collect clinical information, including the age at which the patient started, the course of the disease, type of mood episodes, their duration (focus on the most severe episode), the number of episodes, the type of current episode, the history of medication, and the response to treatment. Diagnosis Confirmation In order to improve the accuracy of the final clinical diagnosis, all patients enrolled are followed for as long as possible, aiming at least 6 months and at least 3 follow-ups (the number of follow-up visits may be reduced in patients who are hospitalized or have previously been diagnosed with bipolar disorder). The monitoring shall include the following indicators: (1) (hypo)manic or mixed episodes: clinical observation and information from informants are used to evaluate the presence of (hypo)manic or mixed episodes during ambulatory monitoring or hospitalization. (2) Response to diagnostic therapy: Patients diagnosed with depression are treated with antidepressants without mood stabilizers (e.g. lithium, anticonvulsants, or second-generation antipsychotics) as much as possible at the time of entry. In patients with bipolar disorder, mood stabilizers should be used as widely as possible without the use of antidepressants. All enrolled patients may be prescribed concomitant sedative-hypnotic medicinal products. Follow-up measures the patient’s response to antidepressants or mood stabilizers: If a patient responds well to antidepressant monotherapy (with or without sedative-hypnotics) for 6 months, this supports the diagnosis of depression. - if, on the other hand, the patient experiences a switch to mania or mixed episode following treatment with antidepressant, the diagnosis of bipolar disorder is confirmed. In addition, if the patient does not respond to antidepressant treatment but has responded to six months of mood stabilizers, this is also evidence for bipolar disorder. Effective treatment is defined as a patient who shows sustained improvement in symptoms over follow-up (with a clinical global impression severity score < 4 on the last two consecutive visits and a less than 3 score of efficacy index on each visit from the second visit) without the need for medication from the opposite treatment group (no mood stabilizers in the depression group, no antidepressants in the bipolar group). Based on the patient's medical history, follow-up observations and the results of diagnostic therapy, two attending or senior psychiatrists will make the final diagnosis of each patient based on the DSM-5 diagnostic criteria for major depressive disorder and bipolar disorder. Quality Control The researchers who were responsible for conducting the clinical diagnostic interviews in this study were all members from the same clinician team. Before the study began, the two psychiatrists responsible for final diagnosis received a month of training in the field of diagnostic consistency. After the training, they independently diagnosed 40 patients with bipolar disorder, and achieved a diagnostic concordance rate of 0.975. Statistical Methods Statistical analysis was carried out with SPSS 22.0 software. To evaluate whether the data follow a normal distribution, the Kolmogorov-Smirnov test was applied. Data following a normal distribution were expressed as median (interquartile range), and the Mann-Whitney U comparison was made between groups. Data following a normal distribution were expressed as mean ± standard deviation (x ± s), and comparisons between groups were done by t-test. The categorical data were expressed in terms of frequencies and percentages and the comparisons between the groups was made by the means of the χ² test. The Cronbach’s alpha was used to assess the internal consistency reliability of the scales and the confirmatory factor analysis was employed to evaluate the structural validity of the scales. The questionnaire screening performance was evaluated by plotting ROC curves. Sensitivity and specificity were calculated for each theoretically possible cut-off, and linear interpolation was used to calculate the sensitivity and specificity for each of the true positive response rates. The optimal threshold was determined by maximizing the Youden index (= sensitivity + specificity − 1). Sensitivity is the percentage of genuinely positive cases correctly detected by a screening test, which reflects the patient detection capability of the test. Sensitivity = number of true positives and number of gold-standard positives. Specificity refers to the percentage of genuinely negative cases correctly identified by the screening test, which reflects its ability to detect non-patients. Specificity = number of true negatives and number of gold-standard negatives. The Youden index, also known as the accuracy index, measures the overall ability of a screening method to detect real patients and false patients. The Yield Index = sensitivity + specificity − 1. P-value < 0.05 was considered statistically significant for the differences between the groups. Results Demographics and Clinical Characteristics of the subjects A total of 445 participants were enrolled in the study, including 345 with bipolar disorder (BD) and 100 with major depressive disorder (MDD). Among the bipolar cases, 11 cases of bipolar I disorder (BD-I), accounting for 3.2% (11/345); 181 cases of Bipolar II disorder (BD-II), accounting for 52.4% (181/345); 131 cases of bipolar disorder with mixed features, accounting for 38.0% (131/345); and 22 cases of unspecified types (BD-NOS), accounting for 6.4% (22/345). As shown in Table 1 , the BD group had a significantly higher mean age (t = 5.395, P < 0.001) and younger age of onset (t = 5.122, P < 0.001), and a lower proportion of men and women who were married compared to the MDD group (χ² = 22.838, P < 0.001). The number of mood episodes was higher in the BD group than in the MDD group (Z = 6.672, P < 0.001). There were no significant differences between the groups in the proportion of women and men (χ² = 0.032, P = 0.902) or education level (t = -0.737, P = 0.463). Table 1 Comparison of demographics and clinical characteristics between BD and MDD Item Bipolar Disorder Group BD-I( n = 11) BD-II( n = 181) BD-mixed( n = 131) BD-NOS( n = 22) Total( n = 345) MDD group( n = 100) Female [cases (%)] 5(45.4) 123(68.0) 92(70.2) 11(50.0) 232(67.0) 66(66.0) Married [cases (%)] 3(27.3) 55(30.4) 27(20.6) 5(22.7) 90(26.1) 52(52.0) Age (years, x ± s ) 30.4 ± 16.5 28.3 ± 11.5 25.9 ± 9.4 27.4 ± 12.4 27.3 ± 11.0 34.8 ± 12.9 Educated years(x ± s ) 12.1 ± 3.0 14.2 ± 2.5 13.9 ± 2.7 14.5 ± 2.4 14.0 ± 2.6 13.7 ± 3.8 Onset age(years, x ± s) 23.5 ± 15.1 22.9 ± 11.0 21.5 ± 9.2 23.1 ± 11.0 22.4 ± 10.4 29.8 ± 13.5 Number of past mood episodes [ M ( P 25 , P 75 )] 4(3, 6) 4(3, 7) 2(1, 5) 2(1, 6) 3(2, 6) 2(1, 3) Note: M (P 25 , P 75 ) represents the median (interquartile range) Scale Properties Internal Consistency and Reliability of the Scale A reliability analysis was performed on a 21-item questionnaire and the results showed that the Cronbach's alpha value for the whole scale was 0.872. After the items 1–21 have been incrementally deleted, the remaining Cronbach alpha scale ranges from 0.863 to 0.871. The correlation coefficient between the score of each item and the overall scale score ranged from 0.359 (item 10) to 0.557 (item 5) for all items. Structural Validity of the Scale The questionnaire provided a basis for analyzing factors (see Table 2 ). Kaiser-Meier-Olkin (KMO) was 0.904 and the correlation coefficient was 2.396, df = 210, p < 0.001. Using principal component analysis and varimax orthogonal rotation without restricting the number of factors, four factors with eigenvalues exceeding 1 were identified, resulting in a cumulative contribution to variance of 46.22 percent. According to the smoothing plot, the slope flattened after the fourth factor and therefore the number of coefficients was set at 4. Based on the content of the items, the four factors were identified as: social activity, emotional state, self-awareness, and instinctive activity. The coefficient loadings for each item ranged from 0.325 to 0.755, and with the exception of item 7, all items had coefficients above 0.4 (see Table 3 ). Table 2 Frequency of scale items between the two groups and intergroup comparison Item No. Item content BD (N = 344) MDD (N = 100) χ² p value 1 I sometimes feel very down, and at other times I feel very happy. 87.50% 62.00% 33.778 < 0.001 2 I sometimes feel the future is full of hope, and other times I feel it is doomed. 80.50% 54.00% 28.727 < 0.001 3 I sometimes feel completely worthless, and at other times I feel very confident. 75.30% 47.00% 28.949 < 0.001 4 I sometimes feel the world is beautiful, and at other times I feel the world is dark and bleak. 71.80% 48.00% 19.687 < 0.001 5 I sometimes feel physically exhausted and lacking energy, and at other times I feel full of energy and vitality. 75.00% 44.00% 34.227 < 0.001 6 I sometimes feel sharp and quick-thinking, and at other times I feel slow and dull. 74.70% 51.00% 20.497 < 0.001 7 I sometimes feel bold and decisive, and at other times I am very hesitant. 70.90% 50.00% 15.813 < 0.001 8 My interests shift between having none and having many. 54.10% 28.00% 21.09 < 0.001 9 I sometimes binge eat, yet sometimes I can have little to no appetite for days. 38.10% 14.00% 20.43 < 0.001 10 I sometimes feel little to no sexual interest, and at other times I experience a strong sex drive. 43.60% 26.00% 10.036 0.002 11 Sometimes I am an isolated introvert, other times I am an extrovert and life of the party. 66.00% 40.00% 21.828 < 0.001 12 Sometimes I spend money cautiously, other times I can go on reckless spending sprees. 59.90% 46.00% 6.085 0.014 13 I go from being easily irritated by others to being warm and generous. 52.60% 40.00% 4.933 0.026 14 I sometimes sleep only 3–4 hours (or less) and don’t feel tired, and at other times I sleep excessively and still feel fatigued. 58.70% 31.00% 23.874 < 0.001 15 I sometimes feel ambitious and full of plans, and at other times I procrastinate and struggle to get things done. 81.10% 59.00% 20.83 < 0.001 16 I sometimes feel shy and tongue-tied, and at other times I feel charismatic and articulate. 61.60% 31.00% 29.334 < 0.001 17 I sometimes feel I’m the luckiest person in the world, and sometimes I feel miserable and unfortunate 68.90% 44.00% 20.667 < 0.001 18 Sometimes I am forgetful and clumsy, other times I feel my memory is exceptional. 45.30% 30.00% 7.498 0.006 19 Sometimes I feel in control of my destiny, and at other times I feel powerless in the face of fate. 53.20% 39.00% 6.247 0.012 20 I sometimes feel life is meaningless, and at other times I feel life is precious and worth living. 64.80% 48.00% 9.223 0.002 21 I sometimes feel physically unwell, and at other times I feel full of life. 71.50% 49.00% 17.609 < 0.001 BD = bipolar disorder; MDD = major depressive disorder. Table 3 Results of the Exploratory Factor Analysis Item No. Component 1 2 3 4 21 .621 .284 .243 − .054 12 .591 .073 − .055 .316 11 .549 .157 .049 .215 6 .525 .210 .386 − .047 16 .512 .134 .222 .239 13 .492 .027 .141 .303 8 .405 .123 .319 .276 7 .325 .133 .294 .151 2 .013 .743 .229 .222 3 .139 .731 .160 .120 1 .301 .641 .052 .030 4 .004 .571 .349 .278 5 .414 .567 .145 .040 15 .450 .466 .144 − .016 17 − .031 .140 .739 .105 19 .192 .234 .610 .108 20 .187 .245 .569 .060 18 .380 .013 .544 .041 9 .154 .034 .092 .755 10 .122 .175 .076 .610 14 .332 .166 .108 .466 Sensitivity and Specificity of the Scale Figure 1. ROC curve of BD-I vs. MDD. The AUC for BD-I is 0.689. Figure 2. ROC curve of BDII vs. MDD. The AUC for BD-II is 0.745. Figure 3. ROC curve of BD-mix vs MDD. The AUC for BD-mixed is 0.741. Figure 4. ROC curve of BD-NOS vs MDD. The AUC for BD-unspecified is 0.741. Figure 5. ROC curve of all BD vs MDD. The AUC for BD is 0.741. For all figures: he x-axis represents 1 – specificity, and the y-axis represents sensitivity. The blue line indicates the ROC curve and the red diagonal line represents chance level. AUC = area under the curve; BD = bipolar disorder; MDD = major depressive disorder; NOS = not otherwise specified. Figures 1–5 show the ROCs for BD-I, BD-II, BD-MX, BD-NOS and total BD. Areas under the ROC curve (AUC) were 0.689, 0.745, 0.741, 0.741 and 0.741, suggesting that the Bipolarity Questionnaire is well-equipped to distinguish between different clinical subtypes of bipolar disorder and unipolar depression. Figure 6. Sensitivity and specificity of the Bipolarity Questionnaire in diagnosing different subtypes of bipolar disorder based on different cut-off values. The x-axis shows Bipolarity Questionnaire scores (0–20). The y-axis shows sensitivity and specificity values (0–1). Sensitivity is plotted separately for BD-I in orange, BD-II in yellow, bipolar disorder with mixed features (BP-MX) in green, and bipolar disorder not otherwise specified (BP-NOS) in turquoise, as well as for the total bipolar disorder group in red. Specificity is shown in blue. Figure 6 shows the sensitivity and specificity of the Bipolarity Questionnaire for the diagnosis of different subtypes of bipolar disorder based on different cut-off values. Further statistical analysis revealed that the optimal cut-off values for BD-I, BD-II, BD-MX, BD-NOS and total BD were 12, 12, 12, 10 and 11, respectively, when maximized by the Youden index. The corresponding sensitivity and specificity for these cut-off points were: 0.73 and 0.71 for BD-I, 0.66 and 0.71 for BD-II, 0.67 and 0.71 for BD-mixed, 0.84 and 0.58 for BD-NOS, and 0.71 and 0.65 for overall BD. Discussion This study found that the Bipolarity Questionnaire is reliable and valid for the identification and distinction of unipolar and bipolar depression. The internal consistency reliability is quite high (0.872) and comparable to the two standard bipolar disorder questionnaires, the MDQ (0.73–0.91) [ 6 , 11 ] and the HCL-32 (0.82–0.88) [ 5 , 7 ]. From a structural validity perspective, the Bipolarity Questionnaire generated a total of 4 factors with a cumulative variance contribution rate of 46.22%. Although this is not as ideal as 60% or more, and some items do not correspond to the theoretical factors, such as item 21, which should theoretically fall under factor 4—instinctive activity, but which is actually in factor 1—social activity. However, overall, its structural validity appears s to be better than that of HCL-32 (which has two factors and a cumulative variance contribution rate of 26.8%). In terms of validity, the positive response rates for each item of the Bipolarity Questionnaire are higher in patients with bipolar disorder than in those with unipolar depression. Further ROC analysis shows that the Bipolarity Questionnaire is highly sensitive (0.66–0.84) and specific (0.58–0.71) for the different subtypes of bipolar disorder, with corresponding AUC in the range of 0.689 to 0.741. Other studies summarized the sensitivity and specificity of the three standard diagnostic scales for bipolar disorder, namely the HCL-32, MDQ and the Bipolar Spectrum Diagnostic Scale (BSDS), based on 53 initial studies: 81%, 66%, and 69% for sensitivity, and 67%, 79%, and 86% for specificity, respectively [ 12 ]. In a previous study using HCL-32 in the same subjects as this study [ 3 ], the sensitivity and specificity of HCL-32 in BD-I, BD-II, BD-MX, BD-NOS, and total BD were 0.73 and 0.67, 0.66 and 0.67, 0.80 and 0.67, 0.70 and 0.67, and 0.70 and 0.67, respectively. This indicates that the sensitivity and specificity of the Bipolar Disorder Questionnaire are comparable to the HCL-32, MDQ, and BSDS. Although emotional instability has long been regarded as a key pathological feature of bipolar disorder and is widely used in the screening, diagnosis, and prognostic evaluation of the disorder [ 13 – 15 ], in recent years there has been a growing emphasis on the energy/activity instability in bipolar diagnosis [ 16 ]. The study found that the instability and bipolarity of symptoms of bipolar disorder were reflected not only in emotions but also in various aspects such as energy, social interaction, interest in activities, cognition, self-awareness and instinctive activity. Moreover, many of the symptom items on the Bipolar Disorder Questionnaire, such as somatization and well-being, are not present in the earlier diagnostic tools. It therefore assesses a wide range of symptoms than previous screening tools based solely on emotional instability. This is the first self-assessment questionnaire to screen for bipolar disorder based solely on the bipolarity and instability of symptoms in both domestic and international contexts. Although emotional instability has long been regarded as a core pathological feature of bipolar disorder and is widely used in screening, diagnosing, and prognostic assessment of the disorder [ 13 – 15 ], emphasis on the instability of energy/activity in the diagnosis of bipolar disorder is seen in recent years [ 16 ]. This study found that the instability of symptoms in bipolar disorder and bipolarity is reflected not only in emotions but also in various aspects such as energy, social interactions, interest in activities, cognition, self-perception, and instinctive activities. Moreover, many symptom items in the Bipolarity Questionnaire, such as somatization and well-being, are absent in previous diagnostic tools. Therefore, it assesses a broader spectrum of symptoms compared to earlier screening tools developed solely based on emotional instability. To our knowledge, this is the first self-assessment questionnaire for screening bipolar disorder entirely based on symptoms of bipolarity and instability in both domestic and international contexts. This study also found that the Bipolarity Questionnaire demonstrates comparable sensitivity for BD-MX and BD-NOS as for BD-I and BD-II, although the threshold for BD-NOS is slightly lower, sacrificing some specificity. This finding contrasts with the higher sensitivity of the MDQ for BD-I and the higher sensitivity of the HCL-32 for BD-II [ 12 ]. As emotional instability is observed not only during depressive or (hypo)manic episodes but also during periods of intermittent episodes or different subthreshold mood episodes [ 17 ], the higher sensitivity of the Bipolarity Questionnaire for BD-MX and BD-NOS may be explained by this. In addition, the Bipolarity Questionnaire is easier to use than some other screening tools [ 16 , 18 , 19 ] that require apps to record changes in mood or activity daily or weekly, Finally, unlike MDQ, HCL-32, and BSDS, which stress that all depressive and manic symptoms must be temporally synchronous (although this is not explicitly stated in the revised MDQ and HCL-32), the item arrangement deliberately allows for a disorderly sequence of depressive and manic symptoms. This is more in keeping with the complexity and uncertainty of temporal and spatial relationships of bipolar symptoms [ 9 , 20 ], and corresponds to Kraepelin's definition of the condition as a manic-depressive disorder [ 10 ]. One strength of this study is its large sample size, which ensures sufficient statistical power. Another strength of this study is that all cases were diagnosed not only through structured diagnostic interviews but also through clinical observation and follow-up, rather than relying solely on a single structured diagnostic interview. This approach not only enhances the diagnostic specificity of the depression sample but also allows for the inclusion of bipolar disorder cases that may be difficult to identify through structured diagnostic interviews alone. Consequently, the study sample becomes more clinically representative. However, limitations include the small sample size of BD-I and BD-NOS and the fact that all participants were recruited from the same psychiatric institution and all were currently experiencing depressive episodes. Therefore, further research is needed to determine whether this questionnaire is applicable to other populations, including the general population. Declarations Ethics approval and consent to participate The study protocol was approved by the Ethics Committee of the Third Affiliated Hospital of Sun Yat-sen University (Ethics Approval No.: 2018-02-207-01) and is conducted per accordance with the Declaration of Helsinki. All participants provided written informed consent and agreed to participate in the study. Consent for publication Not applicable Availability of data and material The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding This study is funded by the Third Affiliated Hospital of Sun Yat-Sen University’s Clinical Research Program (grant number: YHJH201805). Authors' contributions ZG designed the study, handled grant applications, conducted MSCI interviews, and reviewed the manuscript. YL was responsible for data entry, statistical analysis and drafting the manuscript. TY handled data curation and verification, manuscript editing and administration. XW administered HCL-32, conducted clinical follow-up, and established the final diagnoses. QZ was responsible for SCID-I/P interviews with participants, clinical follow-up, and establishing the final diagnoses. All authors reviewed and approved the final manuscript. Acknowledgements We extend our sincere gratitude to all participants who contributed their time and insights to this study, as well as to the clinicians and researchers who provided expertise during the development and validation of the Bipolarity Questionnaire. References Merikangas KR, Jin R, He JP, Kessler RC, Lee S, Sampson NA, Viana MC, Andrade LH, Hu C, Karam EG, et al. Prevalence and correlates of bipolar spectrum disorder in the world mental health survey initiative. Arch Gen Psychiatry. 2011;68(3):241–51. 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Salvatore P, Baldessarini RJ, Centorrino F, Egli S, Albert M, Gerhard A, Maggini C. Weygandt's On the Mixed States of Manic-Depressive Insanity: a translation and commentary on its significance in the evolution of the concept of bipolar disorder. Harv Rev Psychiatry. 2002;10(5):255–75. Additional Declarations No competing interests reported. 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-7685744","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":531949463,"identity":"d63d3238-9529-4d7e-af00-c95b031e9a45","order_by":0,"name":"Zhaoyu 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The AUC for BD-I is 0.689.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure1ROCcurveofBDIvsMDD.png","url":"https://assets-eu.researchsquare.com/files/rs-7685744/v1/e30b1a12f97169103f2d2bf1.png"},{"id":94214728,"identity":"198d8e3f-4845-43d6-8be2-5c7a2c3e5239","added_by":"auto","created_at":"2025-10-23 16:18:38","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":238631,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eROC curve of BDII vs. MDD. The AUC for BD-II is 0.745.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure2ROCcurveofBDIIvsMDD.png","url":"https://assets-eu.researchsquare.com/files/rs-7685744/v1/60cf03d47c605e016838f6e4.png"},{"id":94214727,"identity":"ea256b8c-022e-4505-b48e-39e4739d1ffb","added_by":"auto","created_at":"2025-10-23 16:18:38","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":207503,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eROC curve of BD-mix vs MDD. The AUC for BD-mixed is 0.741.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure3ROCcurveofBDmxvsMDD.png","url":"https://assets-eu.researchsquare.com/files/rs-7685744/v1/2bae29ccaea4199ee222a062.png"},{"id":94214385,"identity":"19a27bc9-0876-45bd-a4d0-c86393c0a90e","added_by":"auto","created_at":"2025-10-23 16:10:38","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":185792,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eROC curve of BD-NOS vs MDD. The AUC for BD-unspecified is 0.741.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure4ROCcurveofBDunspecifiedvsMDD.png","url":"https://assets-eu.researchsquare.com/files/rs-7685744/v1/ddcb2edec335c50773b8571b.png"},{"id":94214730,"identity":"e6687176-2c90-41ea-8d61-598594a392ee","added_by":"auto","created_at":"2025-10-23 16:18:38","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":160350,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eROC curve of all BD vs MDD. The AUC for BD is 0.741.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Figure5ROCcurveofallBDvsMDD.png","url":"https://assets-eu.researchsquare.com/files/rs-7685744/v1/91f298d20f52d69bdf7e267e.png"},{"id":94215258,"identity":"97d9f004-e0ff-4c39-ac2b-896e5596048f","added_by":"auto","created_at":"2025-10-23 16:26:38","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":267813,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eSensitivity and specificity of the Bipolarity Questionnaire in diagnosing different subtypes of bipolar disorder based on different cut-off values.\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThe x-axis shows Bipolarity Questionnaire scores (0–20). The y-axis shows sensitivity and specificity values (0–1). Sensitivity is plotted separately for BD-I in orange, BD-II in yellow, bipolar disorder with mixed features (BP-MX) in green, and bipolar disorder not otherwise specified (BP-NOS) in turquoise, as well as for the total bipolar disorder group in red. Specificity is shown in blue.\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Fig.6SensitivityandspecificityoftheBipolarityQuestionnaireindiagnosingdifferentsubtypesofbipolardisorderbasedondifferentcutoffvalues.png","url":"https://assets-eu.researchsquare.com/files/rs-7685744/v1/b49f18d00d1654e41cc030df.png"},{"id":101839207,"identity":"bfa94204-0221-470d-afef-f8c5965f1003","added_by":"auto","created_at":"2026-02-04 08:11:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2591375,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7685744/v1/7d3ab746-9dce-4b0b-b295-174122a7163c.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Bipolarity Questionnaire: Preliminary Construction of a Screening Questionnaire for Bipolar Disorder","fulltext":[{"header":"Introduction","content":"\u003cp\u003eBipolar disorder (BD) is a prevalent mental health condition with a global lifetime prevalence of 2.4% [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Despite its prevalence, clinical management of BD is impeded by high incidence of misdiagnosis, underdiagnosis and delayed diagnosis. The current gold standard for diagnosing bipolar disorder relies on structured interviews to ascertain the history of manic or hypomanic episodes, which exhibit high specificity but a low sensitivity [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. To address these limitations, researchers have developed screening tools such as the Mood Disorder Questionnaire (MDQ) [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e] and the 32-item Hypomania Checklist (HCL-32) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, initial studies found that the sensitivity of these scales was significantly reduced by items related to the course and severity of the disease. Both scales have since been revised to screen for BD by assessing whether there have been sufficient number of manic symptoms in the past[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Although the revised versions are of good reliability and validity in BD screening, they do not fully capture the essential characteristics of the disorder as originally intended. In addition, screening tools developed specifically for and by Chinese populations are not yet available and are appropriate for use in China.\u003c/p\u003e\u003cp\u003eThe aim of this study is to develop a screening questionnaire for BD based on the Chinese population which will focus on the key features of polarity and symptom instability.\u003c/p\u003e"},{"header":"Methods","content":"\u003ch3\u003eSubjects\u003c/h3\u003e\n\u003cp\u003eAll of the participants in this study were recruited from a clinical research project (Project No.: YHJH201805) under the \"Yuanhang Plan\" at the Third Affiliated Hospital of Sun Yat-sen University. The participants were patients who visited the psychiatric outpatient or inpatient department of the Third Affiliated Hospital of Sun Yat-sen University between October 17, 2018 and June 30, 2020, and who met the following criteria: (1) are currently meet the DSM-5 criteria for major depressive episode; (2) are between the age of 18 and 65; (3) have at least a middle school education and are able to complete the questionnaire; (4) have signed informed consent.\u003c/p\u003e\u003cp\u003e The study protocol was approved by the Ethics Committee of the Third Affiliated Hospital of Sun Yat-sen University (Ethics Approval No.: 2018-02-207-01). All participants provided written informed consent and agreed to participate in the study.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eTheoretical Framework of the Questionnaire\u003c/h2\u003e\u003cp\u003eBipolar disorder, also known as manic depression, is a mental illness characterized by extreme mood swings, including emotional highs (mania or hypomania) and lows (depression). Although there is no universally accepted definition, the most widely recognized features are the bipolarity and instability of symptoms. Bipolarity refers to two contrasting symptoms experienced by people with bipolar disorder: mania and depression. Instability describes the variability and unpredictability of symptoms. Moreover, the timing of mood episodes in bipolar disorder is not in a linear pattern, meaning that there is no predictable pattern to when a person may move from a depressive episode to a manic episode, or vice versa [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Finally, from a cross-sectional perspective, symptoms of bipolar disorder are not always present in parallel, which means that not all symptoms occur at the same time and that severity may vary [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Therefore, the screening tool for bipolar disorder should be capable of reflecting the above-mentioned features of this disorder.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eItems Pool and Draft Construction of the Scale\u003c/h3\u003e\n\u003cp\u003eDrawing from previous mania and depression scales, as well as the diagnostic criteria for depressive and manic episodes, the items in this scale consist of 21 pairs of corresponding symptoms of mania and depression. The scale emphasizes the inter-temporal alternation of these symptoms, but does not specify the length or frequency of the cycles of manic and depressive symptoms.\u003c/p\u003e\n\u003ch3\u003eResearch Procedure\u003c/h3\u003e\n\u003cp\u003eFirst, an initial evaluation of the patient is performed by an outpatient physician to determine if the patient meets the inclusion criteria for the study. If a patient is eligible, the physician refers him/her to the staff of the research team, who then verify that the patient meets the inclusion and exclusion criteria. Patients meeting these criteria are given written informed consent is obtained, and a questionnaire is distributed. After the patient completes the self-assessment questionnaire, the researchers conduct a structured interview using the Chinese version of SCID-P, focusing on sections relating to manic or hypomanic episodes, depressive episodes, and atypical depressive symptoms. In addition, a custom questionnaire is used to collect clinical information, including the age at which the patient started, the course of the disease, type of mood episodes, their duration (focus on the most severe episode), the number of episodes, the type of current episode, the history of medication, and the response to treatment.\u003c/p\u003e\n\u003ch3\u003eDiagnosis Confirmation\u003c/h3\u003e\n\u003cp\u003eIn order to improve the accuracy of the final clinical diagnosis, all patients enrolled are followed for as long as possible, aiming at least 6 months and at least 3 follow-ups (the number of follow-up visits may be reduced in patients who are hospitalized or have previously been diagnosed with bipolar disorder). The monitoring shall include the following indicators:\u003c/p\u003e\u003cp\u003e(1) (hypo)manic or mixed episodes: clinical observation and information from informants are used to evaluate the presence of (hypo)manic or mixed episodes during ambulatory monitoring or hospitalization.\u003c/p\u003e\u003cp\u003e(2) Response to diagnostic therapy: Patients diagnosed with depression are treated with antidepressants without mood stabilizers (e.g. lithium, anticonvulsants, or second-generation antipsychotics) as much as possible at the time of entry. In patients with bipolar disorder, mood stabilizers should be used as widely as possible without the use of antidepressants. All enrolled patients may be prescribed concomitant sedative-hypnotic medicinal products. Follow-up measures the patient\u0026rsquo;s response to antidepressants or mood stabilizers:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eIf a patient responds well to antidepressant monotherapy (with or without sedative-hypnotics) for 6 months, this supports the diagnosis of depression.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e- if, on the other hand, the patient experiences a switch to mania or mixed episode following treatment with antidepressant, the diagnosis of bipolar disorder is confirmed.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eIn addition, if the patient does not respond to antidepressant treatment but has responded to six months of mood stabilizers, this is also evidence for bipolar disorder.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eEffective treatment is defined as a patient who shows sustained improvement in symptoms over follow-up (with a clinical global impression severity score\u0026thinsp;\u0026lt;\u0026thinsp;4 on the last two consecutive visits and a less than 3 score of efficacy index on each visit from the second visit) without the need for medication from the opposite treatment group (no mood stabilizers in the depression group, no antidepressants in the bipolar group).\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eBased on the patient's medical history, follow-up observations and the results of diagnostic therapy, two attending or senior psychiatrists will make the final diagnosis of each patient based on the DSM-5 diagnostic criteria for major depressive disorder and bipolar disorder.\u003c/p\u003e\n\u003ch3\u003eQuality Control\u003c/h3\u003e\n\u003cp\u003eThe researchers who were responsible for conducting the clinical diagnostic interviews in this study were all members from the same clinician team. Before the study began, the two psychiatrists responsible for final diagnosis received a month of training in the field of diagnostic consistency. After the training, they independently diagnosed 40 patients with bipolar disorder, and achieved a diagnostic concordance rate of 0.975.\u003c/p\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Methods\u003c/h2\u003e\u003cp\u003eStatistical analysis was carried out with SPSS 22.0 software. To evaluate whether the data follow a normal distribution, the Kolmogorov-Smirnov test was applied. Data following a normal distribution were expressed as median (interquartile range), and the Mann-Whitney U comparison was made between groups. Data following a normal distribution were expressed as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (x\u0026thinsp;\u0026plusmn;\u0026thinsp;s), and comparisons between groups were done by t-test. The categorical data were expressed in terms of frequencies and percentages and the comparisons between the groups was made by the means of the χ\u0026sup2; test. The Cronbach\u0026rsquo;s alpha was used to assess the internal consistency reliability of the scales and the confirmatory factor analysis was employed to evaluate the structural validity of the scales. The questionnaire screening performance was evaluated by plotting ROC curves. Sensitivity and specificity were calculated for each theoretically possible cut-off, and linear interpolation was used to calculate the sensitivity and specificity for each of the true positive response rates. The optimal threshold was determined by maximizing the Youden index (=\u0026thinsp;sensitivity\u0026thinsp;+\u0026thinsp;specificity \u0026minus;\u0026thinsp;1).\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003eSensitivity is the percentage of genuinely positive cases correctly detected by a screening test, which reflects the patient detection capability of the test. Sensitivity\u0026thinsp;=\u0026thinsp;number of true positives and number of gold-standard positives.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSpecificity refers to the percentage of genuinely negative cases correctly identified by the screening test, which reflects its ability to detect non-patients. Specificity\u0026thinsp;=\u0026thinsp;number of true negatives and number of gold-standard negatives.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eThe Youden index, also known as the accuracy index, measures the overall ability of a screening method to detect real patients and false patients. The Yield Index\u0026thinsp;=\u0026thinsp;sensitivity\u0026thinsp;+\u0026thinsp;specificity \u0026minus;\u0026thinsp;1.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cp\u003eP-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant for the differences between the groups.\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003eDemographics and Clinical Characteristics of the subjects\u003c/h2\u003e\u003cp\u003eA total of 445 participants were enrolled in the study, including 345 with bipolar disorder (BD) and 100 with major depressive disorder (MDD). Among the bipolar cases, 11 cases of bipolar I disorder (BD-I), accounting for 3.2% (11/345); 181 cases of Bipolar II disorder (BD-II), accounting for 52.4% (181/345); 131 cases of bipolar disorder with mixed features, accounting for 38.0% (131/345); and 22 cases of unspecified types (BD-NOS), accounting for 6.4% (22/345).\u003c/p\u003e\u003cp\u003eAs shown in Table \u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, the BD group had a significantly higher mean age (t\u0026thinsp;=\u0026thinsp;5.395, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and younger age of onset (t\u0026thinsp;=\u0026thinsp;5.122, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and a lower proportion of men and women who were married compared to the MDD group (χ\u0026sup2; = 22.838, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The number of mood episodes was higher in the BD group than in the MDD group (Z\u0026thinsp;=\u0026thinsp;6.672, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). There were no significant differences between the groups in the proportion of women and men (χ\u0026sup2; = 0.032, P\u0026thinsp;=\u0026thinsp;0.902) or education level (t = -0.737, P\u0026thinsp;=\u0026thinsp;0.463).\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\u003eComparison of demographics and clinical characteristics between BD and MDD\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eItem\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e\u003cp\u003eBipolar Disorder Group\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBD-I(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;11)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBD-II(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;181)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBD-mixed(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;131)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eBD-NOS(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;22)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eTotal(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;345)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eMDD group(\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;100)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFemale [cases (%)]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e5(45.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e123(68.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e92(70.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e11(50.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e232(67.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e66(66.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarried [cases (%)]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3(27.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e55(30.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e27(20.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e5(22.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e90(26.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e52(52.0)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAge (years, x\u0026thinsp;\u0026plusmn;\u0026thinsp;\u003cem\u003es\u003c/em\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e30.4\u0026thinsp;\u0026plusmn;\u0026thinsp;16.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e28.3\u0026thinsp;\u0026plusmn;\u0026thinsp;11.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e25.9\u0026thinsp;\u0026plusmn;\u0026thinsp;9.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e27.4\u0026thinsp;\u0026plusmn;\u0026thinsp;12.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e27.3\u0026thinsp;\u0026plusmn;\u0026thinsp;11.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e34.8\u0026thinsp;\u0026plusmn;\u0026thinsp;12.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEducated years(x\u0026thinsp;\u0026plusmn;\u0026thinsp;\u003cem\u003es\u003c/em\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e12.1\u0026thinsp;\u0026plusmn;\u0026thinsp;3.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14.2\u0026thinsp;\u0026plusmn;\u0026thinsp;2.5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e13.9\u0026thinsp;\u0026plusmn;\u0026thinsp;2.7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e14.5\u0026thinsp;\u0026plusmn;\u0026thinsp;2.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e14.0\u0026thinsp;\u0026plusmn;\u0026thinsp;2.6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e13.7\u0026thinsp;\u0026plusmn;\u0026thinsp;3.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOnset age(years, x\u0026thinsp;\u0026plusmn;\u0026thinsp;s)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23.5\u0026thinsp;\u0026plusmn;\u0026thinsp;15.1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22.9\u0026thinsp;\u0026plusmn;\u0026thinsp;11.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e21.5\u0026thinsp;\u0026plusmn;\u0026thinsp;9.2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e23.1\u0026thinsp;\u0026plusmn;\u0026thinsp;11.0\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e22.4\u0026thinsp;\u0026plusmn;\u0026thinsp;10.4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e29.8\u0026thinsp;\u0026plusmn;\u0026thinsp;13.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNumber of past mood episodes [\u003cem\u003eM\u003c/em\u003e(\u003cem\u003eP\u003c/em\u003e\u003csub\u003e25\u003c/sub\u003e, \u003cem\u003eP\u003c/em\u003e\u003csub\u003e75\u003c/sub\u003e)]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e4(3, 6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4(3, 7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2(1, 5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2(1, 6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e3(2, 6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e2(1, 3)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003e\u003cem\u003eNote: M (P\u003c/em\u003e\u003csub\u003e\u003cem\u003e25\u003c/em\u003e\u003c/sub\u003e, \u003cem\u003eP\u003c/em\u003e\u003csub\u003e\u003cem\u003e75\u003c/em\u003e\u003c/sub\u003e\u003cem\u003e) represents the median (interquartile range)\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eScale Properties\u003c/h2\u003e\u003cdiv id=\"Sec12\" class=\"Section3\"\u003e\u003ch2\u003eInternal Consistency and Reliability of the Scale\u003c/h2\u003e\u003cp\u003eA reliability analysis was performed on a 21-item questionnaire and the results showed that the Cronbach's alpha value for the whole scale was 0.872. After the items 1\u0026ndash;21 have been incrementally deleted, the remaining Cronbach alpha scale ranges from 0.863 to 0.871. The correlation coefficient between the score of each item and the overall scale score ranged from 0.359 (item 10) to 0.557 (item 5) for all items.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eStructural Validity of the Scale\u003c/h2\u003e\u003cp\u003eThe questionnaire provided a basis for analyzing factors (see Table \u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Kaiser-Meier-Olkin (KMO) was 0.904 and the correlation coefficient was 2.396, df\u0026thinsp;=\u0026thinsp;210, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001. Using principal component analysis and varimax orthogonal rotation without restricting the number of factors, four factors with eigenvalues exceeding 1 were identified, resulting in a cumulative contribution to variance of 46.22 percent. According to the smoothing plot, the slope flattened after the fourth factor and therefore the number of coefficients was set at 4. Based on the content of the items, the four factors were identified as: social activity, emotional state, self-awareness, and instinctive activity. The coefficient loadings for each item ranged from 0.325 to 0.755, and with the exception of item 7, all items had coefficients above 0.4 (see Table \u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\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\u003eFrequency of scale items between the two groups and intergroup comparison\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"7\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eItem No.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eItem content\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e\u003cp\u003eBD\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;344)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eMDD\u003c/p\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;100)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eχ\u0026sup2;\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003ep value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eI sometimes feel very down, and at other times I feel very happy.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e87.50%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e62.00%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e33.778\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eI sometimes feel the future is full of hope, and other times I feel it is doomed.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e80.50%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e54.00%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e28.727\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eI sometimes feel completely worthless, and at other times I feel very confident.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e75.30%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e47.00%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e28.949\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eI sometimes feel the world is beautiful, and at other times I feel the world is dark and bleak.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e71.80%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e48.00%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e19.687\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eI sometimes feel physically exhausted and lacking energy, and at other times I feel full of energy and vitality.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e75.00%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e44.00%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e34.227\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eI sometimes feel sharp and quick-thinking, and at other times I feel slow and dull.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e74.70%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e51.00%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e20.497\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eI sometimes feel bold and decisive, and at other times I am very hesitant.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e70.90%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e50.00%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e15.813\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eMy interests shift between having none and having many.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e54.10%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e28.00%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e21.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eI sometimes binge eat, yet sometimes I can have little to no appetite for days.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e38.10%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e14.00%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e20.43\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eI sometimes feel little to no sexual interest, and at other times I experience a strong sex drive.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e43.60%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e26.00%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e10.036\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eSometimes I am an isolated introvert, other times I am an extrovert and life of the party.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e66.00%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e40.00%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e21.828\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eSometimes I spend money cautiously, other times I can go on reckless spending sprees.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e59.90%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e46.00%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e6.085\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.014\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eI go from being easily irritated by others to being warm and generous.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e52.60%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e40.00%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e4.933\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.026\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eI sometimes sleep only 3\u0026ndash;4 hours (or less) and don\u0026rsquo;t feel tired, and at other times I sleep excessively and still feel fatigued.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e58.70%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e31.00%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e23.874\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eI sometimes feel ambitious and full of plans, and at other times I procrastinate and struggle to get things done.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e81.10%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e59.00%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e20.83\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eI sometimes feel shy and tongue-tied, and at other times I feel charismatic and articulate.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e61.60%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e31.00%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e29.334\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eI sometimes feel I\u0026rsquo;m the luckiest person in the world, and sometimes I feel miserable and unfortunate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e68.90%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e44.00%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e20.667\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eSometimes I am forgetful and clumsy, other times I feel my memory is exceptional.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e45.30%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e30.00%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e7.498\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.006\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eSometimes I feel in control of my destiny, and at other times I feel powerless in the face of fate.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e53.20%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e39.00%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e6.247\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.012\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eI sometimes feel life is meaningless, and at other times I feel life is precious and worth living.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e64.80%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e48.00%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e9.223\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.002\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eI sometimes feel physically unwell, and at other times I feel full of life.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e71.50%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e49.00%\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e17.609\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"7\"\u003eBD\u0026thinsp;=\u0026thinsp;bipolar disorder; MDD\u0026thinsp;=\u0026thinsp;major depressive disorder.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\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\u003eResults of the Exploratory Factor Analysis\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\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\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u003cp\u003eItem No.\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e\u003cp\u003eComponent\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e.621\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.284\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.243\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.054\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e12\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e.591\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.073\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.055\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.316\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e.549\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.157\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.049\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.215\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e6\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e.525\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.210\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.386\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.047\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e.512\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.134\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.222\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.239\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e13\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e.492\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.027\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.141\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.303\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e.405\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.123\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.319\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.276\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e.325\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.133\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.294\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.151\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.013\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e.743\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.229\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.222\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.139\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e.731\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.160\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.120\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.301\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e.641\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.052\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.030\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.004\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e.571\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.349\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.278\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.414\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e.567\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.145\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.040\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.450\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e.466\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.144\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.016\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e17\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026minus;\u0026thinsp;.031\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.140\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e.739\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.105\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.192\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.234\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e.610\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.108\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.187\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.245\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e.569\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.060\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.380\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.013\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e.544\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e.041\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.154\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.034\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.092\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e.755\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.122\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.175\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.076\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e.610\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e.332\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e.166\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e.108\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e.466\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eSensitivity and Specificity of the Scale\u003c/h2\u003e\u003cp\u003e\u003cem\u003eFigure\u0026nbsp;1. ROC curve of BD-I vs. MDD. The AUC for BD-I is 0.689.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eFigure\u0026nbsp;2. ROC curve of BDII vs. MDD. The AUC for BD-II is 0.745.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eFigure\u0026nbsp;3. ROC curve of BD-mix vs MDD. The AUC for BD-mixed is 0.741.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eFigure\u0026nbsp;4. ROC curve of BD-NOS vs MDD. The AUC for BD-unspecified is 0.741.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eFigure\u0026nbsp;5. ROC curve of all BD vs MDD. The AUC for BD is 0.741.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eFor all figures: he x-axis represents 1 \u0026ndash; specificity, and the y-axis represents sensitivity. The blue line indicates the ROC curve and the red diagonal line represents chance level. AUC\u0026thinsp;=\u0026thinsp;area under the curve; BD\u0026thinsp;=\u0026thinsp;bipolar disorder; MDD\u0026thinsp;=\u0026thinsp;major depressive disorder; NOS\u0026thinsp;=\u0026thinsp;not otherwise specified.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eFigures 1\u0026ndash;5 show the ROCs for BD-I, BD-II, BD-MX, BD-NOS and total BD. Areas under the ROC curve (AUC) were 0.689, 0.745, 0.741, 0.741 and 0.741, suggesting that the Bipolarity Questionnaire is well-equipped to distinguish between different clinical subtypes of bipolar disorder and unipolar depression.\u003c/p\u003e\u003cp\u003e\u003cem\u003eFigure\u0026nbsp;6. Sensitivity and specificity of the Bipolarity Questionnaire in diagnosing different subtypes of bipolar disorder based on different cut-off values.\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003eThe x-axis shows Bipolarity Questionnaire scores (0\u0026ndash;20). The y-axis shows sensitivity and specificity values (0\u0026ndash;1). Sensitivity is plotted separately for BD-I in orange, BD-II in yellow, bipolar disorder with mixed features (BP-MX) in green, and bipolar disorder not otherwise specified (BP-NOS) in turquoise, as well as for the total bipolar disorder group in red. Specificity is shown in blue.\u003c/em\u003e\u003c/p\u003e\u003cp\u003eFigure 6 shows the sensitivity and specificity of the Bipolarity Questionnaire for the diagnosis of different subtypes of bipolar disorder based on different cut-off values. Further statistical analysis revealed that the optimal cut-off values for BD-I, BD-II, BD-MX, BD-NOS and total BD were 12, 12, 12, 10 and 11, respectively, when maximized by the Youden index. The corresponding sensitivity and specificity for these cut-off points were: 0.73 and 0.71 for BD-I, 0.66 and 0.71 for BD-II, 0.67 and 0.71 for BD-mixed, 0.84 and 0.58 for BD-NOS, and 0.71 and 0.65 for overall BD.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study found that the Bipolarity Questionnaire is reliable and valid for the identification and distinction of unipolar and bipolar depression. The internal consistency reliability is quite high (0.872) and comparable to the two standard bipolar disorder questionnaires, the MDQ (0.73\u0026ndash;0.91) [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] and the HCL-32 (0.82\u0026ndash;0.88) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. From a structural validity perspective, the Bipolarity Questionnaire generated a total of 4 factors with a cumulative variance contribution rate of 46.22%. Although this is not as ideal as 60% or more, and some items do not correspond to the theoretical factors, such as item 21, which should theoretically fall under factor 4\u0026mdash;instinctive activity, but which is actually in factor 1\u0026mdash;social activity. However, overall, its structural validity appears s to be better than that of HCL-32 (which has two factors and a cumulative variance contribution rate of 26.8%).\u003c/p\u003e\u003cp\u003eIn terms of validity, the positive response rates for each item of the Bipolarity Questionnaire are higher in patients with bipolar disorder than in those with unipolar depression. Further ROC analysis shows that the Bipolarity Questionnaire is highly sensitive (0.66\u0026ndash;0.84) and specific (0.58\u0026ndash;0.71) for the different subtypes of bipolar disorder, with corresponding AUC in the range of 0.689 to 0.741. Other studies summarized the sensitivity and specificity of the three standard diagnostic scales for bipolar disorder, namely the HCL-32, MDQ and the Bipolar Spectrum Diagnostic Scale (BSDS), based on 53 initial studies: 81%, 66%, and 69% for sensitivity, and 67%, 79%, and 86% for specificity, respectively [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. In a previous study using HCL-32 in the same subjects as this study [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e], the sensitivity and specificity of HCL-32 in BD-I, BD-II, BD-MX, BD-NOS, and total BD were 0.73 and 0.67, 0.66 and 0.67, 0.80 and 0.67, 0.70 and 0.67, and 0.70 and 0.67, respectively. This indicates that the sensitivity and specificity of the Bipolar Disorder Questionnaire are comparable to the HCL-32, MDQ, and BSDS.\u003c/p\u003e\u003cp\u003eAlthough emotional instability has long been regarded as a key pathological feature of bipolar disorder and is widely used in the screening, diagnosis, and prognostic evaluation of the disorder [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], in recent years there has been a growing emphasis on the energy/activity instability in bipolar diagnosis [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The study found that the instability and bipolarity of symptoms of bipolar disorder were reflected not only in emotions but also in various aspects such as energy, social interaction, interest in activities, cognition, self-awareness and instinctive activity. Moreover, many of the symptom items on the Bipolar Disorder Questionnaire, such as somatization and well-being, are not present in the earlier diagnostic tools. It therefore assesses a wide range of symptoms than previous screening tools based solely on emotional instability. This is the first self-assessment questionnaire to screen for bipolar disorder based solely on the bipolarity and instability of symptoms in both domestic and international contexts.\u003c/p\u003e\u003cp\u003eAlthough emotional instability has long been regarded as a core pathological feature of bipolar disorder and is widely used in screening, diagnosing, and prognostic assessment of the disorder [\u003cspan additionalcitationids=\"CR14\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], emphasis on the instability of energy/activity in the diagnosis of bipolar disorder is seen in recent years [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. This study found that the instability of symptoms in bipolar disorder and bipolarity is reflected not only in emotions but also in various aspects such as energy, social interactions, interest in activities, cognition, self-perception, and instinctive activities. Moreover, many symptom items in the Bipolarity Questionnaire, such as somatization and well-being, are absent in previous diagnostic tools. Therefore, it assesses a broader spectrum of symptoms compared to earlier screening tools developed solely based on emotional instability. To our knowledge, this is the first self-assessment questionnaire for screening bipolar disorder entirely based on symptoms of bipolarity and instability in both domestic and international contexts.\u003c/p\u003e\u003cp\u003eThis study also found that the Bipolarity Questionnaire demonstrates comparable sensitivity for BD-MX and BD-NOS as for BD-I and BD-II, although the threshold for BD-NOS is slightly lower, sacrificing some specificity. This finding contrasts with the higher sensitivity of the MDQ for BD-I and the higher sensitivity of the HCL-32 for BD-II [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. As emotional instability is observed not only during depressive or (hypo)manic episodes but also during periods of intermittent episodes or different subthreshold mood episodes [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e], the higher sensitivity of the Bipolarity Questionnaire for BD-MX and BD-NOS may be explained by this. In addition, the Bipolarity Questionnaire is easier to use than some other screening tools [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e] that require apps to record changes in mood or activity daily or weekly, Finally, unlike MDQ, HCL-32, and BSDS, which stress that all depressive and manic symptoms must be temporally synchronous (although this is not explicitly stated in the revised MDQ and HCL-32), the item arrangement deliberately allows for a disorderly sequence of depressive and manic symptoms. This is more in keeping with the complexity and uncertainty of temporal and spatial relationships of bipolar symptoms [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e], and corresponds to Kraepelin's definition of the condition as a manic-depressive disorder [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOne strength of this study is its large sample size, which ensures sufficient statistical power. Another strength of this study is that all cases were diagnosed not only through structured diagnostic interviews but also through clinical observation and follow-up, rather than relying solely on a single structured diagnostic interview. This approach not only enhances the diagnostic specificity of the depression sample but also allows for the inclusion of bipolar disorder cases that may be difficult to identify through structured diagnostic interviews alone. Consequently, the study sample becomes more clinically representative. However, limitations include the small sample size of BD-I and BD-NOS and the fact that all participants were recruited from the same psychiatric institution and all were currently experiencing depressive episodes. Therefore, further research is needed to determine whether this questionnaire is applicable to other populations, including the general population.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study protocol was approved by the Ethics Committee of the Third Affiliated Hospital of Sun Yat-sen University (Ethics Approval No.: 2018-02-207-01) and is conducted per accordance with the Declaration of Helsinki. All participants provided written informed consent and agreed to participate in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study is funded by the Third Affiliated Hospital of Sun Yat-Sen University\u0026rsquo;s Clinical Research Program (grant number: YHJH201805).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eZG designed the study, handled grant applications, conducted MSCI interviews, and reviewed the manuscript. YL was responsible for data entry, statistical analysis and drafting the manuscript. TY handled data curation and verification, manuscript editing and administration. XW administered HCL-32, conducted clinical follow-up, and established the final diagnoses. QZ was responsible for SCID-I/P interviews with participants, clinical follow-up, and establishing the final diagnoses. All authors reviewed and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe extend our sincere gratitude to all participants who contributed their time and insights to this study, as well as to the clinicians and researchers who provided expertise during the development and validation of the Bipolarity Questionnaire.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eMerikangas KR, Jin R, He JP, Kessler RC, Lee S, Sampson NA, Viana MC, Andrade LH, Hu C, Karam EG, et al. Prevalence and correlates of bipolar spectrum disorder in the world mental health survey initiative. Arch Gen Psychiatry. 2011;68(3):241\u0026ndash;51.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRegeer EJ, Kupka RW, Have MT, Vollebergh W, Nolen WA. Low self-recognition and awareness of past hypomanic and manic episodes in the general population. Int J Bipolar Disord. 2015;3(1):22.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGan Z, Liang X, Yang T, Wu X, Zhu Q, He H. An applied study of a modified semi-structured clinical interview in the diagnosis of bipolar disorder. Chin J psychiatry. 2023;56(2):114\u0026ndash;21.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHirschfeld RM, Williams JB, Spitzer RL, Calabrese JR, Flynn L, Keck PE Jr., Lewis L, McElroy SL, Post RM, Rapport DJ, et al. Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Am J Psychiatry. 2000;157(11):1873\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAngst J, Adolfsson R, Benazzi F, Gamma A, Hantouche E, Meyer TD, Skeppar P, Vieta E, Scott J. The HCL-32: towards a self-assessment tool for hypomanic symptoms in outpatients. J Affect Disord. 2005;88(2):217\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTwiss J, Jones S, Anderson I. Validation of the Mood Disorder Questionnaire for screening for bipolar disorder in a UK sample. J Affect Disord. 2008;110(1\u0026ndash;2):180\u0026ndash;4.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eYang HC, Yuan CM, Liu TB, Li LJ, Peng HJ, Liao CP, Rong H, Fang YR, Angst J. Validity of the 32-item Hypomania Checklist (HCL-32) in a clinical sample with mood disorders in China. BMC Psychiatry. 2011;11:84.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBonsall MB, Wallace-Hadrill SM, Geddes JR, Goodwin GM, Holmes EA. Nonlinear time-series approaches in characterizing mood stability and mood instability in bipolar disorder. Proc Biol Sci. 2012;279(1730):916\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMalhi GS, Irwin L, Hamilton A, Morris G, Boyce P, Mulder R, Porter RJ. Modelling mood disorders: An ACE solution? Bipolar Disord. 2018;20(Suppl 2):4\u0026ndash;16.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZivanovic O, Nedic A. Kraepelin's concept of manic-depressive insanity: one hundred years later. J Affect Disord. 2012;137(1\u0026ndash;3):15\u0026ndash;24.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGan Z, Han Z, Li K, Diao F, Wu X, Guan N, Zhang J. Validation of the Chinese version of the Mood Disorder Questionnaire for screening bipolar disorder among patients with a current depressive episode. BMC Psychiatry. 2012;12:8.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eCarvalho AF, Takwoingi Y, Sales PM, Soczynska JK, Kohler CA, Freitas TH, Quevedo J, Hyphantis TN, McIntyre RS, Vieta E. Screening for bipolar spectrum disorders: A comprehensive meta-analysis of accuracy studies. J Affect Disord. 2015;172:337\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMiklowitz DJ, Weintraub MJ, Singh MK, Walshaw PD, Merranko JA, Birmaher B, Chang KD, Schneck CD. Mood Instability in Youth at High Risk for Bipolar Disorder. J Am Acad Child Adolesc Psychiatry. 2022;61(10):1285\u0026ndash;95.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eO'Donnell LA, Ellis AJ, Van de Loo MM, Stange JP, Axelson DA, Kowatch RA, Schneck CD, Miklowitz DJ. Mood instability as a predictor of clinical and functional outcomes in adolescents with bipolar I and bipolar II disorder. J Affect Disord. 2018;236:199\u0026ndash;206.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBenazzi F, Akiskal HS. A downscaled practical measure of mood lability as a screening tool for bipolar II. J Affect Disord. 2005;84(2\u0026ndash;3):225\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFaurholt-Jepsen M, Busk J, Bardram JE, Stanislaus S, Frost M, Christensen EM, Vinberg M, Kessing LV. Mood instability and activity/energy instability in patients with bipolar disorder according to day-to-day smartphone-based data - An exploratory post hoc study. J Affect Disord. 2023;334:83\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFaurholt-Jepsen M, Frost M, Busk J, Christensen EM, Bardram JE, Vinberg M, Kessing LV. Differences in mood instability in patients with bipolar disorder type I and II: a smartphone-based study. Int J Bipolar Disord. 2019;7(1):5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eFaurholt-Jepsen M, Frost M, Busk J, Christensen EM, Bardram JE, Vinberg M, Kessing LV. Is smartphone-based mood instability associated with stress, quality of life, and functioning in bipolar disorder? Bipolar Disord. 2019;21(7):611\u0026ndash;20.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBjella TD, Collier Hoegh M, Holmstul Olsen S, Aminoff SR, Barrett E, Ueland T, Icick R, Andreassen OA, Nerhus M, Myhre Ihler H, et al. Developing MinDag - an app to capture symptom variation and illness mechanisms in bipolar disorder. Front Med Technol. 2022;4:910533.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSalvatore P, Baldessarini RJ, Centorrino F, Egli S, Albert M, Gerhard A, Maggini C. Weygandt's On the Mixed States of Manic-Depressive Insanity: a translation and commentary on its significance in the evolution of the concept of bipolar disorder. Harv Rev Psychiatry. 2002;10(5):255\u0026ndash;75.\u003c/span\u003e\u003c/li\u003e\u003c/ol\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":false,"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":"Bipolar disorder, diagnosis, self-report questionnaire, questionnaire properties","lastPublishedDoi":"10.21203/rs.3.rs-7685744/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7685744/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground \u003c/strong\u003eBipolar disorder (BD) is often underdiagnosed or misdiagnosed due to limitations in current diagnostic tools, which may not adequately capture the disorder’s defining characteristics, such as symptom polarity and instability. Existing self-report scales, like the MDQ and HCL-32, have limited sensitivity and are not culturally tailored to Chinese populations. To address this gap, a new self-report questionnaire was developed to aid in the differentiation between unipolar and bipolar depression, with an emphasis on broader symptom coverage.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e A 21-item self-rated questionnaire was drafted and administered to 445 patients with Major Depressive Disorder (MDD) or Bipolar Disorder (BD) confirmed by structural diagnostical interview according to DSM-5 and a at least 6-month follow-up. The internal consistency was assessed using Cronbach's alpha, structural validity was evaluated through confirmatory factor analysis, and the screening performance was determined using an ROC curve analysis.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults \u003c/strong\u003eThe Cronbach's coefficient for the entire questionnaire was 0.872. Exploratory factor analysis revealed four factors with a cumulative variance contribution of 46.22%. The questionnaire demonstrated good sensitivity (0.66-0.84) and specificity (0.58-0.71) for different BD subtypes, with AUC values ranging from 0.689 to 0.741.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion \u003c/strong\u003eThe Bipolarity Questionnaire is a reliable and valid tool for differentiating unipolar and bipolar depression, with a broader symptom assessment compared to existing tools.\u003c/p\u003e","manuscriptTitle":"Bipolarity Questionnaire: Preliminary Construction of a Screening Questionnaire for Bipolar Disorder","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-23 16:10:33","doi":"10.21203/rs.3.rs-7685744/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":"6e4c334c-9ff5-4896-bce7-1ffa2c361e9a","owner":[],"postedDate":"October 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-04T08:10:36+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-23 16:10:33","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7685744","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7685744","identity":"rs-7685744","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}