Interview Questionnaires

1. Evaluation of a Patient Presenting with Depression and Use of Screening Tools to Evaluate for Mania or Hypomania, Substance Abuse, and Suicide RiskJ. Sloan Manning, MDAdjunct Associate ProfessorUniversity of North Carolina–Chapel HillPrivate PracticeGreensboro, North Carolina

2. Interview Questionnaires

3. Patient Health Questionnaire 9 (PHQ-9) Name:Pauline Over the last 2 weeks, how often have you been bothered by any of the following problems? (use “” to indicate your answer) More than half the days Several days Nearly every day Not at all 1. Little interest or pleasure in doing things 0 1 2 3 2. Feeling down, depressed, or hopeless 0 1 2 3 3. Trouble falling or staying asleep, or sleeping too much 0 1 2 3 4. Feeling tired or having little energy 0 1 2 3 5. Poor appetite or overeating 0 1 2 3 6. Feeling bad about yourself–or that you are a failure or have let yourself or your family down 0 1 2 3 7. Trouble concentrating on things such as reading the newspaper or watching television 0 1 3 2 8. Moving or speaking so slowly that other people could have noticed. Or the opposite–being so fidgety or restless that you have been moving around a lot more than usual 0 1 2 3 9. Thoughts that you would be better off dead, or of hurting yourself in some way 0 1 2 3 Total 21 10. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home or get along with other people? Not difficult at all Somewhat difficult Very difficult Extremely difficult  Kroenke K, et al. J Gen Intern Med. 2001;16:606-613

4. Generalized Anxiety Disorder 7 (GAD-7) Name:Pauline Over the last 2 weeks, how often have you been bothered by any of the following problems? (use “” to indicate your answer) More than half the days Nearly every day Several days Not at all 1. Feeling nervous, anxious or on edge 0 2 3 1 2. Not being able to stop or control worrying 0 1 2 3 3. Worrying too much about different things 0 1 2 3 4. Trouble relaxing 0 1 2 3 5. Being so restless that it is hard to sit still 0 1 2 3 6. Becoming easily annoyed or irritable 0 2 3 1 7. Feeling afraid as if something awful might happen 0 1 2 3 18 Total Spitzer R, et al. Arch Int Med. 2006;166:1092-1097.

5. Evaluation of Suicide Risk for Clinicians Patient Name: Pauline • Suicide Screening Questions • When you make a diagnosis of unipolar of bipolar depression, suicide risk requires assessment. Ask the following progressive questions. If question 1 is negative and suspicion is low, you can skip the subsequent questions. • Questions to assess thoughts of suicide • Risk factors for suicide1 (VERDICT UTHSCSA) YES NO Have these symptoms/feelings (of depression) we’ve been talking about led you to think you might be better off dead? This past week, have you had any thoughts that life is not work living or that you’d be better off dead? What about thoughts about hurting or even killing yourself? If “Yes”, go to question 4. If “No”, stop. 4. What have you thought about? Have you actually done anything to hurt yourself? X X X 1. Suicide Risk as designated by the faculty and staff of South Texas Veterans Healthcare Systems and the University of Texas Health Care Service Center. (VERDICT UTHSCSA) Hopelessness Substance abuse Prior suicide attempts X Caucasian race X Family history of suicide attempts Medical illness Male gender Psychosis Family history of substance abuse Advanced age Access to means Living alone

6. Evaluation of Suicide Risk for Clinicians (cont) • Assessment of Suicide Risk and Action Plan • Description of Patient Symptoms • No current thoughts; no major • risk factors • (Major Risks are BOLDED above) • Current thoughts, but no plans • With or without risk factors • Current thoughts with plans Level of Risk Action Continue follow-up visits and monitoring Low Assess suicide risk carefully at each visit and contract with patient to call you if suicide thoughts become more prominent. Consult with mental health specialist as needed. Intermediate XX Emergency management by qualified expert High STABLE Toolkit. http://www.cqaimh.org/pdf/STABLE_toolkit.pdf. Accessed June 2011.

7. Mood Disorder Questionnaire Patient Name: Pauline

8. Mood Disorder Questionnaire (MDQ) Scoring • A positive screen for possible bipolar disorder includes the following: • YES to at least 7 of the 13 items in Question #1 • AND • YES to Question #2 • AND • ‘Moderate Problem’ or ‘Serious Problem’ for Question #3 • The MDQ is for screening purposes only • A comprehensive evaluation should follow a positive screen • In primary care • Sensitivity: 58% • Specificity: 93% Hirschfeld RM, et al. Am J Psychiatry. 2000;157:1873-1875. Hirschfeld RM, et al. J Clin Psychiatry Prim Care Comp. 2002;4:9-11. Hirschfeld RM, et al. J Am Board FamPract. 2005;18:233-239. STABLE Toolkit. http://www.cqaimh.org/pdf/STABLE_toolkit.pdf. Accessed June 2011.

9. WHO CIDI 3.0Clinician-Administered Screening Tool Patient Name: Pauline Euphoria Stem Question 1. Some people have periods lasting several days when they feel much more excited and full of energy than usual. Their minds go too fast. They talk a lot. They are very restless or unable to sit still and they sometimes do things that are unusual for them, such as driving too fast or spending too much money. Have you ever had a period like this lasting several days or longer? Irritability Stem Question 2. Have you ever had a period lasting several days or longer when most of the time you were so irritable or grouchy that you started arguments, shouted at people or hit people? Criterion B Screening Question 3. People who have episodes like this often have changes in their thinking and behavior at the same time, like being more talkative, needing very little sleep, being very restless, going on buying sprees, and behaving in many ways they would normally think inappropriate. Did you ever have any of these changes during your episodes of being excited and full of energy or very irritable or grouchy? Yes [If this question is endorsed, the next question (the irritability stem question) is skipped and the respondent goes directly to the Criterion B screening question] Yes Kessler R, et al. J Affect Disord. 2006;96:259-269.

10. WHO CIDI 3.0 Bipolar Screening Scales Scoring The complete set of 12 Questions takes approximately three minutes to complete 2 Stem questions: Questions 1 & 2 Respondents who fail to endorse either of these first two questions are skipped out of the remainder of the question series • 1 Criterion B Screening Question: Question 3 • Respondents who fail to endorse this question after endorsing one of the • first two stem questions (above) are skipped out of the remainder of the • question series • Respondents who do endorse this question are then administered the 9 • additional symptom questions • Note: In a general population sample, it can be expected that as many as 90% of the sample will skip out by the end of this third question Kessler R, et al. J Affect Disord. 2006;96:259-269..

11. WHO CIDI 3.0Clinician-Administered Screening Tool (cont) Patient Name: Pauline • Criterion B Symptom Questions • Think of an episode when you had the largest number of changes like these at the same time. During that episode, which of the following changes did you experience? • Were you so irritable that you either started arguments, shouted at people, or hit people? • The first symptom question is asked only if the euphoria stem question (#1 above) is endorsed. • Did you become so restless or fidgety that you paced up and down or couldn’t stand still? • Did you do anything else that wasn’t usual for you – like talking about things you would normally keep private, or acting in ways that you would usually find embarrassing? • Did you try to do things that were impossible to do, like taking on large amounts or work? • Did you constantly keep changing your plans or activities? • Did you find it hard to keep you mind on what you were doing? • Did your thoughts seem to jump from one thing to another or race through your head so fast you couldn’t keep track of them? • Did you sleep far less than usual and still not get tired or sleepy? • Did you spend so much more money than usual that it caused you to have financial trouble? No Yes Yes Yes Yes Yes Yes Yes Yes Kessler R, et al. J Affect Disord. 2006;96:259-269..

12. WHO CIDI 3.0 Bipolar Screening Scales Scoring (cont) • 9 Criterion B Symptom Questions • Each of the 9 symptom questions are administered • Note: The first question in this group is asked only if the first Stem Question is endorsed. If this scenario occurs, then only the 8 remaining symptom questions would be administered. Very high risk (80% or more) 9 questions with positive endorsement High risk (50-79%) 7-8 questions with positive endorsement Moderate risk (25-49%) 6 questions with positive endorsement Low risk (5-24%) 5 questions with positive endorsement Very low risk (less than 5%) 0-4 questions with positive endorsement Diagnosis based on the screening scales have excellent concordance with diagnoses based on the full WHO Composite International Diagnostic Interview (CIDI 3.0). CIDI Diagnoses, in turn, have excellent concordance with clinical diagnoses based on blinded SCID clinical appraisal interviews.

13. AUDIT-C Name:Pauline AUDIT-C Questionnaire • 1. How often do you have a drink containing alcohol? • Never • Monthly or less • 2-4 times a month • 2-3 times a week • 4 or more times a week • How many standard drinks containing alcohol do you have on a typical day? • 1 or 2 • 3 or 4 • 5 or 6 • 7 to 9 • 10 or more • How often do you have six or more drinks on one occasion? • Never • Less than monthly • Monthly • Weekly • Daily or almost daily

14. AUDIT-C Scoring • Each question is scored according to the following point allotment: a: 0 points b: 1 point c: 2 points d: 3 points e: 4 points • For men, a score of ≥ 4 is considered positive; optimal for identifying heavy drinking or active alcohol use disorders • For women, a score of ≥ 3 is considered positive • When the points are from Question #1 only, and the responses for Questions #2 and 3 are ‘a’ (point value 0), the individual’s drinking behavior is considered below recommended limits • A higher score on the AUDIT-C is generally associated with greater likelihood that drinking is impacting the patient’s safety Bush K, et al. Arch Int Med. 1998;158(16):1789-1795. STABLE Toolkit. http://www.cqaimh.org/pdf/STABLE_toolkit.pdf. Accessed June 2011.

15. Mixtures of Manic and Depressed Symptoms are Commonly Seen Dysphoric Mania Depressive Mixed States1 Mixed Mania Full Mania Full Mania 2+ Mania Symptoms Mania MDE 2+ Depressive Symptoms Full MDE Full MDE MDE = major depressive episode 1. BenazziF. Psychiatry Res. 2004;127:247-257. 2. MajM, et al. Am J Psychiatry. 2003;160:2134-2140. 3. AkiskalHS, et al. J Affect Disord. 2005;85:245-258. Agitated depressions? 2,3

16. Factors Distinguishing Bipolar and Unipolar Depression Manning JS. Prim Care Companion J Clin Psychiatry. 2010;12(S1):17-22.

17. Key Elements Differential Diagnosis: Bipolar Disorder or Unipolar Depression? 1. Family History Higher rates of psychiatric illness Positive for bipolar disorder 5. Mania SymptomsDistractibility, decreased need for sleep, grandiosity, racing thoughts, increased activities, pressured speech, persistent irritable mood, thoughtlessness 2. Course of Illness Age of first mood disturbance < age 25 Greater severity of episodes Higher frequency of episodes Marked seasonality 3. Treatment Response Multiple treatment failures Non-response or erratic response to antidepressants 4. Associated FeaturesUnevenness in intimate relationships Frequent career changes Substance use disorders Adapted from the American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. Text Revision. Washington, DC: American Psychiatric Association; 2000:345-428.

18. Critical Take Away In its most common expression, bipolar disorder is a depressive illness. Manic or hypomanic episodes may be discrete and relatively pure, but are often mixed with depressed mood.