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The "Bipolarity Index" 

This system has recently been described in an article by Harvard's Director of the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD), Dr. Gary Sachs.  It represents a "clinical" diagnostic approach -- what matters to doctors and patients when they are trying to understand a particular patient's mood problems. Unlike a DSM-based diagnostic system which emphasizes separate diagnostic categories, the Bipolarity Index places patients on a spectrum.  As you'll see, it also emphasizes diagnostic features other than hypomania.  


Dr. Sachs' system was developed with several colleagues at Harvard, including Dr. Nassir Ghaemi, whose name you will find mentioned frequently on this website, as he is a well-known researcher of this "spectrum" way of looking at bipolar diagnosis.

The system considers 5 "dimensions" of bipolarity.  Note that the presence of hypomania or mania is only one of the five dimensions. All the others receive equal weight, for now (the system has not been subjected to the usual tests a "diagnostic instrument" would receive; thus we do not yet know how much weight each of these 5 dimensions should carry): 

  1. Hypomania or mania

  2. Age of onset of first mood symptoms

  3. Illness course and other features generally only visible over time 

  4. Response to medications (antidepressants and mood stabilizers)

  5. Family history of mood and substance use problems

For now, until we know better how to "weight" each of these dimensions for greatest predictive power (e.g. regarding which medications to use, or how symptoms will show up in the future), each dimension is  worth up to 20 points (for a maximum possible score of 100), as follows: 

Dimension

20 points

15 points

10 points

5 points

2 points

Episode Characteristics

Manic symptoms with "prominent euphoria, grandiosity or expansiveness". 

Manic symptoms with dysphoria, irritability

Hypomanic symptoms; or mania following an antidepressant

Hypomanic symptoms following an antidepressant; or hypomania below DSM threshold; or major soft signs: atypical or postpartum depression

Psychosis, without other signs of mania

Age of Onset

15-19

<15 or 20-30

30-45

>45

--

Illness Course (and Other Features)

Manic episodes separated by periods of full recovery

Incomplete recovery between manic episodes; or hypomania with full recovery between episodes

Mania, incomplete recovery, but also substance use; or psychosis only during mood episodes; or legal problems associated with mania

Repeated episodes of unipolar depression, no hypomania (3 or more); or hypomania with incomplete recovery between episodes; or any of several other features: borderline; anxiety disorder; ADHD as a child; gambling or other risk behaviors without mania per se; or PMS

Hyperthymic temperament; >3 marriages, or two jobs in two years; or two advanced degrees (see Akiskal reference on these latter features)

Response to Medications

Full recovery within 4 weeks of treatment with mood stabilizers

Full recovery within 12 weeks of treatment; or relapse within 12 weeks of stopping mood stabilizers; or switch to mania within 12 weeks of starting antidepressant

Worsening dysphoria or mixed state symptoms during antidepressant; or partial response to mood stabilizers; or antidepressant induced rapid cycling or worsening thereof

Lack of response to 3 or more antidepressants; or mania/hypomania when antidepressant stopped

Immediate  response, almost complete, to antidepressant within 1 week or less

Family History

1st degree relative (brother/sister, parent, or child) with clear bipolar disorder

2nd degree relative with bipolar diagnosis; or 1st degree relative with recurring unipolar depression and features suggestive of bipolar disorder

1st degree relative with recurring unipolar depression or schizoaffective disorder; or any relative with clear bipolar diagnosis; or any other relative with unipolar depression and symptoms suggestive of bipolar

1st degree relative has clear problem with drugs or alcohol

1st degree relative has repeated episodes of depression; or has an anxiety disorder, an eating disorder, or ADHD

Dr. Sachs' article indicates that in their experience so far, most Bipolar I patients score above 60.  Note that's Bipolar I, not Bipolar II or other more subtle variations, which would presumably have lower scores. Notice that a patient can "get points" for many different features of bipolarity, not just hypomania or mania.  In fact, she could get 60 points even without any history of hypomania or mania at all, you see? For example, she might have had: her first depression at age 18 (20 points); post-partum depression (5 points); more than 3 episodes of depression (5 points); agitation while taking an antidepressant (10 points); and have a sister with clear bipolar disorder (20 points).  

But beyond this -- Bipolar I patients score above 60 -- we do not yet know what a particular "score" might mean.  Therefore this table is not offered to help you score patients (or yourself).  It is presented to demonstrate that some of the most respected mood experts in the world are now using a system which approaches bipolar disorders as existing on a "spectrum", rather than a yes/no, you-have-it-or-you-don't matter. Dr. Sachs himself explains this in an interview conducted shortly after this article, excerpted here.  To see the Harvard version of this "Bipolarity Index", see page 13 of their Affective Disorders Evaluation.

If after all this you still want a "fine-tooth comb" to look for hypomanic/manic symptoms -- only 1/5th of the points here, but still the major diagnostic feature in the official DSM system -- here is a 32-item checklist of such symptoms.