CQAIMH - center for quality assessment and improvement in mental health


Depression: Screening for bipolar mania/hypomania prior to treatment for depression


This measure assesses the percentage of patients presenting with depression who were assessed, prior to the initiation of treatment, for the presence of prior or current symptoms and/or behaviors associated with mania or hypomania.

Clinical Rationale:

Bipolar Disorder is an episodic illness with a variable course: 

  • It is generally a lifetime condition associated with significant disability
  • It is frequently unrecognized, underdiagnosed, and thus, not treated appropriately

Recognition Considerations

  • Depressive episodes are the frequent presenting characteristics of both major depressive disorder and bipolar disorder
  • Symptomatic bipolar disorder patients spend, on average, 33% of their time in a depressive phase compared to about 11% of their time in a manic/hypomanic phase (1)
  • Bipolar patients report considerable distress associated with their depressive symptoms and seek treatment for depression (2)
  • Bipolar depressive episodes are not only more numerous but, on average, also last longer than a patient’s manic or hypomanic episodes (3)
  • Patients generally do not recognize or spontaneously report prior episodes of hypomania as these periods may be considered as normal happiness or well-being (4)
  • The most common incorrect diagnosis associated with bipolar disorder is unipolar depression (5)

Denominator Population:

Patients diagnosed and treated for unipolar depression

Data Sources:

  • Administrative data
  • Medical Record

Numerator Population:

Patients who receive an assessment, prior to treatment for unipolar depression, that includes consideration of current and/or prior manic or hypomanic symptoms or behaviors

Data Source:

  • Medical Record

Initial Case-finding Guidance:

Patients with a diagnosis involving unipolar depression
ICD9CM or DSM IV TR:  296.2x; 296.3x; 300.4 or 311

STABLE Resource Toolkit:

The following instruments are recommended by the STABLE National Coordinating Council for use in screening for bipolar disorder.  The tools are available in the corresponding section of the STABLE Resource Toolkit.

  • Mood Disorders Questionnaire (MDQ):  Brief self-report tool
  • CIDI-based Bipolar Disorder Screening Scale: Brief clinician-administered tool


  1. Post RM, Calabrese JR, Bipolar depression: the role of atypical antipsychotics; Expert Rev. Neurother. 2004 Nov; 4 (6 Suppl 2): S27-33
  2. Angst J, Do many patients with depression suffer from bipolar disorder?; Can. J Psychiatry, vol. 51, Jan 2006 3-6
  3. Thase MD, Bipolar depression: issues in diagnosis and treatment, Harv. Rev. Psychiatry, 2005 Spt-Oct; 13 (5): 257-71
  4. Berk M, Dodd S, Bipolar II disorder: a review, Bipolar Disorders 2005: 7: 11-21
  5. Kupfer DJ, Emerging therapies for bipolar depression, J Clin Psychiatry 67:7, July 2006 1140-1151

Copyright 2007 by the Center for Quality Assessment and Improvement in Mental Health