589601 research-article2015
JHI0010.1177/1460458215589601Health Informatics JournalWoo et al.
Article
Use of a smartphone application to screen for bipolar spectrum disorder in a community sample
Health Informatics Journal 1–10 © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1460458215589601 jhi.sagepub.com
Young Sup Woo and Won-Myong Bahk
Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
Jeongwan Hong
Department of Psychiatry, Namwon Sungil Mental Hospital, Namwon, Korea
Bo-Hyun Yoon
Department of Psychiatry, Naju National Hospital, Naju, Korea
Tae-Yeon Hwang
WHO Collaborating Center of Yongin Mental Hospital, Yongin, Korea
Moon-Doo Kim
Department of Psychiatry, College of Medicine, Jeju National University, Jeju, Korea
Duk-In Jon
Department of Psychiatry, College of Medicine, Hallym University, Anyang, Korea
Abstract This study describes the use of a smartphone application based on the Korean version of the Mood Disorder Questionnaire in screening for bipolar spectrum disorders in a large general population. All data were collected between May 2011 and July 2011. A total of 27,159 individuals participated in the survey, using a smartphone application. The prevalence of positive screening results for bipolar spectrum disorders among 27,159 participants using the smartphone Korean Mood Disorder Questionnaire application was 8.2 percent. These results are similar to traditional paper-based results. The Korean Mood Disorder Questionnaire positive group exhibited more frequent occurrences of previous psychiatric treatment than the group with negative results. In a logistic regression analysis involving subjects with past psychiatric history, age group
Corresponding author: Won-Myong Bahk, Department of Psychiatry, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 62, Yeouidodong, Yeoungdeungpogu, Seoul 150-713, Korea. Email: [email protected]
Downloaded from jhi.sagepub.com at Duke University Libraries on August 9, 2015
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significantly predicted Korean Mood Disorder Questionnaire results. The smartphone application may be a useful screening tool for bipolar spectrum disorders. This study included only individuals who actively participated, and thus, the possibility of a selection bias should be considered.
Keywords bipolar spectrum disorder, Korean Mood Disorder Questionnaire, mobile health, screening, smartphone
Introduction Bipolar disorder is a serious and relatively common psychiatric illness that is clinically associated with significant morbidity and mortality rates. The prevalence of typical bipolar I disorder is approximately 1 percent of the general population. However, recent research has suggested that bipolar spectrum disorders (BSD), including bipolar I disorder, bipolar II disorder, cyclothymic disorder, and bipolar disorder, not otherwise specified, are considerably more prevalent (3.0%–6.5%).1,2 The problems of misdiagnosis and underdiagnosis of BSD have been highlighted previously.1,3 Studies of depressed patients have found evidence that BSD patients are often misdiagnosed with other psychiatric disorders, particularly major depressive disorder; in addition, patients may be misdiagnosed with personality disorders, psychotic disorders, and anxiety disorders.4,5 Even among patients who are accurately diagnosed with BSD, the latency between the first experiences of symptoms and the correct diagnosis is often greater than 10 years,6,7 and the long duration of the untreated BSD may result in subsequent morbidity.8 Hence, there is substantial need for screening tools for BSD that have a high degree of sensitivity and specificity and that can be easily implemented. Several self-report screening questionnaires have been developed to detect BSD.9–12 The Mood Disorder Questionnaire (MDQ) is the most widely studied because it can be quickly and easily used to recognize BSD in a clinical setting with relatively good sensitivity and very good specificity.13,14 Comparison of the three most widely used self-report screening instruments—the MDQ, the bipolar spectrum diagnostic scale (BSDS),15 and the hypomanic checklist for BSD (HCL32)11—within a primary care or general population has shown that the highest degree of sensitivity was obtained with the BSDS, with the MDQ exhibiting the highest degree of specificity.16,17 A recent systematic review revealed that screening tests for bipolar disorder may include a high number of false positives;18 therefore, applying the MDQ, which exhibits the highest degree of specificity, may be desirable in screening for BSD. Several studies have used the MDQ to estimate the prevalence of BSD.2,19–21 However, previous studies within the general population or in a primary care setting have used traditional paper-based collection through mail or face-to-face communication. Using mail may be logistically easier than face-to-face evaluation; however, neither method is anonymous, leading to the possibility that subjects respond differently because they are aware that their identities are not concealed.22 Indeed, an anonymous survey resulted in a much higher prevalence of BSD in mental health screening.23 The rapid diffusion and accessibility of smartphones provides opportunities to enhance the screening of psychiatric illness within the general population with a greater degree of anonymity. According to a survey by the Korean Communications Commission,24 approximately 27 percent of adults in South Korea own and use a smartphone. Moreover, in one recent study, 50 percent of psychiatric patients indicated an interest in using an app on a daily basis to monitor their mental health,25 and another study has explored the role of mobile phone apps in screening for
Downloaded from jhi.sagepub.com at Duke University Libraries on August 9, 2015
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Woo et al.
depression.26 Given the accessibility of smartphones, further investigation of the role of smartphone apps in screening and monitoring psychiatric illness is likely to be useful. In this study, therefore, our purpose was to enhance the detection of BSD by developing and distributing a free Korean MDQ (K-MDQ) smartphone application that can be completed anonymously. We relied on a Korean translation of the MDQ whose validity has been established.27 The purpose of our study was to evaluate the feasibility of the MDQ application and to determine correlates for positive results on the MDQ with the aim of demonstrating that mental health screening can be done easily and reliably on a smartphone in a smartphone-using population.
Methods The K-MDQ includes three criteria. In Criterion 1, the K-MDQ screens for a lifetime history of manic or hypomanic symptoms, using 13 yes/no items. Criterion 2 queries whether several manic or hypomanic symptoms or behaviors have been experienced during the same period, and Criterion 3 assesses the functional impairment resulting from the illness on a 4-point scale (from “no” to “severe” problems).27 In this study, respondents were considered as testing positive for BSD when they provided “yes” responses to at least seven of the symptoms in Criterion 1, in addition to confirming that multiple symptoms clustered in the same time period (Criterion 2) and indicating that the symptoms caused “moderate” or “serious” problems (Criterion 3). We used the K-MDQ as the basis for a smartphone application that was developed in both Android and iOS versions. The iOS version was registered with the iPhone App Store on 12 May 2011, and the Android version was registered on the Android market on 5 May 2011. Data collection was performed on 11 July 2011. On the first page of the application, participants were informed that the information they submitted could be used for the purpose of academic or scientific research. Each item of the K-MDQ was presented sequentially one item at a time on the smartphone screen such that the next item did not appear if a score was not entered for the displayed item. Demographic data including age, sex, and past psychiatric treatment history were collected. The result of the screening test was made available to respondents. The internal consistency of the K-MDQ was determined, using Cronbach’s α. We performed a factor analysis to determine construct validity, extracting principal components using varimax rotation. To define the factors that were associated with a positive K-MDQ result, we compared the frequency of the K-MDQ positive rate between age groups and gender groups using a chi-squared test. In addition, we performed a logistic regression using gender, age group, and past psychiatric history as predictors and K-MDQ positive results as the dependent variable. All statistical tests were two-tailed with a significance level set at 0.05. Our Institutional Review Board reviewed and approved the protocol, and the study was conducted in accordance with sound clinical practices and the Helsinki Declaration. Our Institutional Review Board waived patient-specific informed consent for this confidential survey and the anonymous reporting of aggregate data.
Results Demographics characteristics Data from 27,159 participants were collected during the 2 months from 5 May 2011 to 11 July 2011. There were 17,985 downloads of the iPhone application and 3816 of the Android application. The majority of the subjects were female (74.6%) and between the ages of 10 and 29 years (75.0%). The demographic characteristics are presented in Table 1.
Downloaded from jhi.sagepub.com at Duke University Libraries on August 9, 2015
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Table 1. Demographic characteristics of respondents. Total (N = 27,159), N (%) Sex Male Female Age (years) 10–20 30–40 ⩾50
6894 (25.4) 20,265 (74.6) 20,362 (75.0) 6196 (22.8) 601 (2.2)
Table 2. Clinical characteristics of respondents. Past psychiatric history Sex Male Female Age group (years) 10–20 30–40 ⩾50
Significance
Presence (n = 2864)
Absence (n = 24,295)
722 (10.5%) 2142 (10.6%)
6172 (89.5) 18,123 (89.4)
1969 (9.7%) 687 (11.1%) 208 (34.6%)
18,393 (90.3%) 5509 (88.9%) 393 (65.4%)
0.821
JHI0010.1177/1460458215589601Health Informatics JournalWoo et al.
Article
Use of a smartphone application to screen for bipolar spectrum disorder in a community sample
Health Informatics Journal 1–10 © The Author(s) 2015 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1460458215589601 jhi.sagepub.com
Young Sup Woo and Won-Myong Bahk
Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
Jeongwan Hong
Department of Psychiatry, Namwon Sungil Mental Hospital, Namwon, Korea
Bo-Hyun Yoon
Department of Psychiatry, Naju National Hospital, Naju, Korea
Tae-Yeon Hwang
WHO Collaborating Center of Yongin Mental Hospital, Yongin, Korea
Moon-Doo Kim
Department of Psychiatry, College of Medicine, Jeju National University, Jeju, Korea
Duk-In Jon
Department of Psychiatry, College of Medicine, Hallym University, Anyang, Korea
Abstract This study describes the use of a smartphone application based on the Korean version of the Mood Disorder Questionnaire in screening for bipolar spectrum disorders in a large general population. All data were collected between May 2011 and July 2011. A total of 27,159 individuals participated in the survey, using a smartphone application. The prevalence of positive screening results for bipolar spectrum disorders among 27,159 participants using the smartphone Korean Mood Disorder Questionnaire application was 8.2 percent. These results are similar to traditional paper-based results. The Korean Mood Disorder Questionnaire positive group exhibited more frequent occurrences of previous psychiatric treatment than the group with negative results. In a logistic regression analysis involving subjects with past psychiatric history, age group
Corresponding author: Won-Myong Bahk, Department of Psychiatry, Yeouido St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, 62, Yeouidodong, Yeoungdeungpogu, Seoul 150-713, Korea. Email: [email protected]
Downloaded from jhi.sagepub.com at Duke University Libraries on August 9, 2015
2
Health Informatics Journal
significantly predicted Korean Mood Disorder Questionnaire results. The smartphone application may be a useful screening tool for bipolar spectrum disorders. This study included only individuals who actively participated, and thus, the possibility of a selection bias should be considered.
Keywords bipolar spectrum disorder, Korean Mood Disorder Questionnaire, mobile health, screening, smartphone
Introduction Bipolar disorder is a serious and relatively common psychiatric illness that is clinically associated with significant morbidity and mortality rates. The prevalence of typical bipolar I disorder is approximately 1 percent of the general population. However, recent research has suggested that bipolar spectrum disorders (BSD), including bipolar I disorder, bipolar II disorder, cyclothymic disorder, and bipolar disorder, not otherwise specified, are considerably more prevalent (3.0%–6.5%).1,2 The problems of misdiagnosis and underdiagnosis of BSD have been highlighted previously.1,3 Studies of depressed patients have found evidence that BSD patients are often misdiagnosed with other psychiatric disorders, particularly major depressive disorder; in addition, patients may be misdiagnosed with personality disorders, psychotic disorders, and anxiety disorders.4,5 Even among patients who are accurately diagnosed with BSD, the latency between the first experiences of symptoms and the correct diagnosis is often greater than 10 years,6,7 and the long duration of the untreated BSD may result in subsequent morbidity.8 Hence, there is substantial need for screening tools for BSD that have a high degree of sensitivity and specificity and that can be easily implemented. Several self-report screening questionnaires have been developed to detect BSD.9–12 The Mood Disorder Questionnaire (MDQ) is the most widely studied because it can be quickly and easily used to recognize BSD in a clinical setting with relatively good sensitivity and very good specificity.13,14 Comparison of the three most widely used self-report screening instruments—the MDQ, the bipolar spectrum diagnostic scale (BSDS),15 and the hypomanic checklist for BSD (HCL32)11—within a primary care or general population has shown that the highest degree of sensitivity was obtained with the BSDS, with the MDQ exhibiting the highest degree of specificity.16,17 A recent systematic review revealed that screening tests for bipolar disorder may include a high number of false positives;18 therefore, applying the MDQ, which exhibits the highest degree of specificity, may be desirable in screening for BSD. Several studies have used the MDQ to estimate the prevalence of BSD.2,19–21 However, previous studies within the general population or in a primary care setting have used traditional paper-based collection through mail or face-to-face communication. Using mail may be logistically easier than face-to-face evaluation; however, neither method is anonymous, leading to the possibility that subjects respond differently because they are aware that their identities are not concealed.22 Indeed, an anonymous survey resulted in a much higher prevalence of BSD in mental health screening.23 The rapid diffusion and accessibility of smartphones provides opportunities to enhance the screening of psychiatric illness within the general population with a greater degree of anonymity. According to a survey by the Korean Communications Commission,24 approximately 27 percent of adults in South Korea own and use a smartphone. Moreover, in one recent study, 50 percent of psychiatric patients indicated an interest in using an app on a daily basis to monitor their mental health,25 and another study has explored the role of mobile phone apps in screening for
Downloaded from jhi.sagepub.com at Duke University Libraries on August 9, 2015
3
Woo et al.
depression.26 Given the accessibility of smartphones, further investigation of the role of smartphone apps in screening and monitoring psychiatric illness is likely to be useful. In this study, therefore, our purpose was to enhance the detection of BSD by developing and distributing a free Korean MDQ (K-MDQ) smartphone application that can be completed anonymously. We relied on a Korean translation of the MDQ whose validity has been established.27 The purpose of our study was to evaluate the feasibility of the MDQ application and to determine correlates for positive results on the MDQ with the aim of demonstrating that mental health screening can be done easily and reliably on a smartphone in a smartphone-using population.
Methods The K-MDQ includes three criteria. In Criterion 1, the K-MDQ screens for a lifetime history of manic or hypomanic symptoms, using 13 yes/no items. Criterion 2 queries whether several manic or hypomanic symptoms or behaviors have been experienced during the same period, and Criterion 3 assesses the functional impairment resulting from the illness on a 4-point scale (from “no” to “severe” problems).27 In this study, respondents were considered as testing positive for BSD when they provided “yes” responses to at least seven of the symptoms in Criterion 1, in addition to confirming that multiple symptoms clustered in the same time period (Criterion 2) and indicating that the symptoms caused “moderate” or “serious” problems (Criterion 3). We used the K-MDQ as the basis for a smartphone application that was developed in both Android and iOS versions. The iOS version was registered with the iPhone App Store on 12 May 2011, and the Android version was registered on the Android market on 5 May 2011. Data collection was performed on 11 July 2011. On the first page of the application, participants were informed that the information they submitted could be used for the purpose of academic or scientific research. Each item of the K-MDQ was presented sequentially one item at a time on the smartphone screen such that the next item did not appear if a score was not entered for the displayed item. Demographic data including age, sex, and past psychiatric treatment history were collected. The result of the screening test was made available to respondents. The internal consistency of the K-MDQ was determined, using Cronbach’s α. We performed a factor analysis to determine construct validity, extracting principal components using varimax rotation. To define the factors that were associated with a positive K-MDQ result, we compared the frequency of the K-MDQ positive rate between age groups and gender groups using a chi-squared test. In addition, we performed a logistic regression using gender, age group, and past psychiatric history as predictors and K-MDQ positive results as the dependent variable. All statistical tests were two-tailed with a significance level set at 0.05. Our Institutional Review Board reviewed and approved the protocol, and the study was conducted in accordance with sound clinical practices and the Helsinki Declaration. Our Institutional Review Board waived patient-specific informed consent for this confidential survey and the anonymous reporting of aggregate data.
Results Demographics characteristics Data from 27,159 participants were collected during the 2 months from 5 May 2011 to 11 July 2011. There were 17,985 downloads of the iPhone application and 3816 of the Android application. The majority of the subjects were female (74.6%) and between the ages of 10 and 29 years (75.0%). The demographic characteristics are presented in Table 1.
Downloaded from jhi.sagepub.com at Duke University Libraries on August 9, 2015
4
Health Informatics Journal
Table 1. Demographic characteristics of respondents. Total (N = 27,159), N (%) Sex Male Female Age (years) 10–20 30–40 ⩾50
6894 (25.4) 20,265 (74.6) 20,362 (75.0) 6196 (22.8) 601 (2.2)
Table 2. Clinical characteristics of respondents. Past psychiatric history Sex Male Female Age group (years) 10–20 30–40 ⩾50
Significance
Presence (n = 2864)
Absence (n = 24,295)
722 (10.5%) 2142 (10.6%)
6172 (89.5) 18,123 (89.4)
1969 (9.7%) 687 (11.1%) 208 (34.6%)
18,393 (90.3%) 5509 (88.9%) 393 (65.4%)
0.821
