研究背景
雙極症(bipolar disorder)是一種嚴重且失能的精神疾病，涵蓋了一大群臨床表現，其主要特徵為情緒失調、特定的冒險行為、衝動表現、人際關係障礙以及憂鬱症狀。雙極症患者自殺嘗試行為(suicide attempt)的終生盛行率甚至可高達百分之25至50，且有百分之10至15患者在沒有接受適當治療的情況下會因自殺而死亡，或在病程初期延遲使用情緒穩定劑也可能會增加自殺可能性，並使患者的功能及症狀惡化。以往對於雙極症的病程研究發現，第二型雙極症患者較第一型雙極症患者有較長的發病時期、更容易產生快速週期特性、病程較為慢性、較常發作憂鬱期、社會心理功能的損害與所消耗的心理衛生資源也較多。此外，第二型雙極症患者也常合併極高的自殺風險、有較致命性的自殺方式與較高的自殺成功率。但是就目前的臨床情境而言，雙極症的錯誤診斷與不當治療極為常見，尤其對第二型雙極症患者來說，以往的研究顯示可能需花費近12年的時間才能得到正確診斷與治療。如何提高對躁鬱症患者的正確診治率，以減低其自殺風險，已是一刻不容緩的議題。

研究目的
本研究擬翻譯由Angst等人(2005)所編製的32項目輕躁症狀自評量表(Hypomania Check List-32 item, HCL-32)，進行此量表之信、效度等計量分析，並建立篩選標準值(cut-off point)，以協助臨床工作者對雙極症患者的正確診治。並將比較先前HCL-32之量表驗證研究結果。

研究方法
本研究收取於精神科門診追蹤或住院之第一型雙極症、第二型雙極症及單極型憂鬱症患者。在正式收取案例前，將先取得Angst同意，將32項目輕躁症狀自評量表進行雙向翻譯及量表預試工作。在經由精神科專科醫師進行初步評估、可進入研究之臨床個案，將先填寫中文版HCL-32，之後以中文化終生精神疾病診斷晤談手冊（Schedule for Affective Disorder and Schizophrenia-Lifetime, SADS-L)確定DSM-IV診斷。本研究中擬採用已獲得目前實徵研究支持的最少兩天標準作為診斷第二型雙極症患者時的輕躁期持續時間準則。最後將進行中文版HCL-32之因素分析、信效度分析，評估此量表的區辨力、建立篩選標準值，並探討個案的心情及情緒症狀是否影響其HCL-32的填答表現。

研究結果
本研究共收取306位臨床個案，其中有4位患者在後續的診斷晤談中發現達到物質濫用/依賴準則，另有17位患者因填答並不完整，因此他們的資料未列入中文版HCL-32的分析中。最後納入量表分析的患者共有285位，其中單極型憂鬱症為51位、第一型雙極症有94位、第二型雙極症有140位。研究結果顯示中文版HCL-32有極佳的內部一致性，且也支持其他HCL-32版本研究中所發現的二因素結構－過動/高亢（active/elated）與冒險/易怒（risk-taking/irritable），但與DSM-IV診斷僅達顯著的低相關（γ = 0.244）。此量表亦可有效區辨出雙極症及單極型憂鬱症、第二型雙極症及單極型憂鬱症患者，對於第一型雙極症及第二型雙極症患者亦具有可接受的區辨力。而在14分的標準篩選值下，此量表在區辨雙極症與單極型憂鬱症患者的敏感度為0.80、精確度為0.73、正向預測值為0.93、負向預測值為0.45，在區辨第二型雙極症與單極型憂鬱症患者的敏感度為0.77、精確度為0.73、正向預測值0.89、負向預測值0.74；而在以21分作為區辨第一型與第二型雙極症患者的標準下，此量表之敏感度為0.63、精確度為0.74、正向預測值為0.61、負向預測值為0.75。最後，本研究發現躁期症狀的嚴重度與HCL-32量表總得分呈現顯著的正相關、處於（輕）躁期個案的量表得分顯著高於處於憂鬱期及緩解期案例（p值皆小於0.01），但漢氏憂鬱量表的總分與中文版HCL-32量表總分未達顯著相關、且憂鬱期及緩解期個案表現亦未達顯著差異。

研究討論
本量表具有極佳的內部一致性、敏感度、正向預測值與尚可的精確度，不過負向預測值卻偏低，且與DSM-IV診斷僅達顯著低相關，此可能與本研究中單極型憂鬱症組案例數仍過少有關。此外，本研究發現個案在量表的填答反應上可能會受到當時躁期症狀的影響。不過，由於HCL-32是為協助臨床工作者從處於憂鬱期個案中找出可能曾經有過輕躁狀態的雙極症患者（因為輕躁/躁期症狀較容易被發現），故此發現對HCL-32的實用性影響較小。

研究限制
由於本研究中之單極型憂鬱症案例數過少，往後仍需要積極收取更多的單極型憂鬱症患者來確定中文版HCL-32協助一般門診情境中的臨床工作者及早正確診治雙極症患者之可行性。

Background: Bipolar disorder is a serious and disabling psychiatric disease, encompassing a wide range of clinical features, characterized by emotional dysregulation, specific risk-taking behaviors, impulsivity, impaired interpersonal relationship and depressive symptoms. Previous studies on course of bipolar disorder showed that patients with bipolar II (BP II) had longer duration of symptomatic period, more rapid-cycling features, more chronic course of illness, more depressive episodes, more psychosocial impairment and greater use of mental health services compared to those with bipolar I disorder. Moreover, high suicide risk, more lethal suicidality and higher rates of complete suicide were found in BP II patients; the prevalence rate of suicide attempt in BPII was as high as the range of 25% and 50%, and without appropriate treatment about 10% to 15% BP II patients would die of suicide. Delaying the use of mood stabilizers at the beginning of the course would also increase suicide risk, deteriorate symptoms and worsen patients' function. In current clinical practice, misdiagnosis and inappropriate treatment of bipolar disorder is very common; especially for BP II, studies displayed that it took 12 years for these patients to receive the correct diagnosis and treatment. Thus in order to lower the suicide risk of BP, how to enhance the correct diagnostic rate of these patients demands immediate attention. The recognition of (hypo)manic episodes is essential for the correct diagnosis of BP. The Hypomania CheckList (HCL-32) is developed to increase the detection of suspected or manifest but mistreated BP cases. We aimed to determine the accuracy and validity of the Chinese version of the HCL-32 in an adult psychiatric setting. We also compared the results with prior studies carried out in a comparable sample.

Methods: Patients suffering from mood disorders completed the HCL-32 before being interviewed with the Schedule for Affective Disorder and Schizophrenia-Lifetime (SADS-L) to make DSM-IV diagnosis. The 4 day duration criterion for hypomania was replaced by a 2-day cut-off for BPII. The internal consistency and discriminatory capacity of the HCL-32 were analyzed.

Results: Of the 306 individuals enrolled, 21 were excluded due to comorbid substance abuse/ dependence (n=4), refusal or inability to fill out the HCL-32 (n=17). Thus, the study included 94 patients with BPI, 140 with BPII and 51 with unipolar depression for further statistical analyses. Results indicated high internal consistency of the Chinese version of the HCL-32. The dual factor structure was confirmed. A score of 14 or more on the HCL-32 total scale distinguished between BP and MDD yielding a sensitivity of 80% and specificity of 73%. This scale also distinguished between BPI and BPII with a sensitivity of 63% and a specificity of 74% for the cut-off score of 21.

Limitations: The sample size of MDD patients needs to be increased.

Conclusions: The Chinese HCL-32 is a useful screening tool for BP in a psychiatric setting. Its performance is also comparable to that reported in previous studies.

柯慧貞，孫苑庭，林木芬，葉宗烈，陸汝斌（民88）：由行為抑制探討婦女焦慮與憂慮之共病機制。台灣精神醫學，第14卷，第1期，13~21頁。
柯慧貞（民89）國人犯罪行為之分類。行政院國科會專題計畫申請書。
胡海國 (民88)。精神醫學診斷手冊（胡海國編著），健康文化事業股份有限公司出版。
Aalto-Setala T, Haarasilta L, Marttunen M et al. (2002) Major depressive episode among young adults: CIDI-SF versus SCAN consensus diagnoses. Psychol Med 32(7):1309-14.
Akiskal HS (1996) The prevalent clinical spectrum of bipolar disorders: beyond DSM-IV. J Clin Psychopharmacol 16 (suppl1): 4S-14S.
Akiskal HS, Pinto O (1999) The evolving bipolar spectrum. Prototypes I, II, III, and IV. Psychiatr Clin North Am 22(3):517-34, vii.
Akiskal HS, Bourgeois ML, Angst J et al. (2000) Re-evaluating the prevalence of and diagnostic composition within the broad clinical spectrum of bipolar disorders. J Affect Disord 59 (Suppl1):S5-S3.
Akiskal HS (2002a) The bipolar spectrum--the shaping of a new paradigm in psychiatry. Curr Psychiatry Rep 4(1):1-3.
Akiskal HS (2002b) Classification, diagnosis and boundaries of bipolar disorders: a review. In: Maj M, Akiskal HS, Lopez-Ibor JJ, Satorius N (eds) Bipolar disorder. John Wiley&Sons, Ltd, Chichester, UK, pp 1-52.
Akiskal HS, Hantouche EG, Allilaire JF (2003) Bipolar II with and without cyclothymic temperament: “dark” and “sunny” expressions of soft bipolarity. J Affect Disord 73: 49–57.
Alloy LB, Flannery-Schroeder E, Safford S et al. (1999) Lifetime comorbidity in 17-24 year olds with bipolar spectrum disorders. Bipolar Disorders 1: 22.
American Psychiatric Association (2000) Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). American Psychiatric Association, Washington, DC.
American Psychiatric Association (2002) Practice guidelines for the treatment of patients with bipolar disorder (revision). Am J Psychiatry 159(suppl):1-50.
Andreasen NC, Grove WM, Shapiro RW et al. (1981) Reliability of lifetime diagnosis. A multicenter collaborative perspective. Arch Gen Psychiatry 38(4):400-5.
Angst J (1998) The emerging epidemiology of hypomania and bipolar II disorder. J Affect Disord 50(2-3):143-51.
Angst J, Sellaro R, Angst F (1998) Long-term outcome and mortality of treated versus untreated bipolar and depressed patients: a preliminary report. Int J Psychiatry Clin Pract 2:115-119.
Angst J, Gamma A (2002) In Update on maintenance treatments for bipolar disorder. A data given approach.Barcelona Spain, 6th October 2002, pp. 4-5.
Angst J, Gamma A, Benazzi F et al. (2003a) Diagnostic issues in bipolar disorder. European Neuropsychopharmacology 13 Suppl 2:S43-50.
Angst J, Gamma A, Benazzi F et al. (2003b) Toward a re-definition of subthreshold bipolarity: epidemiology and proposed criteria for bipolar-II, minor bipolar disorders and hypomania. J Affect Disord 73(1-2):133-46.
Angst J, Adolfsson R, Benazzi F et al. (2005) The HCL-32: Towards a self-assessment tool for hypomanic symptoms in outpatients. J Affect Disord 88(2):217-33.
Arato M, Demeter E, Rihmer Z et al. (1988) Retrospective psychiatric assessment of 200 suicides in Budapest. Acta Psychiatr Scand 77(4):454-6.
Baldessarini RJ (2000) A plea for integrity of the bipolar disorder concept. Bipolar Disord 2(1):3-7.
Baldessarini RJ, Tondo L, Floris G et al. (2000) Effects of rapid cycling on response to lithium maintenance treatment in 360 bipolar I and II disorder patients. J Affect Disord 61(1-2):13-22.
Barraclough B, Bunch J, Nelson B et al. (1974) A hundread cses of suicide: clinical aspects. Br J Psychiatry 125: 355-73.
Bauer MS, Crits-Christoph P, Ball WA et al. (1991) Independent assessment of manic and depressive symptoms by self-rating. Scale characteristics and implications for the study of mania. Arch Gen Psychiatry 48: 807-812.
Benazzi F (2001) Is 4 days the minimum duration of hypomania in bipolar II disorder? Eur Arch Psychiatry Clin Neurosci 251:32-4.
Benazzi F (2003a) Improving the mood disorder questionnaire to detect bipolar II disorder. (Letter to the editor). Can J Psychiatry 48: 770-771.
Benazzi F (2003b) Bipolar II disorder and major depressive disorder: continuity or discontinuity? World J Biol Psychiatry 4: 166-171.
Benazzi F (2004) Toward better probing for hypomania of bipolar-II disorder by using Angst's checklist. International Journal of Methods in Psychiatric Research 13(1):1-9.
Benazzi F, Akiskal HS (2003) The dual factor structure of self-rated MDQ hypomania: energized-activity versus irritable-thought racing. J Affect Disord 73(1-2):59-64.
Benazzi F, Akiskal H (2006) The duration of hypomania in bipolar-II disorder in private practice: methodology and validation. J Affect Disord 96(3):189-96.
Benazzi F, Helmi S, Bland L (2002) Agitated depression: unipolar? bipolar? or both? Ann Clin Psychiatry 14: 97-104.
Boerlin HL, Gitlin MJ, Zoellner LA et al. (1998) Bipolar depression and antidepressant-induced mania: a naturalistic study. J Clin Psychiatry 59(7): 374-9.
Bottlender R, Jager M, Strauss A et al. (2000) Suicidality in bipolar compared to unipolar depressed inpatients. Eur Arch Psychiatry Cini Neurosci 250: 257-61.
Bowden CL (2001) Strategies to reduce misdiagnosis of bipolar depression. Psychiatric Service 52: 51-55.
Brugha TS, Bebbington PE, Jenkins R et al. (1999) Cross validation of a general population survey diagnostic interview: a comparison of CIS-R with SCAN ICD-10 diagnostic categories. Psychol Med 29(5):1029-42.
Carta MG, Hardoy MC, Cadeddu M et al. (2006) The accuracy of the Italian version of the Hypomania Checklist (HCL-32) for the screening of bipolar disorders and comparison with the Mood Disorder Questionnaire (MDQ) in a clinical sample. Clin Pract Epidemol Ment Health 8(2): 2.
Cassano GB, Akiskal HS, Savino M et al. (1992) Proposed subtypes of bipolar II and related disorders: with hypomanic episodes (or cyclothymia) and with hyperthymic temperament. J Affect Disord 26: 127-40.
Cassano GB, Rucci P, Frank E et al. (2004) The mood spectrum in unipolar and bipolar disorder: arguments for a unitary approach. Am J Psychiatry 161(7):1264-9.
Cassidy F, Forest K, Murry E et al. (1998) A factor analysis of the signs and symptoms of mania. Arch Gen Psychiatry 55(1):27-32.
Cattell RB (1966). The scree test for the number of factors. Multivariate Behavioral Research 1: 245-276.
Cheng ATA (1995) Mental illness and suicide: a case-control study in East Taiwan. Arch Gen Psychiatry 52: 594-603.
Cheng ATA, Chen HS, Chen CC et al. (2000) Psychosocial and psychiatric risk factors of suicide: a case-control psychological autopsy study. Brit J Psychiat 177: 360-365.
Coryell W, Endicott J, Maser JD et al. (1995) Long-term stability of polarity distinctions in the affective disorders. Am J Psychiatry 152: 385–390.
Coryell W (1999) Bipolar II disorder: the importance of hypomania. In: Goldberg JF, Harrow M (Eds), Bipolar Disorders. Clinical Course and Outcome. American Psychiatric Press, Washington, DC, pp-219-236.
Cronbach LJ (1951) Coefficient alpha and the internal structure of tests. Psychometrika 16: 297-334.
Depue RA, Slater JF, Wolfstetter-Kausch H et al. (1981) A behavioral paradigm for identifying persons at risk for bipolar depressive disorder: a conceptual framework and five validation studies. J Abnorm Psychol 90: 381-437.
Dunner DL, Tay LK (1993) Diagnostic reliability of the history of hypomania in bipolar II patients and patients with major depression. Compr Psychiatry 34(5):303-7.
Dunner DL (1998) Diagnostic revisions for DSM-IV. In: Goodnick PL (ed), Mania. Clinical and research perspectives. American Psychiatric Press, Washington, DC, pp3-10.
Eaton WW, Neufeld K, Chen LS et al. (2000) A comparison of self-report and clinical diagnostic interviews for depression: diagnostic interview schedule and schedules for clinical assessment in neuropsychiatry in the Baltimore epidemiologic catchment area follow-up. Arch Gen Psychiatry 57(3):217-22.
Eckblad M, Chapman LJ (1986) Development and validation of a scale for hypomanic personality. J Abnorm Psychol 95(3): 214-22.
Elgie R, Morselli PL (2007) Social functioning in bipolar patients: the perception and perspective of patients, relatives and advocacy organizations - a review. Bipolar Disord 9(1-2):144-57.
Endicott J, Spitzer RL (1978) A diagnostic interview: the schedule for affective disorders and schizophrenia. Arch Gen Psychiatry 35(7): 837-44.
Foster T, Gillespie K, McClelland R et al. (1999) Risk factors for suicide independent of DSM-III-R Axis I disorder. Case-control psychological autopsy study in Northern Ireland. Br J Psychiatry 175:175-9.
Geiselmann B, Bauer M (2000) Subthreshold depression in the elderly: qualitative or quantitative distinction? Compr Psychiatry 41:32-38.
Gelenberg AJ, Kane JM, Keller MB (1989) Comparison of standard and low serum levels of lithium for maintenance treatment of bipolar disorders. New England Journal of Medicine 321: 1489-1493.
Ghaemi SN, Stoll AL, Pope HG Jr. (1995) Lack of insight in bipolar disorder. The acute manic episode. J Nerv Ment Dis 183(7):464-7.
Ghaemi SN, Sachs GS, Chiou AM et al. (1999) Is bipolar disorder still underdiagnosed? Are antidepressants overutilized? J Affect Disord 52(1-3):135-44.
Ghaemi SN, Boiman EE, Goodwin FK (2000) Diagnosing bipolar disorder and the effect of antidepressant: a naturalistic study. J Clin Psychiatry 61(10): 804-808.
Ghaemi SN, Ko JY, Goodwin FK (2002) "Cade's disease" and beyond: misdiagnosis, antidepressant use, and a proposed definition for bipolar spectrum disorder. Can J Psychiatr 47(2):125-34.
Ghaemi SN, Rosenquist KJ (2004) Is insight in mania state-dependent?: A meta-analysis. J Nerv Ment Dis 192(11):771-5.
Gladstone GL, Mitchell PB, Parker G et al. (2001) Indicators of suicide over 10 years in a specialist mood disorders unit sample. J Clin Psychiatry 62(12):945-51.
Goldberg JF, Ernst CL (2002) Features associated with the delayed initiation of mood stabilizers at illness onset in bipolar disorder. J Clin Psychiatry 63(11):985-91.
Goodwin FK, Jamison K (1990) Manic-Depressive Illness. New York, NY: Oxford University Press Inc; pp. 56.
Goodwin G (2002) Hypomania: what's in a name? Br J Psychiat 181:94-5.
Hamilton M (1960) "A rating scale for depression". J Neurol Neurosurg Psychiatry 23: 56-62.
Hamilton M (1967) "Development of a rating scale for primary depressive illness". Br J Soc Psychol 6: 278-296.
Hantouche EG, Akiskal HS, Lancrenon S et al. (1998) Systematic clinical methodology for validating bipolar-II disorder: data in mid-stream from a French national multi-site study (EPIDEP). J Affect Disord 50:163-173.
Hantouche EG, Angst J, Akiskal HS (2003) Factor structure of hypomania: interrelationships with cyclothymia and the soft bipolar spectrum. J Affect Disord 73 (1–2): 39–47.
Harman HH (1976) Modern Factor Analysis. University of Chicago Press, Chicago.
Helzer JE, Robins LN, McEvoy LT et al. (1985) A comparison of clinical and diagnostic interview schedule diagnoses. Physician reexamination of lay-interviewed cases in the general population. Arch Gen Psychiatry. 42(7):657-66.
Henriksson MM, Aro HM, Marttunen MJ et al. (1993) Mental disorders and comorbidity in suicide. Am J Psychiatry 150(6):935-40.
Hirschfeld RM, Williams JB, Spitzer RL et al. (2000) Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire. Am J Psychiatry 157(11):1873-5.
Hirschfeld RMA, Lewis L, Vornik LA (2003a) Perceptions and impact of bipolar disorder: How far have we really come? Results of the National Depressive and Manic-Depressive Association 2000 Survey of individuals with bipolar disorder. J Clin Psychiatry 64: 161-174.
Hirschfeld RMA, Calabrese JR, Weissman MM et al. (2003b) Screening for bipolar disorder in the community. J Clin Psychiatry 64: 53-59.
Hirschfeld RMA, Holzer C, Calabrese JR et al. (2003c) Validity of the mood disorder questionnaire: a general population study. (brief report). Am J Psychiatry 160: 178-180.
Huang CL, Yang YK, Chen M et al. (2003) Patient-and Family-Rated Scale for Bipolar Disorder Symptoms: Internal State Scale. The Kaohsiung Journal of Medical Sciences 19:4:170-176.
Huang SY, Lin WW, Ko HC et al. (2004) Possible interaction of alcohol dehydrogenase and aldehyde dehydrogenase genes with the dopamine D2 receptor gene in anxiety-depressive alcohol dependence. Alcohol Clin Exp Res 28(3):374-84.
Hunter EE, Powell BJ, Penick EC et al. (2000) Development and validation of a mania scale for the Symptom Checklist 90. J Nerv Ment Dis 188:176-179.
Judd LL, Akiskal HS, Schettler PJ et al. (2002) The long-term natural history of the weekly symptomatic status of bipolar I disorder. Arch Gen Psychiatry 59: 530-537.
Judd LL, Akiskal HS (2003) The prevalence and disability of bipolar spectrum disorders in the US population: re-analysis of the ECA database taking into account subthreshold cases. J Affect Disord 73(1-2):123-31.
Judd LL, Akiskal HS, Schettler PJ et al. (2003a) The comparative clinical phenotype and long term longitudinal episode course of bipolar I and II: a clinical spectrum or distinct disorders?. J Affect Disord 73:19-32.
Judd LL, Akiskal HS, Schettler PJ et al. (2003b) A prospective investigation of the natural history of the long-term weekly symptomatic status of bipolar II disorder. Arch Gen Psychiatry 60(3):261-9.
Judd LL, Akiskal HS, Schettler PJ et al. (2005) Psychosocial disability in the course of bipolar I and II disorders: a prospective, comparative, longitudinal study. Arch Gen Psychiatry 62(12):1322-30.
Keck PE (2004) Defining and improving response to treatment in patients with bipolar disorder. J Clin Psychiatry 65 Suppl: 25-9.
Keck PE Jr, McElroy SL, Arnold LM (2001) Bipolar disorder. Med Clin North Am 85(3): 645-61.
Keller MB, Lavori PW, McDonald-Scott P et al. (1981) Reliability of lifetime diagnoses and symptoms in patients with a current psychiatric disorder. Journal of Psychiatric Research 16(4):229-40.
Kupfer DJ, Frank E, Grouchocinski VJ et al. (2002) Demographic and clinical characteristics of individuals in a bipolar disorder case registry. J Clin Psychiatry 63: 120-125.
Leverich GS, Altshuler LL, Frye MA et al. (2003) Factors associated with suicide attempts in 648 patients with bipolar disorder in the Stanley Foundation Bipolar Network. J Clin Psychiatry 64(5):506-15.
Lish JD, Dime-Meenan S, Whybrow PC et al. (1994) The National Depressive and Manic-depressive Association (DMDA) survey of bipolar members. J Affect Disord 31(4):281-94.
MacQueen GM, Young LT (2001) Bipolar II disorder: symptoms, course, and response to treatment. Psychiatr Serv 52(3): 358-61.
Magill CA (2004) The boundary between borderline personality disorder and bipolar disorder: current concepts and challenges. Can J Psychiatry 49(8):551-6.
Mago R (2001) Bipolar disorder questionnaire. (Letter to the editor). Am J Psychiatry 158: 1743.
Mantere O, Suominen K, Leppamaki S et al. (2004) The clinical characteristics of DSM-IV bipolar I and II disorders: baseline findings from the Jorvi Bipolar Study (JoBS). Bipolar Disord 6(5):395-405.
Mazure C, Gershon ES (1979) Blindness and reliability in lifetime psychiatric diagnosis. Arch Gen Psychiatry 36(5):521-5.
McCombs JS, Ahn J, Tencer T et al. (2007) The impact of unrecognized bipolar disorders among patients treated for depression with antidepressants in the fee-for-services California Medicaid (Medi-Cal) program: a 6-year retrospective analysis. J Affect Disord 97(1-3):171-9.
Merikangas KR, Stevens DE, Fenton B et al. (1998) Co-morbidity and familial aggregation of alcoholism and anxiety disorders. Psychol Med 28:773-788.
Meyer B, Johnson SL, Carver CS (1999) Exploring behavioral activation and inhibition sensitivities among college students at risk for bipolar-spectrum symptomatology. Journal of Psychopathology and Behavioral Assessment 212: 275-292.
Meyer B, Johnson SL, Winters R (2001) Responsiveness to threat and incentive in bipolar disorder: Relations of the BIS/BAS scales with symptoms. Journal of Psychopathology and Behavioral Assessment 23: 133-143.
Meyer TD, Hautzinger M (2003) Screening for bipolar disorders using the hypomanic personality scale. J Affect Disord 75:149-154.
Meyer TD, Hammelstein P, Nilsson LG et al. (2007). The Hypomania Checklist (HCL-32): its factorial structure and association to indices of impairment in German and Swedish nonclinical samples. Compr Psychiatry: 48(1):79-87.
Michaelis BH, Goldberg JF, Singer TM et al. (2003) Characteristics of first suicide attempts in single versus multiple suicide attempters with bipolar disorder. Compr Psychiatry: 44(1):15-20.
Michalakeas A, Skoutas C, Charalambous A et al. (1994) Insight in schizophrenia and mood disorders and its relation to psychopathology. Acta Psychiatr Scand 90(1):46-9.
Miller CJ, Klugman J, Berv DA et al. (2004) Sensitivity and specificity of the Mood Disorder Questionnaire for detecting bipolar disorder. J Affect Disord 81(2):167-71.
Murphy JM, Monson RR, Olivier DC et al. (1987) Affective disorders and mortality. A general population study. Arch Gen Psychiatry 44(5):473-80.
Nierenberg AA, Stephan MG, Grandin LD (2001) Mood disorders and suicide. J Clin Psychiatry 62(25): 27-30.
Ösby U, Brandt L, Correia N et al. (2001) Excess mortality in bipolar and unipolar disorder in Sweden. Arch Gen Psychiatry 58(9): 844-50.
Perugi G, Akiskal HS, Lattanzi L et al. (1998) The high prevalence of "soft" bipolar (II) features in atypical depression. Compr Psychiatry 39:63-71.
Perugi G, Maremmani I, Toni C et al. (2001) The contrasting influence of depressive and hyperthymic temperaments on psychometrically derived manic subtypes. Psychiatry Res 101(3):249-58.
Piver A, Yatham LN, Lam RW (2002) Bipolar spectrum disorders. New perspectives. Canadian Family Physician. 48:896-904.
Potash JB, DePaulo JR Jr. (2000) Searching high and low: a review of the genetics of bipolar disorder. Bipolar Disorders 2(1):8-26.
Rice JP, McDonald-Scott P, Endicott J et al. (1986) The stability of diagnosis with an application to bipolar II disorder. Psychiatry Res 19(4):285-96.
Rihmer Z, Barsi J, Arato´ M et al. (1990) Suicide in subtypes of primary major depression. J Affect Disord 18: 221–225.
Rihmer Z, Kiss K (2002) Bipolar disorders and suicidal behaviour. Bipolar Disord 4 Suppl 1:21-5.
Rihmer Z, Pestality P (1999) Bipolar II disorder and suicidal behavior. Psychiatric Clinics of North America. 22(3):667-73, ix-x.
Robins E, Murphy GE, Wilkinson RH et al. (1959) Some clinical considerations in the prevention of suicide based on a study of 134 successful suicides. Am J Public Health 49:888-899.
Robins LN, Reiger DA, eds. (1991) Psychiatric Disorders in America: The Epidemilogical Catcament Area Study. New York, MY: Free Press.
Scott J (2001) Overcoming mood swings. Constable Robinson, London. pp. 21-36.
Serretti A, Rietschel M, Lattuada E et al. (1999) Factor analysis of mania. Arch Gen Psychiatry 56(7):671-2.
Shaffer D, Gould MS, Fisher P et al. (1996) Psychiatric diagnosis in child and adolescent suicide. Arch Gen Psychiatry 53(4):339-48.
Shugar G, Schertzer S, Toner BB et al. (1992) Development, use, and factor analysis of a self-report inventory for mania. Compr Psychiatry 33:325-331.
Simpson SG, McMahon FJ, McInnis MG et al. (2002) Diagnostic reliability of bipolar II disorder. Arch Gen Psychiatry. 59(8):736-40.
Suppes T, Leverich GS, Keck PE et al. (2001) The Stanley Foundation Bipolar Treatment Outcome Network. II. Demographics and illness characteristics of the first 261 patients. J Affect Disord 67(1-3): 45-59.
Swann AC, Bowden CL, Calabrese JR et al. (1999) Differential effect of number of previous episodes of affective disorder on response to lithium or divalproex in acute mania. Am J Psychiatry 156: 1264-1266.
Szadoczky E, Papp Z, Vitrai J et al. (1998) The prevalence of major depressive and bipolar disorders in Hungary. Results from a National Epidemiologic Survey. J Affect Disord 50:153-162.
Tanney BL (2000) Psychiatric diagnoses and suicidal acts. In: Maris RW, Berman AL, Silverman MM eds. Comprehensive textbook of suicidology. New York: Guilford Press. pp.311-41.
Tondo L, Baldessarini RJ, Hennen J et al. (1998) Lithium maintenance treatment of depression and mania in bipolar I and bipolar II disorders. Am J Psychiatry. 155(5):638-45.
Tondo L, Isacsson G, Baldessarini R (2003) Suicidal behaviour in bipolar disorder: risk and prevention. CNS Drugs 17(7):491-511.
Tondo L, Lepri B, Baldessarini RJ (2007) Suicidal risks among 2826 Sardinian major affective disorder patients. Acta Psychiatr Scand 116(6):419-28.
Tully L, Parker G (2007) How low do we go? Is duration of a 'high' integral to the definition of bipolar disorder? Acta Neuropsychiatrica 19 (1): 38–44.
Valtonen HM, Suominen K, Mantere O et al. (2007) Suicidal behaviour during different phases of bipolar disorder. J Affect Disord 97(1-3):101-7.
Varga M, Magnusson A, Flekkoy K et al. (2006) Insight, symptoms and neurocognition in bipolar I patients. J Affect Disord 91(1):1-9.
Vieta E, Colom F, Martinez-Aran A et al. (2000) Bipolar II disorder and comorbidity. Compr Psychiatry 41(5):339-43.
Vieta E, Sánchez-Moreno J, Bulbena A et al. (2007) Cross validation with the mood disorder questionnaire (MDQ) of an instrument for the detection of hypomania in Spanish: the 32 item hypomania symptom check list (HCL-32). J Affect Disord 101(1-3):43-55.
Weissman MM, Leaf PJ, Tischler GL et al. (1988) Affective disorders in five United States communities. Psychol Med 18(1):141-53.
Yen CF, Chen CS, Ko CH et al. (2005) Relationships between insight and medication adherence in outpatients with schizophrenia and bipolar disorder: prospective study. Psychiatry Clin Neurosci 59(4):403-9.
Young RC, Biggs, JT, Ziegler VE et al. (1978) A Rating Scale for Mania: Reliability, Validity and Sensitivity. Br J Psychiat133: 429-35.
Zalsman G, Braun M, Arendt M et al. (2006) A comparison of the medical lethality of suicide attempts in bipolar and major depressive disorders. Bipolar Disord 8(5 Pt 2):558-65.
Zheng D, Macera CA, Croft JB et al. (1997) Major depression and all-cause mortality among white adults in the United States. Ann Epidemiol 7(3):213-8.
Zheng Y, Zhao J, Phillips M et al. (1988) Validity and reliability of the Chinese Hamilton Depression Rating Scale. Br J Psychiat 152:660-64.
Zimmermann M, Posternak MA, Chelminski I et al. (2004) Using questionnaires to screen for psychiatric disorders: A comment on a study of screening for bipolar disorder in the community. J Clin Psychiatry 65: 605-610.