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The Mood Disorder Questionnaire (MDQ) is a brief self-report screening instrument developed by Dr. Robert Hirschfeld and colleagues in 2000 at the University of Texas Medical Branch. It was specifically designed to screen for bipolar spectrum disorders (bipolar I disorder, bipolar II disorder, and bipolar disorder not otherwise specified) in clinical and community settings. The MDQ addresses a critical gap in psychiatric practice: the average delay between symptom onset and correct diagnosis of bipolar disorder is approximately 5 to 10 years, during which patients are frequently misdiagnosed with unipolar depression and treated with antidepressants alone, which can worsen the course of bipolar illness. The MDQ consists of three sections. The first section contains 13 yes or no items derived from the DSM-IV criteria for mania and hypomania and from clinical experience. These items assess symptoms such as elevated or irritable mood, increased energy, decreased need for sleep, rapid speech, racing thoughts, increased goal-directed activity, excessive spending, hypersexuality, and grandiosity. The second section asks whether several of these symptoms occurred during the same time period. The third section asks about the degree of functional impairment caused by these symptoms (no problem, minor problem, moderate problem, or serious problem). A positive screen on the MDQ requires all three criteria to be met: endorsement of 7 or more of the 13 symptom items, co-occurrence of at least 2 symptoms during the same time period, and at least moderate functional impairment. Using these criteria, the MDQ demonstrates sensitivity of approximately 73 percent and specificity of approximately 90 percent for bipolar spectrum disorders in psychiatric outpatient settings. However, sensitivity drops significantly in community samples (approximately 28 percent), making it more appropriate for clinical rather than general population screening. The MDQ takes approximately 5 minutes to complete and is freely available for clinical use. It is the most widely used bipolar disorder screening instrument worldwide and has been translated and validated in over 30 languages.
MDQ Screening Result = Positive if ALL three criteria met: 1. Symptom Count: Number of 'Yes' responses to 13 symptom items >= 7 2. Co-occurrence: 'Yes' to whether several symptoms happened during the same time period 3. Functional Impairment: 'Moderate problem' or 'Serious problem' selected Worked Example: A 34 year old woman currently being treated for depression completes the MDQ: Section 1 (13 symptom items): 1. Felt so good or hyper that others thought you were not your normal self? Yes (1) 2. Were so irritable that you shouted or started fights? Yes (1) 3. Felt much more self-confident than usual? Yes (1) 4. Got much less sleep than usual and did not miss it? Yes (1) 5. Were much more talkative or spoke faster than usual? Yes (1) 6. Thoughts raced through your head? Yes (1) 7. Were so easily distracted that you had trouble concentrating? Yes (1) 8. Had much more energy than usual? Yes (1) 9. Were much more active or did many more things than usual? Yes (1) 10. Were much more social or outgoing than usual? No (0) 11. Were much more interested in sex than usual? Yes (1) 12. Did things that were unusual for you or that others might think were excessive, foolish, or risky? Yes (1) 13. Spending money got you or your family in trouble? No (0) Symptom Count = 11 (meets threshold of >= 7) Section 2: Did several of these happen during the same period of time? Yes Section 3: How much of a problem did any of these cause? Moderate problem Result: POSITIVE SCREEN - All three criteria met (11 symptoms, co-occurrence confirmed, moderate impairment). This patient should be evaluated for bipolar spectrum disorder. Current antidepressant monotherapy should be reviewed, as it may be inadequate or potentially destabilizing for bipolar disorder.
- 1Identify Patients Who Should Be Screened: The MDQ should be considered for patients presenting with depressive episodes (especially treatment-resistant depression), patients with a family history of bipolar disorder, patients with a history of multiple antidepressant trials without adequate response, patients who report periods of elevated mood or increased energy, young adults presenting with their first depressive episode, and patients whose depression is characterized by atypical features (hypersomnia, increased appetite, leaden paralysis, rejection sensitivity). The MDQ screens for lifetime history, so it can detect bipolar disorder even when the patient is currently in a depressive phase.
- 2Administer the 13-Item Symptom Checklist: Present the 13 symptom items, each requiring a yes or no response. The items assess manic and hypomanic symptoms including elevated mood, irritability, increased self-confidence, decreased need for sleep, pressured speech, racing thoughts, distractibility, increased energy, increased activity level, increased sociability, hypersexuality, risky behavior, and excessive spending. Instruct the patient that these questions refer to any time in their life, not just the current period. Self-administration is preferred to reduce social desirability bias, as patients may be reluctant to disclose behaviors like excessive spending or hypersexuality face-to-face.
- 3Assess Co-occurrence of Symptoms: The second section asks whether several of the endorsed symptoms occurred during the same time period. This question is critical because the DSM requires that manic or hypomanic symptoms cluster together in a distinct episode rather than occurring in isolation at different times. A patient who experienced racing thoughts during a stressful work project and excessive spending during a vacation, but never both simultaneously, may not meet criteria for a manic episode despite endorsing both symptoms. Only patients who confirm co-occurrence proceed to positive screening consideration.
- 4Assess Functional Impairment: The third section asks how much of a problem these symptoms caused, with four response options: no problem, minor problem, moderate problem, or serious problem. A positive screen requires at least moderate functional impairment. This criterion helps distinguish between clinically significant manic or hypomanic episodes and normal variations in mood and energy. Some individuals, particularly those with high baseline energy and extraverted temperaments, may endorse several symptom items without having a mood disorder. The functional impairment criterion reduces false positives by requiring that the symptoms caused meaningful disruption to relationships, work, finances, or legal standing.
- 5Apply the Three-Part Scoring Algorithm: A screen is positive only if all three criteria are simultaneously met: 7 or more symptoms endorsed, confirmed co-occurrence, and at least moderate impairment. If any one criterion is not met, the screen is negative. This three-part algorithm has been validated to provide optimal balance between sensitivity and specificity. Some researchers have proposed alternative scoring methods (such as counting only the 13 symptom items with a cutoff of 7) for community screening where higher sensitivity is desired, but the standard three-part algorithm is recommended for clinical use.
- 6Conduct Diagnostic Follow-Up for Positive Screens: A positive MDQ screen is not a diagnosis. It indicates the need for a comprehensive diagnostic evaluation by a qualified mental health professional. The follow-up evaluation should include a detailed psychiatric history with specific attention to mood episodes (timing, duration, severity, associated symptoms), family history of bipolar disorder and other mood disorders, substance use assessment (substance-induced mania must be ruled out), medical history review (hypothyroidism, corticosteroid use, and other medical causes of mood symptoms), collateral information from family members when possible, and structured diagnostic interview using instruments such as the SCID or MINI.
- 7Integrate Results into Treatment Planning: For patients who screen positive and are subsequently diagnosed with bipolar disorder, treatment plans must be fundamentally restructured. Antidepressant monotherapy, which is the standard first-line treatment for unipolar depression, can destabilize bipolar disorder by triggering manic episodes, rapid cycling, or mixed states. First-line treatments for bipolar depression include mood stabilizers (lithium, lamotrigine, valproate), atypical antipsychotics (quetiapine, lurasidone, cariprazine), and combination approaches. If an antidepressant is used, it should be combined with a mood stabilizer. For patients who screen negative, document the result and consider rescreening if treatment-resistant depression persists.
This 42 year old man with recurrent major depression endorses only 3 of 13 manic symptoms (racing thoughts, distractibility, and increased energy) which are common in agitated depression and do not suggest a bipolar presentation. The symptom count of 3 does not meet the threshold of 7, and functional impairment is only minor. The negative screen supports the current unipolar depression diagnosis, though the MDQ should be readministered if the patient fails to respond to standard antidepressant treatment.
This 28 year old woman has been treated for depression for 6 years with four different antidepressants, none providing sustained improvement. She endorses 9 manic symptoms including periods of elevated mood, decreased sleep need, rapid speech, racing thoughts, increased energy, increased activity, hypersexuality, and risky behavior. These symptoms co-occurred and caused moderate functional problems including strained relationships and impulsive financial decisions. A positive screen with this clinical history strongly suggests bipolar II disorder. She is referred for diagnostic evaluation, and her current SSRI is not increased pending the evaluation results.
This 50 year old man endorses 8 manic symptoms and reports moderate impairment, but denies that these symptoms occurred during the same time period. Without co-occurrence, the screen is negative per the standard algorithm. However, the high symptom count warrants clinical attention. Some patients have difficulty recognizing episode patterns retrospectively, and the lack of co-occurrence may reflect poor recall rather than true absence. Clinical judgment should determine whether further evaluation is warranted despite the technically negative screen.
Detection of Bipolar Disorder in Depression Clinics: The most impactful application of the MDQ is identifying unrecognized bipolar disorder among patients being treated for depression. Studies in psychiatric outpatient settings find that approximately 20 to 25 percent of patients diagnosed with unipolar depression screen positive on the MDQ, and approximately half of those are confirmed to have bipolar disorder on comprehensive evaluation. Early detection allows treatment to be redirected from antidepressant monotherapy to appropriate mood-stabilizing regimens, reducing the risk of treatment-induced mania, rapid cycling, and prolonged illness course.
Primary Care Mental Health Screening: Primary care physicians manage the majority of depression treatment in the United States, and many patients with bipolar disorder present first to their primary care provider with depressive symptoms. The MDQ enables primary care screening for bipolar disorder, which is particularly important given that the average primary care visit length of 15 to 20 minutes does not allow for comprehensive mood disorder evaluation. When a primary care patient with depression screens positive on the MDQ, appropriate next steps include referral to psychiatry for diagnostic evaluation before initiating or continuing antidepressant therapy.
Clinical Trial Screening and Enrollment: The MDQ is widely used in clinical trials for depression to screen out patients with unrecognized bipolar disorder, who should not be enrolled in unipolar depression studies because their treatment response differs fundamentally. Conversely, it is used to identify potential participants for bipolar disorder clinical trials. The FDA has recognized the importance of accurately distinguishing bipolar from unipolar depression in clinical research, and the MDQ provides a standardized, efficient method for initial screening that can be followed by structured diagnostic interviews for enrolled participants.
Insurance and Disability Assessment: The MDQ is used in forensic and disability evaluation contexts to support or refute claims of bipolar disorder. When patients apply for disability benefits based on bipolar disorder, the MDQ provides standardized screening data that can be incorporated into comprehensive psychiatric evaluations. However, the MDQ should never be the sole basis for disability determination, as it is a screening tool subject to both false positives and false negatives. Malingering assessment and comprehensive clinical evaluation must accompany any screening instrument in forensic contexts.
When using the MDQ in patients with comorbid ADHD, clinicians should be aware
When using the MDQ in patients with comorbid ADHD, clinicians should be aware that several MDQ items overlap with ADHD symptoms, including distractibility, racing thoughts, talkativeness, increased energy, and increased activity. Patients with ADHD but not bipolar disorder may endorse 7 or more items based on their ADHD symptoms alone, producing false-positive screens. The co-occurrence criterion helps somewhat (ADHD symptoms are continuous rather than episodic), but differential diagnosis between ADHD and bipolar disorder, or recognition of their comorbidity (which occurs in approximately 20 percent of bipolar patients), requires careful clinical evaluation beyond the MDQ. For patients with borderline personality disorder, the MDQ may produce false positives because emotional dysregulation, impulsivity, risky behavior, and mood instability are core features of both conditions. Distinguishing bipolar disorder from borderline personality disorder is one of the most challenging differential diagnoses in psychiatry. The episodic nature of bipolar disorder (clear periods of wellness between episodes) versus the chronic emotional dysregulation of borderline personality disorder is the key distinguishing feature, but the MDQ does not adequately assess episode duration or pattern. In elderly patients, the MDQ may be less reliable because age-related memory decline can impair recall of lifetime manic symptoms. Late-onset bipolar disorder (first manic episode after age 50) often has different clinical characteristics than earlier-onset illness, including more neurological comorbidity and less family history. For elderly patients, consider supplementing the MDQ with collateral history from family members and longitudinal medical record review.
| Setting | Bipolar Prevalence | Sensitivity | Specificity | PPV | NPV |
|---|---|---|---|---|---|
| Psychiatric outpatient | ~20% | 73% | 90% | ~70% | ~91% |
| Primary care | ~3-5% | 58% | 93% | ~25-30% | ~98% |
| General community | ~2-3% | 28% | 97% | ~25% | ~98% |
| Treatment-resistant depression | ~30-40% | ~75% | ~85% | ~65-75% | ~90% |
| Bipolar I vs Bipolar II | - | ~80% / ~45% | ~90% / ~90% | - | - |
Why is bipolar disorder so frequently misdiagnosed as unipolar depression?
Bipolar disorder is misdiagnosed for several converging reasons. Patients spend approximately three times more time in depressive episodes than in manic or hypomanic episodes, so they are far more likely to present for treatment during depression. Patients often do not report hypomanic or manic episodes because they experienced them as positive, productive periods rather than illness. Family members who might provide collateral information about behavioral changes are often not present at clinical visits. Many clinicians do not routinely screen for bipolar disorder in patients presenting with depression. Additionally, hypomanic episodes in bipolar II disorder are particularly easy to miss because they do not cause the dramatic functional impairment of full mania.
What happens if bipolar depression is treated with antidepressants alone?
Antidepressant monotherapy in bipolar disorder can cause several adverse outcomes. In approximately 15 to 25 percent of bipolar patients, antidepressants can trigger a switch from depression to mania or hypomania. Antidepressants may also induce rapid cycling (four or more mood episodes per year), mixed states (simultaneous depressive and manic symptoms, which carry the highest suicide risk), and treatment resistance. Long-term antidepressant monotherapy may destabilize the course of bipolar illness, leading to more frequent and severe episodes over time. This is why screening for bipolar disorder before prescribing antidepressants for depression is considered a standard of care.
Can the MDQ detect bipolar II disorder?
The MDQ has lower sensitivity for bipolar II disorder (approximately 40-50 percent) compared to bipolar I disorder (approximately 75-80 percent). This is because hypomanic episodes are shorter (4 days minimum versus 7 days for mania), less severe, and less likely to cause the moderate or serious functional impairment required by the third MDQ criterion. Patients with bipolar II may also endorse fewer than 7 symptoms because hypomania involves fewer and milder symptoms than mania. For settings where bipolar II detection is a priority, the Hypomania Checklist (HCL-32) may be a more sensitive alternative because it uses a lower symptom threshold and does not require impairment.
Should the MDQ be given to all patients with depression?
While universal screening of all depressed patients with the MDQ is advocated by some bipolar disorder experts, practical constraints often limit screening to higher-risk populations. The MDQ should be strongly considered for: patients with a family history of bipolar disorder, patients who have not responded adequately to two or more antidepressant trials, patients with early onset of depression (before age 25), patients with a history of antidepressant-induced mania or hypomania, patients with atypical depressive features, and patients with a history of psychotic features during depressive episodes. In psychiatric settings where bipolar disorder prevalence is higher, routine screening of all depressed patients is more efficient and has stronger clinical justification.
Is the MDQ appropriate for children and adolescents?
The MDQ was developed and validated in adult populations. Its use in children and adolescents is controversial because the phenomenology of bipolar disorder in youth differs from adults. Pediatric bipolar disorder is characterized by more irritability, rapid mood cycling, and mixed presentations, which may not map well onto the MDQ items designed to capture adult episodic mania. Some studies have found acceptable psychometric properties of the MDQ in adolescents aged 14 and older, but results are inconsistent. For pediatric populations, the Child Mania Rating Scale (CMRS) or the General Behavior Inventory (GBI) are more appropriate screening instruments.
How does substance use affect MDQ results?
Substance use significantly complicates MDQ interpretation. Many substances can produce symptoms that mimic mania: stimulants (cocaine, amphetamines) cause elevated mood, increased energy, decreased sleep need, and grandiosity; alcohol intoxication can cause disinhibition and impaired judgment; and cannabis can cause altered perception and mood changes. Patients who endorse MDQ symptoms that occurred exclusively during periods of substance intoxication may receive false-positive screens. The diagnostic follow-up for a positive MDQ must include careful assessment of whether manic symptoms occurred independently of substance use, as substance-induced mood disorder requires different treatment than bipolar disorder.
Pro Tip
When a depressed patient has failed to respond to two adequate antidepressant trials, always administer the MDQ before initiating a third antidepressant. Treatment-resistant depression is one of the strongest clinical indicators of unrecognized bipolar disorder. Studies show that approximately 30 to 40 percent of patients labeled as treatment-resistant actually have bipolar disorder and are not responding because antidepressant monotherapy is the wrong treatment. The MDQ takes only 5 minutes and could redirect treatment toward appropriate mood stabilization.
Did you know?
Dr. Robert Hirschfeld developed the MDQ after analyzing data from a National Depressive and Manic-Depressive Association survey of over 600 bipolar patients. He found that 69 percent had been initially misdiagnosed, with the most common incorrect diagnosis being unipolar depression. On average, patients saw 3.3 physicians and waited 8 years before receiving the correct diagnosis. One-third waited more than 10 years. This staggering diagnostic delay, during which patients often received potentially harmful antidepressant monotherapy, motivated the creation of a simple screening tool that any clinician could use.
References
- ›Development and Validation of a Screening Instrument for Bipolar Spectrum Disorder: The Mood Disorder Questionnaire - Hirschfeld et al., American Journal of Psychiatry, 2000
- ›Screening for Bipolar Disorder in the Community - Hirschfeld et al., Journal of Clinical Psychiatry, 2003
- ›Practice Guideline for the Treatment of Patients with Bipolar Disorder, Second Edition - American Psychiatric Association, 2002
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