Many clinicians regularly use the Patient Health Questionnaire-9 (PHQ-9) to monitor treatment of individuals with depression. Using the PHQ-9 consistently is part of a clinical strategy called measurement-based care (MBC). In MBC, symptom measures are administered to patients, which are then reviewed by clinicians, compared to prior results, and used to inform clinical decision making.
Symptoms in bipolar disorder
In bipolar disorder, depressive and manic symptoms often occur concurrently. Many people think of manic symptoms as occurring during a full episode of hypomania or mania, though manic symptoms commonly occur during other times in individuals with bipolar disorder. For example, during bipolar depression, almost three-quarters of people experience concurrent manic symptoms, most commonly faster thinking and distractibility. “Subsyndromal” symptoms (i.e., depressive and manic symptoms not reaching the severity of an ‘episode’) also occur frequently; in two landmark studies participants experienced subsyndromal symptoms almost half of days over a decade of follow-up. The presence of subsyndromal symptoms is also associated with a shorter time until syndromal mood episode (i.e. number of symptoms and severity consistent with a mood episode) recurrence, making it especially important to detect symptoms.
A patient-reported measure for manic symptoms
Because many clinicians already use the PHQ-9 to monitor depressive symptoms, a team based at the University of Washington decided to develop a similar symptom measure for manic symptoms that could be easily combined with the PHQ-9. The result is a new patient-reported measure, the Patient Mania Questionnaire-9 (PMQ-9), that includes 9 items each scored 0 to 3 based on severity, assessing manic symptoms. The team tested the PMQ-9 in 12 Federally Qualified Health Centers in three states with primary care clinicians, psychiatrists and care managers working in collaborative care. More recently, they found the PMQ-9 has ‘sound’ psychometric properties which were recently reported in the Journal of General Internal Medicine.
How is the PMQ-9 used?
The PMQ-9 is a patient-reported symptom measure, which means it can be given to a patient to complete ahead of an appointment time. It can also be read to a patient if that is preferred. Clinicians can use the PMQ-9 in combination with the PHQ-9 to monitor manic and depressive symptoms, and track response to treatment. Higher total scores indicate greater severity of manic symptoms. Cut-offs for symptom severity were determined based on clinical judgement using the measure in trial, with a score of less than 10 identified as ‘lower severity’ or ‘subthreshold’ (with less than 5 as ‘remission’). A change of approximately 3 points indicates a ‘minimally important difference’ meaning a 3-point decrease in score is likely a ‘meaningful improvement’.
Other points
The PMQ-9 is not a ‘screener’ meaning it is not used to ‘find’ people who might have bipolar disorder. So far it has only been used to monitor the treatment of individuals already diagnosed with bipolar disorder. Notably, the PMQ-9 was widely used by clinicians and patients in a large clinical trial even though they were not required to use it, suggesting wide acceptability. The research team also surveyed clinicians (primary care clinicians, psychiatrists, psychiatric ARNPs, social workers, psychologists) about symptom measures and found the most preferred measure to use in measurement-based care for bipolar disorder was the combination of the PHQ-9 and PMQ-9.
Conclusion
The clinical need to monitor depressive and manic symptoms, the ease of scoring and interpretation, the acceptability and perceived helpfulness by clinicians, and similarities with the PHQ-9 make the PMQ-9 plus PHQ-9 a reasonable choice for those looking to adopt measurement-based care for bipolar disorder.
Author
Joseph Cerimele, MD
Assistant Professor, University of Washington School of Medicine, Department of Psychiatry and Behavioral Sciences
Director, Psychiatry and Behavioral Sciences Grand Rounds
Learn More
Patient Mania Questionnaire-9 (PMQ-9) – pdf
The Patient Mania Questionnaire (PMQ-9) is a nine-item scale used to assess and monitor manic symptoms. The PMQ-9 Mania Questionnaire complements use of the PHQ-9 for depressive symptoms to inform measurement-based care. It is also suited for use in mental health care settings.
The Patient Mania Questionnaire (PMQ-9): a Brief Scale for Assessing and Monitoring Manic Symptoms
Journal of General Internal Medicine. Volume 37, pages1680–1687 (2022)
Joseph M. Cerimele MD, MPH, Joan Russo PhD, Amy M. Bauer MD MS, Matt Hawrilenko PhD, Jeffrey M. Pyne MD, Gregory W. Dalack MD, Kurt Kroenke MD, Jürgen Unützer MD MPH & John C. Fortney PhD
The PMQ-9 demonstrated excellent test-retest reliability, concurrent validity, internal consistency, and sensitivity to change and was widely used and acceptable to patients and clinicians in a pragmatic clinical trial. Combined with the Patient Health Questionnaire-9 (PHQ-9) measure of depressive symptoms this brief measure could inform measurement-based care for individuals with bipolar disorder in primary care and mental health care settings given its ease of administration and familiar self-report response format.
Diagnosing and treating bipolar disorder
PCL News | September 15, 2021
Bipolar disorders, sometimes referred to as manic-depressive disorders, are mood disorders that include manic or hypomanic symptoms and depressive symptoms. Accurate diagnosis of bipolar disorder can be difficult, and once a diagnosis is made, clinicians can face numerous decisions regarding acute episode treatment, maintenance treatment, monitoring response, monitoring for adverse effects, and treatment adjustments. These “points to consider” may help as you encounter similar clinical scenarios.