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Concerns have been raised about ecological momentary assessment (EMA) acceptability among patients with schizophrenia spectrum disorders (SSD), which is of major relevance during the e-Mental health-focused COVID-19 pandemic.
To investigate i) the levels of adherence to a passive smartphone-based EMA tool, the Evidence-Based Behavior (eB2), among SSD patients; and ii) putative predictors of this.
Sample: SSD (F20-29-ICD10) outpatients, age 18-64, without financial incentives, recruited over 17/06/2019-11/03/2020 at the Hospital Universitario Fundación Jiménez Díaz (Madrid, Spain). Those who accepted the eB2 installation -users- and those who did not -non-users- were compared in sociodemographic, clinical, premorbid adjustment, neurocognitive, psychopathological, insight and metacognitive variables by a multivariable binary logistic regression model.
Sample (N=77): n=41 males; age: 47.69±9.76 years, n=24 users (31.2%). n=14 users (70%) had the eB2 installed at follow-up (median=14.50 weeks).
Multivariable binary logistic regression model on ‘user’ as outcome
Acceptability of a smartphone-based EMA application among SSD patients was low. Age (young) and good premorbid adjustment predicted acceptability. e-Mental Health methods need to be tailored for patients with SSD. Otherwise, these highly vulnerable individuals may be neglected by e-health-based services in the post-COVID-19 years ahead.
Verbal memory deficits are linked to cannabis use. However, self-reported episodic use does not allow for assessment of variance from other factors (e.g., cannabis potency, route of consumption) that are important for assessing brain-behavior relationships. Further, co-occurring nicotine use may moderate the influence of cannabis on cognition. Here we utilized objective urinary measurements to assess the relationship between metabolites of cannabis, 11-nor-9-carboxy-∆9-tetrahydrocannabinol (THCCOOH), and nicotine (cotinine) on verbal memory in young adults.
Adolescents and young adults (n = 103) aged 16–22 completed urinary drug testing and verbal memory assessment (RAVLT). Linear regressions examined the influence of THCCOOH and cotinine quantitative concentrations, and their interaction, on RAVLT scores, controlling for demographics and alcohol. Cannabis intake frequency was also investigated. Secondary analyses examined whether past month or recency of use related to performance, while controlling for THCCOOH and cotinine concentrations.
THCCOOH concentration related to both poorer total learning and long delay recall. Cotinine concentration related to poorer short delay recall. Higher frequency cannabis use status was associated with poorer initial learning and poorer short delay. When comparing to self-report, THCCOOH and cotinine concentrations were negatively related to learning and memory performance, while self-report was not.
Results confirm the negative relationship between verbal memory and cannabis use, extending findings with objective urinary THCCOOH, and cotinine concentration measurements. No moderating relationship with nicotine was found, though cotinine concentration independently associated with negative short delay performance. Findings support the use of both urinary and self-report metrics as complementary methods in substance use research.
Fiction films offer unexplored opportunities of rehabilitation for schizophrenia and other psychoses. Schizophrenia produces deficits y distortions in the perception and comprehension of reality, also expressed in the perception and comprehension of films. After a year of an “ad hoc” experience, the following technique was developed:
1) Selecting a fiction film for its narrative, affective, cognitive and social cognitive content
2) Briefly presenting of the film to a group of 8-16 patients with diverse psychosis.
3) Screening of the film to the patients and the therapeutic team.
4) Summarizing of the plot by a patient. Group correcting of distortions and deficits caused by problems of attention and working memory, as well as positive, negative, affective and social cognitive symptoms (emotional perception, theory of mind, attributive style)
5) Selecting 1-2 sequences by each patient, and group commenting using the same technique.
6) Field recording of all the commentaries obtained.
7) Second screening of the film two days after, repeating points 2 to 6.
8) Comparing both field records.
An experimental study using this technique is presented. 8 patients with schizophrenia and other psychoses watched 4 fiction films (“The 39 Steps”, “Charade”, “M”, “The General”). The differences founded in both viewings by two external evaluators (using CGI and analogical scales of the main variables) are presented and commented. An evaluation of the perceived usefulness and satisfaction of the participants was included.
Diagnostic stability is the measure of the degree to which a diagnosis remains the same at subsequent assessments of the patient and constitutes a longitudinal validation of the original baseline diagnosis. Follow-up studies including evidence of diagnostic stability and diagnostic consistency over time have been proposed to test the validity of psychiatric diagnoses. Until this moment definitions for psychiatric diagnoses are based on expert opinion rather than on their biological basis, and the modest knowledge base regarding underlying etiologies has hindered the use of etiological factors in psychiatric classification systems. But it is assumed that the higher the diagnostic stability, the more likely is to reflect a consistent psychopathological or pathophysiological process. Being that the main clinical purpose of diagnosis, as a formulation, is to furnish the informational basis for planning and conducting clinical care, stability of a diagnosis gives a relevant base not only for prediction of the course and outcome of a disorder but also for effective planning and provision of treatment. The availability of longitudinal data, however, may cause significant fluctuations in diagnostic stability as changes in clinical presentation are seen. Thus, evolving longitudinal observations should lead to periodic updating of the comprehensive diagnostic formulation, and yet, despite the inherent problems derived from criteria based on cross-sectional observations, our diagnostic system relies on stable diagnoses. Accounting for the potentially harmful consequences of unsuitable treatment options or clinical interventions, the study of diagnostic stability remains an essential issue in psychiatry.
The complex interrelationship between personality disorders and bipolar disorders is still a controversial aspect with multiple diagnosis, therapeutic and ethiologic implications.
Comorbidity has been defined as the presence of more than one disorder in the same patient at the same time.
We made a literature review between 1995 and 2005 about comorbidity in bipolar and personality disorders.
There are different studies that agree the theory that personality disorders are previous forms of bipolar disorders.
Besides, it is important to consider the effect that bipolar disorders have over personality.
In the last years, different authors have suggested that co-morbid personality disorders predict a worse evolution in the course of the bipolar disorders, finding recurrent and resistant to treatment affective symptoms.
The co-occurrence studies of personality and affective disorders have ranged from 3 to 70%.
If we take the global n (428) of all the reviewed articles, we see that the percentage of comorbidity between personality disorders and bipolar disorders is almost the 48% of the studied patients. Looking at the most prevalent cluster, cluster A is the 13%, cluster B is near the 39% and cluster C the 35%.
Personality traits, dimensions and personality disorders seem to play an important role in the evolution of bipolar disorders.
The identification of these specific personality traits and the knowledge of the influence in the evolution of the illness are extremely important in the treatment and prevention of bipolar disorders.
Up to 45% of individuals who commit suicide contact their Primary Care physician (PCP) the month before. The objective is to study clinical characteristics of patients presenting death and/or suicidal ideation (SI) in Primary Care.
195 patients attending their PCP were evaluated using systematic sampling in three Primary Care Centres. Patients completed the PHQ and a Life Changes Checklist. Demographic data, both psychiatric and medical conditions and treatments, visits to their PCP, and days out of work (last year) were also collected.
24 patients had death or suicidal ideation for the previous two weeks (12,4%; IC95% 8,3-18,8%). Most of them (87,5%) had a mental disease, major depressive disorder (62,5%) and general anxiety disorder (50%). Patients with SI had more somatic symptoms (p<0,001), a greater number and score of recent life changes (p<0,001) and days out of work (last year) ((p=0,028) than the rest of the sample.
Compared to patients with any psychiatric disorder, patients with SI had more depressive symptoms (p<0,001) and a higher score in life changes in the 6-12 month period (p=0,044).
14 (58,3%) patients with SI had no previous psychiatric diagnosis and only 8 (33%) were receiving treatment.
In spite of a greater severity in depressive and other clinical characteristics of patients with SI most of them are not correctly detected and treated. Improving the rate of detection and treatment by the PCP of such patients would probably play a key role in the prevention of suicide.
Chronic insomnia (ChI) is a common condition in Primary Care (PC). Regardless that it's often related to psychiatric morbidity it appears to be a strong predictor of future depression and a disabling disorder by itself. The aim of this study was to measure and compare clinical and psychiatric characteristics of both patients with primary ChI and secondary ChI.
A random sample of 225 subjects older than 18 years old, from 3 PC Centres of the area of Madrid (Spain) was interviewed using the Oviedo Sleep Questionnaire, a semi-structured interview for sleep disorders. The subjects completed the Patient Health Questionnaire. Data about medical conditions, drug treatments, days of work lost (last year) and use of health care services (last 3 months), were also collected. Psychiatric and clinical characteristics between groups (primary vs secondary ChI) were compared.
78 patients fulfilled criteria for ChI and 53 (67.9 %) of them were suffering from any psychiatric disorder (including subtreshold conditions). Patients with primary ChI compared to secondary insomnia patients had no significant differences in age, gender, use of health care resources and days of work lost. However, patients with secondary ChI compared to primary ChI had more somatic and depressive symptoms (U-Mann-Witney test; p=0.002 and p<0.001, respectively).
There is an important group of patients among PC attendees suffering primary ChI. Patients suffering primary ChI are comparable to patients with psychiatric disorders and insomnia in terms of days of work lost and use of health care resources.
Natural polyamines (putrescine, spermidine and spermine) are low molecular weight highly protonated aliphatic molecules that physiologically modulate NMDA, AMPA/kainate glutamatergic receptors and limbic dopaminergic neurotransmission. Previous studies had demonstrated that polyamine metabolism might be disrupted in schizophrenia, what could potentially be linked to glutamatergic dysfunction. In particular, polyamine levels in blood and fibroblast cultures from patients with schizophrenia had previously been found to be higher than in healthy controls. Indeed, a significant positive correlation between blood polyamine levels and severity of illness may exist.
In order to test potential differences in blood polyamine levels between drug-free schizophrenia in-patients (n = 12), and healthy controls (n = 26, blood donors), spermidine (spd), spermine (spm), and spermidine/spermine index (spd/spm) were determined using HPLC after dansylation.
No significant differences were found between groups (t = 0,974; df = 36; P = 0,337 for spd, t = l0, 52; df = 36; P = 0,959 for Spm, and, t = 0, 662; df = 36; P = 0,512 for spd/spm).
Though we couldn’t replicate previous findings suggesting disturbances in blood polyamine levels in schizophrenia, this issue may be a promising target. Future research should take into account possible factors such as sex, nutritional state, and stress.
Previous data suggest that there is an important group of patients between primary care (PC) attendees suffering a psychiatric disorder that remain undetected. Our aim was to know data about this group of patients compared with patients without psychiatric pathology (PWP) and patients with already known psychiatric pathology (PKP).
A random sample of 225 subjects older than 18 years old, from 3 PC Centres of the area of Madrid (Spain) completed the Patient Health Questionnaire (PHQ). Data about medical and psychiatric conditions, drug treatments, days of work lost (last year) and use of health care services (last 3 months), were also collected. Psychiatric and clinical characteristics between groups were compared.
50 (22,2%) patients were suffering a psychiatric condition according to PHQ but without recognition by their general practioner. This group of patients were younger than PWP and PKP (ANOVA; p=0,021 and p=0,013). They were suffering more depressive symptoms and somatic complaints than PWP (p<0,001 and p<0,001 respectively). In terms of days of work lost and use of health care services did not differ from PWP.
The results suggest that other reasons rather than the symptomathology (depresive symptoms, somatic complaints) may be important in the proccess of detection of mental health problems in PC. Both days of work lost and the number of visits to general practioner appear to be two determinant factors.
A growing interest in the potential role of polyamines in stress, mood disorders and suicidal behavior has recently emerged. In particular, the expression of polyamine's rate-limiting catabolic enzyme (SAT-1, Spermidine/spermine N1-acetyltransferase-1) may be reduced in ventral prefrontal cortex and posterior cyngulate gyrus of patients who committed suicide. However, there is some controversy regarding the involvement of potential cis-acting loci controlling SAT-1 gene expression (rs6526342 or rs17286006) in suicidal behavior. Moreover, a significant association between SAT-1 rs1960264 SNP and anxiety disorders has been found in a male caucasian spanish sample.
In order to test the potential association of SAT-1 -1415T/C SNP (rs1960264) with suicidal behavior, genotype frequencies for that SNP were compared between 193 suicidal attempters (126 female and 67 male) and 650 non-suicidal patients (314 female and 336 male) from an in-patient sample.
We could not find a significant difference in the distribution of the genotypes for rs1960264 SNP between suicide attempters versus non-suicidal individuals (Linear-by-Linear association X2 = 0,203; df = 1; P = 0,652, females; Linear-by-Linear association X2 = 0,000; df = 1; P = 0,990, males). Neither could we demonstrate a relationship between rs1960264 genotype and past history of suicidal attempts (Linear-by-Linear association X2 = 2,966 ; df = 1; P = 0,085, females; Linear-by-Linear association X2 = 1,171; df = 1; P = 0,279, males).
Although we did not find a link between rs1960264 genotype and suicidal behavior, SAT-1 may be an interesting target to investigate the biology of this phenotype. Future studies should take into account other genetic polymorphisms at SAT-1, and definitively evaluate whether or not rs6526342 and rs1960264 have any functional implications.
Adoption, twin and family studies suggest that suicide behavior is familial and heritable. Both completed and attempted suicide appear to be transmitted in a familial form. Genetics and environment influences had been detected in various studies. But suicidal behavior suggests to be inherited independently from the mental disorders usually associated with it. While traditional statistics emphasizes inference and estimations, data mining emphasizes the fulfillment of a task such as classification, estimation, or knowledge discovery.
The goal of this study was to determine in a large sample of suicide attempts which variables are associated with family history of attempted suicide.
In an emergency room, 539 adult suicide attempters were recruited. The two dichotomous dependent variables were family history of suicide attempt (10%) and of completed suicide (4%). Independent variables were 101 clinical variables explored with two data mining techniques: Random Forest and Forward Selection.
A model for family history of completed suicide could not be developed. A classificatory model for family history of attempted suicide included the use of alcohol in the intent and family history of completed suicide, provide a sensitivity of 78.4%, a specificity of 98.7% and accuracy of 96.6%.
A classificatory model for family history of completed suicide could not be developed using data mining techniques. But it suggested that the use of alcohol in the intent and family history of completed suicide may be associated with familial attempted suicide.
Borderline personality disorder (BPD) seems to be a prevalent condition in Primary Care (PC) with high rates of comorbidity and health care use. The aim of this study is to describe the characteristics and patterns of comorbidity in patients with suspected BPD.
192 consecutive primary health care patients completed the IPDE screening questionnaire, CAGE and the Prime-MD patient questionnaire, and were interviewed by a general practitioner (GP) using the Prime-MD. Number of visits to the GP (last year), medical illnesses and treatments were also collected. “High Risk” of BPD group (RBPDg) was defined by scoring 4 or higher in the IPDE, and it was compared to patients without psychiatric morbidity and patients with any psychiatric disorder but not BPD's risk.
39 (20,3%) patients fulfilled the condition of RBPDg. Compared to the group of patients without psychiatry pathology (n=110) RBPDg had a higher number of visits to their GP (last year) (p<0,001), more somatic complaints (p<0,001), a worse health perception (p<0,001) and higher rates of alcohol abuse or dependence (p=0,016).
In the RBPDg we found a high rate of axis I disorders, mainly major depressive disorder (MDD) (40,0%) and generalized anxiety disorder (33,3%). Furthermore, they had a lower level of education (p=0,03) and a higher rate of MDD (p=0,026) than patients with psychiatric pathology but without risk of BPD (n=43).
Borderline personality traits or disorder could be present in many depressive patients seen in PC. GP's knowledge about personality disorders needs to be improved
Patients with schizophrenia have a reduced life expectancy of 20% in comparison to the general population. They have a relative risk of 1.6 for all cause mortality. Recent innovations in antipsychotic treatment have improved the social integration of patients thanks to a better control of symptoms, however undesirable effects of medication may affect physical health.
To develop a consensus document about the Evaluation of Physical Health of Patients with Schizophrenia along their life, and to propose recommendations for diagnostic and clinical interventions to manage modifiable risk factors which impact on quality of life and life expectancy.
A literature review was performed to identify diseases and/or risk factors potentially related to patient with schizophrenia.
A systematic review of the literature was performed to evaluate the morbid-morbidity of patients with schizophrenia in relation to the identified conditions. 25 psychiatrists and 8 experts from the different specialities participated in the consensus meeting to adapt the general population guidelines to the management of patients with schizophrenia.
The literature review revealed that increased mortality in patients with schizophrenia is associated to respiratory diseases, cardiovascular diseases and cancer. Increased morbidity is associated to diabetes and metabolic syndrome, respiratory diseases, hepatitis, HIV and dyskinesia.
The resulting recommendations were submitted to the Spanish psychiatry medical societies for their validation.
The physical health of patients with schizophrenia requires specific monitoring and follow-up to guarantee that their life expectancy, quality of life and social functioning is similar to the general population.
Comorbidity has been defined as the coexistence of somatic and psychiatric diseases with diferent physiopatology in the same person, and it can appear simultaneously to the schizophrenia or during the patient's lifetime. There are two types of comorbidity: episodical or taking place during the lifetime of the patient. We can diffferenciate between comorbidity itself (in cluster, dependent or associated) to the so-called pseudo-comorbidity. Besides, comorbidity has been classified as a co-syndrome and it is considered a prognosis indicator of this disease, which can determine an increase in the rates related to relapses, worse response to treatment, less capacity to cope with social situations, and suicide in patients suffering from schizophrenia.
177 schizophrenic patients were assessed for affective symptoms and suicide behaviour. 24.3% were suffered for depression. 35% had a previous record of autolytic attempts. The rate of suicide history were higher among depressed schizophrenics (50%) than non-depressed schizophrenics (20%) (p<0,05).
We point out the clinic importance of suicide in schizophrenic patients suffering from depression. Moreover, the study shows the necessity to carry out longitudinal studies to recognize indicators of depression in advance and establish the diagnosis of depression, and, also, to acknowledge the importance of the gender factor in the depression of schizophrenic patients.
Epidemiological study of schizophrenia in Spain with a focus on clinical, diagnostic and treatment trends along the year 2005 compared with those observed in ACE 2004 study;
617 psychiatrists from public and private Spanish clinics registered the first four patients with schizophrenia seen at their offices.
A total of 2,430 patients were entered in the study (70% males, 79% unmarried; median age, 37 years) of which, 1,113 had participated in the ACE 2004 study. Twelve percent of patients had a history of illegal drug abuse, 59% had paranoid schizophrenia, 11% had residual schizophrenia, and 6% showed undifferentiated schizophrenia, with a significant skewing to a greater proportion (71% vs. 47%) of the paranoid subtype among “de novo” patients. On inclusion, 9% were suffering an acute exacerbation, 72% showed a stable disorder, and 18% had active symptoms. Up to 96% of patients included “de novo” had been previously treated with antipsychotic drugs, mainly risperidone (27%), and olanzapine (17%). After inclusion in the study, the antipsychotic drugs most frequentely prescribed were aripiprazole (25%), risperidone (18%), olanzapine (10%), and amisulpiride (8%). Training for psychosocial functioning, and occupational therapy (about 15% each) were the most frequent non-pharmacologic interventions (44% of all patients) used before entering in the study.
Patients observed were predominantly unmarried young males with paranoid schizophrenia. The proportion of patients with this subtype was greater than that recorded for patients who previously participated in ACE 2004 study. A trend towards treatment with aripiprazole or risperidone was observed.
CYP2D6 metabolizes risperidone into 9-hydroxi-risperidone, as well as other drugs. CYP2D6 shows genetic polymorphism, and 6-8% of Caucasians are “slow metabolizers”. “Fast metabolizers” show lower plasma levels of risperidone and higher levels of 9-hydroxi-risperidone than “slow metabolizers”. The aim of this study is to collect information about the hypothetical relationship between metabolism phenotype and parameters related to sanitary resources utilization in patients treated with risperidone.
Plasma levels of risperidone and 9-hydroxi-risperidone were determined in 52 patients treated at the Acute Unit setting, to establish their metabolism phenotype. Patients were grouped as fast (n=11), slow (n=13) or intermediate metabolizers (n=28), according to risperidone/9-hydroxi-risperidone ratio logarithm and using eighty and twenty percentiles as cut-points. Hospitalizations, emergency services utilization and visits to community mental health center during two years were recorded in the three groups.
Fast metabolizers showed a higher mean number of visits to community mental health centers (35.7 vs 24.8, fast and slow metabolizers respectively, p=0.667), a higher mean number of hospitalizations (2.45 vs 1.3, fast and slow metabolizers respectively; p=0.091), a longer mean length of hospitalizations (57.3 vs 47.6 days, fast and slow metabolizers respectively; p=0.581) and a higher number of visits to emergency services (2.45 vs 1, fast and slow metabolizers respectively; p=0.01), although differences only reached statistical significance in this last parameter.
In spite of methodological limitations (mainly the small sample size), the present study shows some preliminary evidence about the influence of pharmacogenetic factors on the evolution of psychotic patients treated with risperidone.
Six hundred psychiatrists from private and public Spanish clinics registered the first four patients with schizophrenia seen at their offices during 2004. Sociodemographic characteristics, diagnostic criteria, clinical features, and therapy patterns, including adherence to treatment, were recorded.
A total of 2,154 patients were included in the study (86% ≤50 years old; 69% males; 79% unmarried), half of them had elementary school studies only while a 28% had a university degree. Male to female significant differences were observed regarding patterns of cigarette, alcohol, and illegal substance comsumption. A 69% of patients had paranoid schizophrenia, 13% presented with residual schizophrenia, and the remaining 18% had other types. The paranoid and hebephrenic types were the predominant types seen in patients ≤50 years old, while residual schizophrenia was most frequently seen in patients >50. When admitted into the study, 10% of patients were in an acute phase, 19% showed active symptoms, and the remaining 71% showed a stable disorder. Antipsychotic medications more frequently prescribed before enrolment were risperidone (29%), olanzapine (19%), and clozapine, quietapine, amisulpiride and haloperidol (7% each). The most common non-pharmacologic therapy prescribed to patients before entering the study was occupational therapy.
Patients included in this observational study were predominantly males <50 year old who presented with paranoid schizophrenia. Almost all patients had received antipsychotic medication before entering the study, mainly risperidone and olanzapine.
The studies about the comorbidity of major depressive disorder (MDD) and bipolar disorder (BD) have increased in the last years. The comorbidity with Axis I psychiatric disorders complicates the diagnosis, prognosis and treatment.
To analyze the prevalence of affective disorders associated with another Axis I psychiatric disorders to treat correctly from the beginning of the diagnosis and to improve the course of the disorder and the quality of life of these patients
The subjects who participated in the study were diagnosed of bipolar I disorder, bipolar II disorder and MDD, according to DSM-IV-TR criteria. The sample (n = 114) was divided into three groups: MDD (n = 58), BD (n = 31) and a control group of healthy subjects (n = 25). The diagnosis and stability were assessed using the MINI International Neuropsyquiatric Interview and the Hamilton Depression Rating Scale (HDRS).
BD had a significantly association with risk of suicide (38%), anxiety disorder (3.3%) and social phobia (12.9%). It was also reported a significant association between MDD and risk of suicide (71%), manic/hypomanic episodes (25.9%), anxiety disorder (37.9%), social phobia (25.9%) and generalized anxiety disorder (37.9%).
It is necessary for clinical practice an integrative model which takes into account the comorbidity of affective disorders to improve the response to treatment and the prognosis of these mental disorders
Recent epidemiological studies suggest that the prevalence of bipolar disorder might be misdiagnosed initially as unipolar depression due to the difficulty to detect episodes of hypomania. The Hypomania Checklist (HCL-32), validated in Spanish, is a self-report questionnaire with 32 hypomania items designed to screen for hypomanic episodes.
To examine the prevalence of hypomania in patients with unipolar depression. Corroborate the efficacy of the HCL-32 to detect symptoms of hypomania.
The presence of hypomanic symptoms was assessed by the HCL-32 in a sample of 128 subjects diagnosed with bipolar I disorder (n = 30), bipolar II disorder (n = 1), unipolar depression (n = 57), and anxiety disorder (n = 15) according to DSM-IV-TR criteria. A control group of healthy subjects was selected (n = 25).
The discriminative capacity was analyzed by the ROC curve. The AUC was 0.65 which did not indicate a good capacity. The sensitivity (S), specificity (E) and prevalence (P) of hypomania in unipolar patients for the following cut-off points were :14: S = 81.6%,95%CI(69.8, 93.5); E = 30.1%,95%CI(19.7,40.6); P = 74.1%; 15: S = 77.6%,95%CI(64.9,90.3); E = 37.4%,95%CI(26.3,48.4); P = 67.2%; 16: S = 59.2%,95%CI(44.4,73.9); E = 55.4%,95%CI(44.1,74.0); P = 51.7%; 17: S = 55.1%,95%CI(40.2,70.1); E = 57.8%,95%CI(46.6,69.1); P = 48.3%.
The HCL-32 has a high sensitivity but a low specificity as screening instrument. This might explain the high proportion of hypomania found in this study. The difference with previous studies is that our sample was heterogeneous, unstable and serious. This suggests that the HCL-32 is not valid for any psychiatric sample. Future research should develop more specific instruments with better external validity.