Transcultural validity of the Hypomania Checklist–32 (HCL-32) in patients with major depressive episodes

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There is mounting evidence that current diagnostic systems inadequately recognize clinically relevant levels of hypomania in depressed patients, thereby leading to an under-diagnosis of bipolar disorders and the associated risk of treatment that is inappropriate or may actually worsen illness course. The Hypomania Checklist–32 revised version 2 (HCL-32-R2) is a self-rating scale for hypomanic symptoms specifically developed to address this problem. The goal of this study was to assess the transcultural validity of the HCL-32-R2.


Measurement invariance of HCL-32-R2 responses from the multinational Bipolar Disorders: Improving Diagnosis, Guidance, and Education (BRIDGE) Study of 5635 patients with major depressive episodes (MDEs) was assessed by exploratory and confirmatory factor analysis across five cultural regions.


Two previously identified factors were reproduced and explained 60% of the variance in test responses. Only three out of 32 items had cross-culturally variable factor loadings. Some moderate measurement invariance was also found with regard to age and gender. In discriminating unipolar from bipolar disorder, the HCL-32-R2 showed a sensitivity of 82% with a specificity of 57% when current DMS-IV criteria for bipolar disorder were used, and substantially higher specificity of 73% when evidence-based modified criteria were applied.


The psychometric properties of the HCL-32-R2 were largely culture-independent. This finding replicates that of our previous international study and is a step towards validating the HCL-32-R2 as a broadly applicable screening instrument for hypomanic features, facilitating the detection of hidden bipolarity in depressed patients.

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