An item response theory evaluation of the young mania rating scale and the montgomery-asberg depression rating scale in the systematic treatment enhancement program for bipolar disorder (STEP-BD)

Abstract

Background: The Young Mania Rating Scale (YMRS) and Montgomery-Asberg Depression Rating Scale (MADRS) are among the most widely used outcome measures for clinical trials of medications for Bipolar Disorder (BD). Nonetheless, very few studies have examined the measurement characteristics of the YMRS and MADRS in individuals with BD using modern psychometric methods. The present study evaluated the YMRS and MADRS in the Systematic Treatment Enhancement Program for BD (STEP-BD) study using Item Response Theory (IRT).

Methods: Baseline data from 3716 STEP-BD participants were available for the present analysis. The Graded Response Model (GRM) was fit separately to YMRS and MADRS item responses. Differential item functioning (DIF) was examined by regressing a variety of clinically relevant covariates (e.g., sex, substance dependence) on all test items and on the latent symptom severity dimension, within each scale.

Results: Both scales: 1) contained several items that provided little or no psychometric information, 2) were inefficient, in that the majority of item response categories did not provide incremental psychometric information, 3) poorly measured participants outside of a narrow band of severity, 4) evidenced DIF for nearly all items, suggesting that item responses were, in part, determined by factors other than symptom severity.

Limitations: Limited to outpatients; DIF analysis only sensitive to certain forms of DIF.

Conclusions: The present study provides evidence for significant measurement problems involving the YMRS and MADRS. More work is needed to refine these measures and/or develop suitable alternative measures of BD symptomatology for clinical trials research.

Trial registration: ClinicalTrials.gov NCT00012558.

Keywords: Item response theory; Montgomery-asberg depression rating scale; STEP-BD; Young mania rating scale.

Figure 1

Category Response Curves for each YMRS item. Curves indicate the probability of individuals at varying levels of manic symptom severity choosing each response option.

Figure 2

Item and test information curves for the YMRS. Curves indicate the amount of psychometric information (i.e., the reciprocal of the standard error of measurement) provided by each item, as well as the overall test, at each level of manic symptom severity.

Figure 3

Category Response Curves for each MADRS item. Curves indicate the probability of individuals at varying levels of depressive symptom severity choosing each response option.

Figure 4

Item and test information curves for the MADRS. Curves indicate the amount of psychometric information (i.e., the reciprocal of the standard error of measurement) provided by each item, as well as the overall test, at each level of depressive symptom severity.