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The Bech-Rafaelsen Mania Scale in Clinical Trials of Therapies for Bipolar Disorder

A 20-Year Review of its Use as an Outcome Measure

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Abstract

Over the last two decades the Bech-Rafaelsen Mania Scale (MAS) has been used extensively in trials that have assessed the efficacy of treatments for bipolar disorder. The extent of its use makes it possible to evaluate the psychometric properties of the scale according to the principles of internal validity, reliability, and external validity.

Studies of the internal validity of the MAS have demonstrated that the simple sum of the 11 items of the scale is a sufficient statistic for the assessment of the severity of manic states. Both factor analysis and latent structure analysis (the Rasch analysis) have been used to demonstrate this. The total score of the MAS has been standardised such that scores below 15 indicate hypomania, scores around 20 indicate moderate mania, and scores around 28 indicate severe mania.

The inter-observer reliability has been found to be high in a number of studies conducted in various countries.

The MAS has shown an acceptable external validity, in terms of both sensitivity and responsiveness. Thus, the MAS was found to be superior to the Clinical Global Impression scale with regard to responsiveness, and sensitivity has been found to be adequate, with the MAS able to demonstrate large drug-placebo differences.

Based on pretreatment scores, trials of antimanic therapies can be classified into: (i) ultrashort (1 week) therapy of severe mania; (ii) short-term therapy (3 to 8 weeks) of moderate mania; (iii) short-term therapy of hypomanic or mixed bipolar states; and (iv) long-term (12 months) therapy of bipolar states. The responsiveness of MAS is such that the scale has been able to demonstrated that typical antipsychotics are effective as an ultrashort therapy of severe mania; that lithium and anticonvulsants are effective in the short-term therapy of moderate mania; and that atypical antipsychotics, electroconvulsive therapy (ECT) and transcranial magnetic stimulation seem to have promising effects in the short-term therapy of moderate mania. In contrast, the scale has been used to demonstrate that calcium antagonists (e.g. verapamil) are ineffective in the treatment of mania. MAS has also been used to add to the literature on the evidence-based effect of lithium as a short-term therapy for hypomania or mixed bipolar states and as a long-term therapy of bipolar states.

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References

  1. 1.

    Hamon J, Paraire J, Velluz J. Remarques sur l’action du 4560 RP sur l’agitation manique. Ann Med Psychol (Paris) 1952; 110:331–5

  2. 2.

    Delay J, Deniker P. 38 cas de psychose traitées par la cure prolongée et continuée de 4560 RP Le Congrès de Psychiat Neurol de langue française. Luxembourg: Masson, 1952: 503–13

  3. 3.

    Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry 1960; 23: 56–62

  4. 4.

    Hamilton M. The assessment of anxiety states by rating. Br J Med Psychol 1959; 32: 50–5

  5. 5.

    Hamilton M. Development of a rating sale for primary depressive illness. Br J Soc Clin Psychol 1967; 6: 278–96

  6. 6.

    Hamilton M. Diagnosis and rating of anxiety. Br J Psychiatry 1969; Spec, issue: 76–9

  7. 7.

    Bech P, Bolwig T, Dein E, et al. Quantitative rating of manic sates. Acta Psychiatr Scand 1975; 52: 1–6

  8. 8.

    Bech P, Rafaelsen OJ, Kramp P, et al. The mania rating scale: scale construction and inter-observer agreement. Neuropharmacology 1978; 17: 430–1

  9. 9.

    Bech P, Bolwig TG, Kramp P, et al. The Bech-Rafaelsen Mania Scale and the Hamilton Depression Scale. Acta Psychiatr Scand 1979; 59: 420–30

  10. 10.

    Bech P, Kastrup M, Rafaelsen OJ. Mini-compendium of rating scale for states of anxiety, depression, mania, schizophrenia with corresponding DSM-III syndromes. Acta Psychiatr Scand 1986; 73Suppl. 326: 1–37

  11. 11.

    Smolka M, Stieglitz RD. On the validity of the Bech-Rafaelsen Melancholia Scale (BRMS).J Affect Disord 1999; 54: 119–28

  12. 12.

    Rafaelsen OJ, Bech P, Bolwig TG, et al. The Bech-Rafaelsen combined rating scales for mania and melancholia. Psychiatr Fennica 1980; Suppl.: 327–31

  13. 13.

    Bech P. The Bech, Hamilton and Zung scales for mood disorders. 2nd ed. Berlin: Springer-Verlag, 1996

  14. 14.

    Rossi A, Daneluzzo E, Arduini L, et al. Afactor analysis of signs and symptoms of the manic episode with Bech-Rafaelsen mania and melancholia scales. J Affect Disord 2001; 64: 267–70

  15. 15.

    Strober M, DeAntonio M, Schmidt-Lackner S, et al. Early childhood attention deficit hyperactivity disorder predicts poorer response to acute lithium therapy in adolescent mania. J Affect Disord 1998; 51: 145–51

  16. 16.

    Bech P, Baastrup PC, de Bleeker E, et al. Dimensionality, responsiveness and standardisation of the Bech-Rafaelsen Mania Scale in the ultra-short therapy with antipsychotics in patients with severe manic episodes. Acta Psychiatr Scand 2001; 104(1): 25–30

  17. 17.

    Gjerris A, Bech P, Broen-Christensen C, et al. Haloperidol plasma levels in relation to antimanic effect. In: Usdin E, Dahl SG, Gram LF, et al., editors. Clinical pharmacology in psychiatry. London: McMillan, 1980: 227–32

  18. 18.

    Abraham G, Delva N, Waldron J, et al. Lithium treatment: a comparison of once- and twice-daily dosing. Acta Psychiatr Scand 1992; 85: 65–9

  19. 19.

    Johnstone EC, Crow TJ, Frith CD, et al. The Northwick Park ‘functional’ psychosis study: diagnosis and treatment response. Lancet 1988 Jul 16; II(8603): 119–25

  20. 20.

    Fleischhacker WW, Barnas C, Gunther V, et al. Mood-altering effects of biperiden in healthy volunteers. J Affect Disord 1987; 12: 153–7

  21. 21.

    Jensen HV, Plenge P, Mellerup ET, et al. Lithium prophylaxis of manic depressive disorder: daily lithium dosing schedule versus every second day. Acta Psychiatr Scand 1995; 92: 69–74

  22. 22.

    American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, DC: American Psychiatric Association, 1994

  23. 23.

    Goethe JW, Fischer EH, Wright JS. Severity as a key concept in depression. J Nerv Ment Dis 1993; 181(12): 718–24

  24. 24.

    Bech P. Clinical features of mood disorders and mania. In: Gelder G, Lopez-Ibor JJ, Andreasen N, editors. New Oxford textbook of psychiatry. Oxford: Oxford University Press, 2000: 682–8

  25. 25.

    Schou M, Juel-Nielsen M, Strömgren E. The treatment of manic psychoses by the administration of lithium salts. J Neurol Neurosurg Psychiatry 1954; 17: 250–60

  26. 26.

    Baastrup PC, Poulsen JC, Schou M, et al. Prophylactic lithium: double-blind discontinuation in manic-depressive and recurrent-depressive disorders. Lancet 1970: II: 326–30

  27. 27.

    Young RC, Biggs JT, Ziegler VE, et al. Arating scale for mania: reliability, validity and sensitivity. Br J Psychiatry 1978; 133: 429–35

  28. 28.

    American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3rd ed. Washington, DC: American Psychiatric Association, 1980

  29. 29.

    American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 3rd ed. rev. Washington, DC: American Psychiatric Association, 1987

  30. 30.

    Tohen M, Sanger TM, McElroy SL, et al. Olanzapine versus placebo in the treatment of acute mania. Am J Psychiatry 1999; 156: 702–9

  31. 31.

    Juckl G, Hegerl U, Mavrogiorgou P, et al. Clinical and biological findings in a case with 48-hour bipolar ultrarapid cycling before and during valproate treatment. J Clin Psychiatry 2000; 61: 585–93

  32. 32.

    Young RC, Biggs JT, Ziegler VE, et al. Young mania rating scale. In: Rush AJ, Pincus HA, First MB, editors. Handbook of psychiatric measures. Washington, DC: American Psychiatric Association, 2000: 540–1

  33. 33.

    Mishory A, Yaroslavsky Y, Bersudsky Y, et al. Phenytoin as an antimanic anticonvulsant: a controlled study. Am J Psychiatry 2000; 157: 463–5

  34. 34.

    Licht RW, Jensen J. Validation of the Bech-Rafaelsen mania scale using latent structure analysis. Acta Psychiatr Scand 1997; 96: 367–72

  35. 35.

    Double DB. The factor structure of manic rating scales. J Affect Dis 1990; 18: 113–9

  36. 36.

    Double DB. A cluster analysis of manic states. Compr Psychiatry 1991; 32(3): 187–94

  37. 37.

    Verdoux H, Bourgeois M. A comparison of manic patient subgroups. J Affect Disord 1993; 27: 267–72

  38. 38.

    Goodwin FK, Jamison KR. Manic depressive illness. New York: Oxford University Press, 1990: 318–31

  39. 39.

    Häfner H, Cesarino AC, Cesarino-Krantz M. Konstanz und Variabilität klinisch psychiatrischer diagnosen über sechs Jahrzehnte. Soc Psychiatry 1967; 2: 14–25

  40. 40.

    Nunnally JC, Bernstein IH. Psychometric theory. 3rd ed. New York: McGraw-Hill, 1994

  41. 41.

    Mokken RJ. A theory and procedure of scale analysis. Paris: Mouton, 1971

  42. 42.

    Janowsky DS, Leff M, Epstein RS. Playing the manic game. Arch Gen Psychiatry 1970; 22: 252–61

  43. 43.

    Ghaemi N, Sachs GS, Goodwin FK. What is to be done? Controversies in the diagnosis and treatment of manic-depressive illness. World J Biol Psychiatry 2000; 2: 65–74

  44. 44.

    Mei Q. Application of schedule for affective disorders and schizophrenia research diagnostic criteria (SADS/RDC) in manic patients [in Chinese]. Zhonghua Shen Jing Jing Shen Ke Za Zhi 1991; 24(4): 200–2, 251

  45. 45.

    Guy W. ECDEU assessment manual for psychopharmacology. Publication No. 76-338. Rockville (MD); National Institute of Mental Health, 1976

  46. 46.

    Thau K, Meszaros K, Simhandl C. Three cases of severe mania successfully treated with high-dosage lithium-carbonate. Pharmacopsychiatry 1991; 24: 85–8

  47. 47.

    Chen PJ. The efficacy and blood concentration monitoring of carbamazepine on mania [in Chinese]. Zhonghua Shen Jing Jing Shen Ke Za Zhi 1990 Oct; 23(5): 261–5, 318

  48. 48.

    Moncrieff J. Lithium: evidence reconsidered. Br J Psychiatry 1997; 171: 113–9

  49. 49.

    Maggs R. Treatment of manic illness with lithium carbonate. Br J Psychiatry 1963; 109: 562–5

  50. 50.

    Goodwin FK, Murphy DL, Bunney WE. Lithium-carbonate treatment in depression and mania: a longitudinal double-blind study. Arch Gen Psychiatry 1969; 21: 486–96

  51. 51.

    Stokes PE, Shamoian CA, Stoll PM, et al. Efficacy of lithium as acute treatment of manic-depressive illness. Lancet 1997; I: 1319–25

  52. 52.

    Bowden CL, Brugger AM, Swann AC, et al. Efficacy of divalproex vs lithium and placebo in the treatment of mania. JAMA 1994; 27: 918–24

  53. 53.

    Frank E, Prien RF, Jarrett RB. Conceptualization and rationale for consensus definitions of terms in major depression. Arch Gen Psychiatry 1991; 48: 851–5

  54. 54.

    Kupfer DJ. Long-term treatment of depression. J Clin Psychiatry 1991; 52 Suppl. 5:28–34

  55. 55.

    Maguire J. Clonidine: an effective anti-manic agent? Br J Psychiatry 1997; 150: 863–4

  56. 56.

    Walton SA, Berk M, Brook S. Superiority of lithium over verapamil in mania: a randomized, controlled single-blind trial. J Clin Psychiatry 1996; 57: 543–46

  57. 57.

    Grunze H, Erfurth A, Amann B, et al. Intravenous valproate loading in acutely manic and depressed bipolar I patients. J Clin Psychopharmacol 1999; 19: 303–9

  58. 58.

    Small JG, Klapper MH, Kellams JJ, et al. Electroconvulsive treatment compared with lithium in the management of manic states. Arch Gen Psychiatry 1988; 45: 727–32

  59. 59.

    Gouliaev G, Licht RW, Vestergaard P, et al. Treatment of manic episodes: zuclopenthixol and clonazepam versus lithium and clonazepam. Acta Psychiatr Scand 1996; 93: 119–24

  60. 60.

    Müller AA, Stoll KD. Carbamazepine and oxcarbazepine in the treatment of manic syndromes. In: Emrich HM, Okuma T, Müller AA, editors. Anticonvulsants in affective disorders. Amsterdam: Excerpta Medica, 1984: 139–47

  61. 61.

    Emrich HM. Studies with oxcarbazepine in acute mania. J Clin Psychopharmacol 1990; 5: 83–8

  62. 62.

    Lusznat RM, Murphy DP, Nunn CM. Carbamazepine vs lithium in the treatment and prophylaxis of mania. Br J Psychiatry 1988; 153: 198–204

  63. 63.

    Hardy MC, Lecrubier Y, Widlöcher D. Efficacy of clonidine in 24 patients with acute mania. Am J Psychiatry 1986; 143: 1450–5

  64. 64.

    Sethi BB, Tiwari SC. Carbamazepine versus chlorpromazine in mania: a double-blind trial. In: Emrich HM, Okuma T, Müller AA, editors. Anticonvulsants in affective disorders. Amsterdam: Excerpta Medica, 1984: 167–76

  65. 65.

    Erfurth A, Kammerer C, Grunze H, et al. An open label study of gabapentin in the treatment of acute mania. J Psychiatr Res 1998; 32: 261–4

  66. 66.

    Bozikas V, Petrikis P, Karavatos A. Treatment of acute mania with gabapentin. Int J Neuropsychopharmacol 2000; 3Suppl. 1:S335

  67. 67.

    Bereen FJ, Harte FB, Maguire J, et al. The use of oral zuclopenthixol in the treatment of functional psychotic illness. Pharmatherapeutica 1987; 5: 62–8

  68. 68.

    Grunze H, Erfurth A, Marcuse A, et al. Tiagabine appears not to be efficacious in treatment of acute mania. J Clin Psychiatry 1999; 60: 759–62

  69. 69.

    Frank E, Kupfer DJ, Gerebtzoff A, et al. The development of study exit criteria for evaluating antimanic compounds. J Clin Psychiatry 2001; 62: 421–5

  70. 70.

    Erfurth A, Michael N, Mostert C, et al. Euphoric mania and rapid transcranial magnetic stimulation. Am J Psychiatry 2000; 157: 835–6

  71. 71.

    Lauritzen L, Odgaard K, Clemmesen L, et al. Relapse prevention of paroxetine in ECT treated patients with major depression: a comparison with imipramine and placebo in medium-term continuation therapy. Acta Psychiatr Scand 1996; 94; 18–25

  72. 72.

    Möller HJ, Kissling W, Riehl T, et al. Double-blind evaluation of the antimanic properties of carbamazepine as a comedication to haloperidol. Prog Neuropsychopharmacol Biol Psychiatry 1989; 13: 127–36

  73. 73.

    Chou JC. Recent advances in treatment of acute mania. J Clin Psychopharmacol 1991 Feb; 11(1): 3–21

  74. 74.

    Sokolski KN, DeMet EM. Pupillary cholinergic sensitivity to pilocarpine increases in manic lithium responders. Biol Psychiatry 1999; 45: 1580–4

  75. 75.

    DeMet EM, Sokolski KN. Sodium valproate increases pupillary responsiveness to a cholinergic agonist in responders with mania. Biol Psychiatry 1999; 46: 432–6

  76. 76.

    Sokolski KN, Green C, Maris DE, et al. Gabapentin as an adjunct to standard mood stabilizers in outpatients with mixed bipolar symptomatology. Ann Clin Psychiatry 1999; 11(4): 217–22

  77. 77.

    Licht RW. Validiteten af randomiserede kliniske undersøgelser af psykofarmakas effekt ved mani [thesis]. Denmark: University of Aarhus, FADL, 1999

  78. 78.

    Tohen M, Jacobs TG, Grundy SL, et al. Efficacy of olanzapine in acute bipolar mania: a double-blind, placebo-controlled study. Arch Gen Psychiatry 2000; 57: 841–9

  79. 79.

    Garfinkel PE, Stancer HC, Persad E. A comparison of haloperidol, lithium carbonate and their combination in the treatment of mania. J Affect Disord 1980; 2: 279–88

  80. 80.

    Rifkin A, Doddi S, Karajgi B, et al. Dosage of haloperidol for mania. Br J Psychiatry 1994; 165: 113–6

  81. 81.

    Klein DF, Oaks G. Importance of psychiatric diagnosis in prediction of clinical drug effects. Arch Gen Psychiatry 1967;16: 118–26

  82. 82.

    Prien RF, Caffey EM, Klett CJ. Comparison of lithium and chlorpromazine in the treatment of mania. Arch Gen Psychiatry 1972; 26: 146–53

  83. 83.

    Schou M. Lithium treatment. Br J Psychiatry 1986; 149: 541–7

  84. 84.

    Tyrer SP. Lithium in the treatment of mania. J Affect Disord 1985; 8: 251–7

  85. 85.

    Segal J, Walton S, Clark H, et al. Pharmacotherapy of mania: a review. Int J Psychiatry Clin Pract 2000; 4: 171–93

  86. 86.

    Post RM, Ketter TA, Denicoff K, et al. The place of anticonvulsant therapies in bipolar illness. Psychopharmacology (Berl) 1996; 128(2): 115–29

  87. 87.

    Licht RW. Drug treatment of mania: a critical review. Acta Psychiatr Scand 1998; 97: 387–97

  88. 88.

    Licht R. Typical and atypical antipsychotics in bipolar disorder. Acta Neuropsychiatr 2000; 12: 115–19

  89. 89.

    Kusumakar V, Yatham LN, Haslam DR, et al. Treatment of mania, mixed state, and rapid cycling. Can J Psychiatry 1997; 42Suppl. 2: 79S–86S

  90. 90.

    Licht RW, Bysted M, Christensen H. Risperidone versus zuclopenthixol in mania: an open experimental trial with a historical control group. Nord J Psychiatry 2000; 54Suppl. 43: 38

  91. 91.

    Segal J, Berk M, Brook S. Risperidone compared with both lithium and haloperidol in mania: a double-blind randomized controlled trial. Clin Neuropharmacol 1998; 21: 176–80

  92. 92.

    Aubry J-M, Simon AE, Bertschy G. Possible induction of mania and hypomania by olanzapine and risperidone: a critical review of reported cases. J Clin Psychiatry 2000; 61: 649–55

  93. 93.

    Mukherjee S, Sackeim HA, Schnur DB. Electroconvulsive therapy of acute manic episodes: a review of 50 years’ experience. Am J Psychiatry 1994; 151: 169–76

  94. 94.

    Grisaru N, Chudakov B, Yaroslavsky Y, et al. Transcranial magnetic stimulation in mania: a controlled study. Am J Psychiatry 1998; 155: 1608–10

  95. 95.

    Frank E, Kupfer DJ, Perel JM. Three-year outcomes for maintenance therapies in recurrent depression. Arch Gen Psychiatry 1990; 47: 1093–9

  96. 96.

    Frank E, Hlastala S, Ritenour A, et al. Inducing lifestyle regularity in recovering bipolar disorder patients: results from the maintenance therapies in bipolar disorder protocol. Biol Psychiatry 1997; 41: 1165–73

  97. 97.

    Kupfer DJ, Frank E, Perel JM, et al. Five year outcome for maintenance therapies in recurrent depression. Arch Gen Psychiatry 1992; 49: 769–73

  98. 98.

    Hlastala SA, Frank E, Mallinger A, et al. Bipolar depression: an underestimated challenge. Depress Anxiety 1997; 5: 73–83

  99. 99.

    Frank E, Kupfer DJ, Gibbon R, et al. Interpersonal and social rhythm therapy: an adjunct to pharmacotherapy of bipolar disorder. Int J Neuropsychiatry 2000; 3Suppl. 1: 9

  100. 100.

    Pradhan SC, Sinha VK, Singh TB. Psycho-social dysfunction in patients after recovery from mania and depression. Int J Rehabil Res 1999; 22: 303–9

  101. 101.

    Coxhead N, Silverstone T, Cookson J. Carbamazepine versus lithium in the prophylaxis of bipolar affective disorder. Acta Psychiatr Scand 1992; 85: 114–8

  102. 102.

    Bech P, Vendsborg PB, Rafaelsen OJ. Lithium maintenance treatment of manic-melancholic patients. Acta Psychiatr Scand 1976; 53: 70–81

  103. 103.

    Baastrup PC, Hollnagel P, Sorensen R. Adverse reactions in treatment with lithium carbonate and haloperidol. JAMA 1976; 231: 2645–6

  104. 104.

    Müller-Oerlinghausen B. Drug interactions with lithium: a guide for clinicians. CNS Drugs 1999; 11(1): 41–8

  105. 105.

    Bech P. Pharmacological treatment of depressive disorders: a review. In: Maj M, Sartorius N, editors. Depressive disorders: WPA series evidence and experience in psychiatry. Chichester: John Wiley & Sons, 1999: 89–127

  106. 106.

    Silverstone T. Is lithium still the maintenance treatment choice for bipolar disorder? CNS Drugs 2000; 14(2): 81–94

  107. 107.

    Baldessarini RJ, Tondo L. Does lithium treatment still work? Evidence of stable responses over three decades. Arch Gen Psychiatry 2000; 57: 187–90

  108. 108.

    Greil W, Ludwig-Mayerhofer W, Erazo W. Lithium versus carbamazepine in the maintenance treatment of bipolar disorders — a randomized study. J Affect Disord 1997;43:151–61

  109. 109.

    Greil W. Pharmacological management of bipolar disorder [abstract]. Eur Neuropsychopharmacol 2001; 11Suppl. 2: 31

  110. 110.

    Hartong E. The prophylactic effect of lithium and carbamazepine in patients with bipolar disorder [thesis; in Dutch]. Nijmegen: University of Nijmegen, 2000

  111. 111.

    Davis LL, Ryan W, Adinoff B, et al. Comprehensive review of the psychiatric uses of valproate. J Clin Psychopharmacol 2000; 20Suppl. 1: 1–17

  112. 112.

    Henry C, Sorbara F, Lacosta J, et al. Antidepressant-induced mania in bipolar patients: identification of risk factors. J Clin Psychiatry 2001; 62: 249–55

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Acknowledgements

This study was initiated when I acted as the official opponent at the defence of Rasmus W. Licht’s thesis. The manuscript has been discussed with Mogens Schou and Jens Christian Baastrup. Both had commented my first lithium study in 1976. Baastrup, for a long time, opposed the use of rating scales but became convinced of their usefulness when evaluating antimanic therapies. Baastrup died in August 2001, just after the release of a joint publication on the MAS. The manuscript was also discussed with Bruno Müller-Oerlinghausen and Wolfgang Fleischhacker who both made valuable suggestions.

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Correspondence to Prof. Per Bech.

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Bech, P. The Bech-Rafaelsen Mania Scale in Clinical Trials of Therapies for Bipolar Disorder. Mol Diag Ther 16, 47–63 (2002). https://doi.org/10.2165/00023210-200216010-00004

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Keywords

  • Attention Deficit Hyperactivity Disorder
  • Bipolar Disorder
  • Haloperidol
  • Transcranial Magnetic Stimulation
  • Clinical Global Impression