Use of the 33-Item Hypomania Checklist (HCL-33) to Distinguish Bipolar Disorder From Major Depressive Disorder in Older Adults

Xinqiao Zhang, Wen Li, Na Zhao, Teris Cheung, Gabor S. Ungvari, Gang Wang, Yu Tao Xiang, Jules Angst

Research output: Journal article publicationJournal articleAcademic researchpeer-review

1 Citation (Scopus)


Background: Bipolar disorder (BD) is often misdiagnosed as major depressive disorder (MDD) in older patients. This study examined the psychometric properties of the 33-item Hypomania Checklist (HCL-33) and its accuracy to differentiate BD from MDD among older adults. 

Method: A total of 215 depressed older patients were recruited; 107 were diagnosed with BD (71 with BD-type I and 36 with BD-type II) and 108 with MDD. Principal components analysis (PCA) was used to explore the factor structure of the HCL-33. Cronbach’s alpha was calculated to test the internal consistency. Intra-class correlation coefficient (ICC) was used to measure test-retest reliability. The receiver operating characteristic (ROC) analysis was used to generate the optimal cut-off value to differentiate between BD and MDD. 

Results: Two factors were identified in the PCA analysis accounting for 33.9% of the total variance. The Cronbach’s alpha value for the HCL-33 was 0.912, with 0.922 for factor I and 0.664 for factor II. The test-retest reliability was excellent (ICC: 0.891). The optimal cut-off of the HCL-33 total score for discriminating between MDD and BD was 14, with a sensitivity of 88.8% and specificity of 82.4%. 

Conclusion: The HCL-33 had satisfactory reliability and validity and could be used to distinguish BD from MDD in older adults.

Original languageEnglish
JournalJournal of Geriatric Psychiatry and Neurology
Publication statusAccepted/In press - 28 May 2021


  • bipolar disorder
  • HCL-33
  • major depressive disorder
  • older adults
  • reliability
  • validity

ASJC Scopus subject areas

  • Clinical Neurology
  • Geriatrics and Gerontology
  • Psychiatry and Mental health


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