Translation and adaptation of the Bipolar Prodrome Symptom Scale-Retrospective: Patient Version to Brazilian portuguese

Tradução e adaptação da Bipolar Prodrome Symptom Scale-Retrospective: Patient Version para português brasileiro

ORIGINAL ARTICLE

Translation and adaptation of the Bipolar Prodrome Symptom Scale-Retrospective – Patient Version to Brazilian portuguese

Tradução e adaptação da Bipolar Prodrome Symptom Scale-Retrospective – Patient Version para português brasileiro

Pedro Mario Pan^I; Danilo Rocha de Jesus^II; Ary Gadelha^I; Rodrigo Affonseca Bressan^I; Christoph U. Correll^III; Rodrigo Barbachan Mansur^I; André Zugman^I; Cristiano Noto^I; Elson de Miranda Asevedo^I; Elisa Brietzke^I

^I Program for Recognition and Intervention in Individuals in At-Risk Mental States (PRISMA), Department of Psychiatry, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP, Brazil. Interdisciplinary Laboratory of Clinical Neurosciences (LINC), UNIFESP

^II Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario, Canada

^III The Zucker Hillside Hospital, Psychiatry Research, North Shore - Long Island Jewish Health System, Glen Oaks, NY, USA. Albert Einstein College of Medicine, Bronx, NY, USA. The Feinstein Institute for Medical Research, Manhasset, NY, USA. Hofstra North Shore LIJ School of Medicine, Hempstead, NY, USA

^{Correspondence}

ABSTRACT

BACKGROUND: Bipolar disorder (BD) is a chronic and often severe mental disease, associated with a significant burden in affected individuals. The characterization of a premorbid (prodromal) period and possible development of preventive interventions are recent advances in this field. Attempts to characterize high-risk stages in BD, identifying symptoms prior to the emergence of a first manic/hypomanic episode, have been limited by a lack of standardized criteria and instruments for assessment. The Bipolar Prodrome Symptom Scale-Retrospective (BPSS-R), developed by Correll and collaborators, retrospectively evaluates symptoms that occur prior to a first full mood episode in individuals with BD.

OBJECTIVE: To describe the translation and adaptation process of the BPSS-R to Brazilian Portuguese.

METHOD: Translation was conducted as follows: 1) translation of the scale from English to Brazilian Portuguese by authors who have Portuguese as their first language; 2) merging of the two versions by a committee of specialists; 3) back-translation to English by a translator who is an English native speaker; 4) correction of the new version in English by the author of the original scale; 5) finalization of the new version in Brazilian Portuguese.

RESULTS: All the steps of the translation process were successfully accomplished, resulting in a final version of the instrument.

CONCLUSIONS: The Brazilian Portuguese version of the BPSS-R is a potentially useful instrument to investigate prodromal period of BD in Brazil.

Keywords: Bipolar disorder, at-risk mental sates, questionnaire, prodromal symptoms.

RESUMO

INTRODUÇÃO: O transtorno bipolar (TB) é um transtorno mental crônico e muitas vezes grave, associado a um significativo prejuízo psicossocial nos indivíduos afetados. A caracterização de um período pré-mórbido (prodrômico) e o possível desenvolvimento de intervenções preventivas são avanços recentes na área. Tentativas de caracterizar estágios de alto risco para o TB, através da identificação de sintomas antes do aparecimento de um primeiro episódio maníaco/hipomaníaco, têm sido limitadas pela falta de critérios padronizados e instrumentos de avaliação. A Bipolar Prodrome Symptom Scale-Retrospective (BPSS-R), desenvolvida por Correll e colaboradores, avalia retrospectivamente os sintomas que ocorrem antes de um episódio sindrômico de humor em indivíduos com TB.

OBJETIVO: Descrever o processo de tradução e adaptação da BPSS-R para português brasileiro.

MÉTODO: A tradução foi conduzida como segue: 1) tradução da escala de inglês para português brasileiro por autores que têm o português como língua materna; 2) junção das duas versões por um comitê de especialistas; 3) retrotradução para inglês por um tradutor que tem inglês como língua materna; 4) correção da nova versão em inglês pelo autor do instrumento original; 5) finalização da nova versão em português brasileiro.

RESULTADOS: Todos os passos do processo de tradução foram completados com sucesso, resultando em uma versão final do instrumento.

CONCLUSÕES: A versão da BPSS-R em português brasileiro é um instrumento potencialmente útil para investigar o período prodrômico do TB no Brasil.

Descritores: Transtorno bipolar, estados mentais de risco, questionário, sintomas prodrômicos.

Introduction

Bipolar disorder (BD) is a chronic, highly prevalent, potentially severe mood disorder, associated with significant suffering, functional impairment, and higher mortality rates compared with the general population.^1,2 In addition, BD requires long-term pharmacological and psychosocial treatment, in most cases with only partial efficacy.³ Therefore, strategies that can help prevent BD, reduce symptom severity and functional deficits, and possibly delay its onset are needed.

Lack of knowledge of the psychopathology and neurobiology of the transition to the first mood episode limits research in the primary prevention of BD.⁴ Consequently, delayed and often mistaken diagnoses are made, leading to exposure of a large number of individuals with BD to antidepressants, benzodiazepines, and psychostimulants, which can have potential negative effects on their symptomatology.⁴

Clinicians and even patients with BD largely recognize the existence of a period before the onset of the first manic/hypomanic episode in which subsyndromic symptoms are present (prodromal period).^5,6 The adequate characterization of this period has received relatively little attention until recently, but studies on prodromal psychosis have revealed promising results.^7,8 The growing evidence showing that the prodromal period is part of the evolution of BD resulted in the inclusion of this pre-clinical or prodromal period in BD staging models.^9,10 Akiskal et al. prospectively studied 68 adolescents who had a first-degree relative diagnosed with BD and were the first to suggest the existence of a prodromal stage of BD. They observed a high rate of mild mood symptoms, especially with a depressive polarity.¹¹ After that first study, several others have tried to characterize this critical period.^12,13 Because pre-clinical symptoms are not observed in all individuals with BD, prospective studies have suggested the denomination "bipolar at-risk" or "ultra-high risk" rather than "prodromal" to refer to these patients.

One important limitation of research on the early stages of BD is the scarcity of instruments available to evaluate prodromal symptoms. In this scenario, the Bipolar Prodrome Symptom Scale-Retrospective (BPSS-R), developed by Correll et al., retrospectively evaluates symptoms occurring prior to the first mood episode in individuals with BD.¹⁴ The BPSS-R consists of a semi-structured interview based on a downward extension of criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) and available rating scales for BD and major depressive disorder. Development of the BPSS-R was informed by a review of the literature regarding risk factors and early symptoms of BD, previously published scales and interviews designed for the assessment of psychotic prodrome and character traits, and input from experts in the prodromal stage of schizophrenia and BD. The BPSS-R assesses the onset pattern, duration, severity, and frequency of 36 symptoms and signs that emerge or worsen prior to the first major depressive and/or first manic episode. Severity of prodromal symptoms is rated using an ordinal scale, as follows: 0 = absent, 1 = mild, 2 = moderate, and 3 = severe. Symptom frequency is rated as follows: 0 = absent, 1 = infrequent, 2 = moderately frequent, 3 = very frequent, and 4 = static lifetime.¹⁴

The objective of this study was to describe the translation and adaptation of the BPSS-R to Brazilian Portuguese, in order to use the instrument in future studies designed to investigate the prodromal period of BD in Brazil.

Method

Prior to the beginning of the translation process, consent was obtained from the author of the original scale, Dr. Christoph U. Correll. Thereafter, translation and adaptation of the BPSS-R from English to Brazilian Portuguese was performed following the guidelines proposed by Guillemin et al for the adaptation of instruments.¹⁵

The translation process included the following steps: 1) translation from English to Brazilian Portuguese by two authors who have Portuguese as their first language, one of them being a psychiatrist; 2) merging of the two versions by a committee of specialists; 3) back-translation to English by a certified translator who is an English native speaker; 4) correction of the English version by the author of the original scale, Dr. Christoph Correll; and 5) final modifications suggested by the latter author and finalization of the new version in Portuguese. These steps are illustrated in Figure 1.

Results

All the steps of the translation process were successfully accomplished, and a final version of the instrument in Brazilian Portuguese was produced. Adaptations consisted primarily of changing words whose literal translation was not very common in Brazil. Following the methodological steps described above, only very few, minor modifications were made in comparison with the original version. Examples of excerpts that generated doubts throughout the process, as taken from the original version, their translation to Portuguese, back-translation, comments by the author of the original scale, and the final version in Portuguese are shown in Table 1. The full version of the scale in Brazilian Portuguese can be found in ^{Appendix 1}.

Discussion

The process of translation and adaptation here described was conducted by the authors, resulting in a Brazilian Portuguese version of a comprehensive instrument that retrospectively evaluates prodromal symptoms in individuals with BD.

The study of prodromal stages of severe mental disorders such as BD and schizophrenia has been a topic of great interest in psychiatry.⁷ The identification of such cases could offer a unique and valuable opportunity in which preventive strategies could be undertaken.^5,6,13 Although BD has been recognized as a disorder where a prodromal period is frequently reported, there is a scarcity of instruments that one can use to measure the severity, frequency, and duration of symptoms preceding the first manic/hypomanic episode. This has led to the use of non-specific scales, developed for different purposes.^16,17 However, systematic studies focusing on the bipolar prodrome and using specific instruments could potentially contribute to better define this period from a psychopathological point of view. Although the prospective evaluation of individuals in at-risk mental states is seen as a more robust research design to evaluate the transition to BD, retrospective studies are also necessary to refine the criteria to be included in prospective instruments.¹⁴ In fact, the retrospective assessment of the prodromal stage before full schizophrenia sparked the development of prospective instruments and further research on at-risk states for schizophrenia.¹⁸

Brazil has been playing a prominent role in BD research, but the lack of translated and adapted instruments has limited advances in the field. The BPSS-R (Patient and Informant versions) is the only instrument now available in Brazilian Portuguese to evaluate the bipolar prodrome. Although the availability of this instrument is a major step forward, validation in a population with BD is a necessary next step before the BPSS-R can be adopted in a number of different settings.

Submitted Feb 06 2012

accepted for publication Apr 05 2012

No conflicts of interest declared concerning the publication of this article

Financial support: none.

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Appendix 1

Publication Dates

• Publication in this collection
  22 May 2013
• Date of issue
  2013

History

• Received
  06 Feb 2012
• Accepted
  05 Apr 2012