1. 1. Name
* must provide value
Today M-D-Y
Today M-D-Y
6. What city and state do you live in?
1. How did you hear about our study/clinic?
Internet search Social media Friend Staff member Doctor or therapist Ad for a specific study Other
2. Are you able to get to our Boston clinic between 9am and 5pm?
Yes No
3. How often are you able to come to our clinic?
More than once a week Once a week Once a month Every other month
4. Do you have a smartphone?
Yes
No
5. Can you do video calls (e.g. Skype, Zoom)?
Yes
No
6. Have you ever been diagnosed with bipolar disorder?
Yes
No
6a. What type of bipolar disorder?
Bipolar I Bipolar II Bipolar disorder not otherwise specified Unsure Other
1. Some people have periods lasting several days or longer when they feel much more excited and full of energy than usual. Their minds go too fast. They talk a lot. They are very restless or unable to sit still and they sometimes do things that are unusual for them, such as driving too fast or spending too much money. Have you ever had a period liked this lasting several days or longer?
Yes
No
2. People who have episodes like this often have changes in their thinking and behavior at the same time, like being more talkative, needing very little sleep, being very restless, going on buying sprees, and behaving in ways they would normally think are inappropriate. Did you ever have any of these changes during your episodes of being excited and full of energy?
Yes
No
Think of an episode when you had the largest number of changes like these at the same time. During that episode, which of the following changes did you experience?
3. Were you so irritable that you started arguments, shouted at people, or hit people?
Yes
No
4. Did you become so restless or fidgety that you paced up and down or couldn't stand still?
Yes
No
5. Did you do anything else that wasn't usual for you-like talking about things that you would normally keep private, or acting in ways that you would usually find embarrassing?
Yes
No
6. Did you try to do things that were impossible to do, like taking on large amounts of work?
Yes
No
7. Did you constantly keep changing your plans or activities?
Yes
No
8. Did you find it hard to keep your mind on what you were doing?
Yes
No
9. Did your thoughts seem to jump from one thing to another or race through your head so fast you couldn't keep track of them?
Yes
No
10. Did you sleep far less than usual and still not get tired or sleepy?
Yes
No
11. Did you spend so much more money than usual that it caused you to have financial trouble?
Yes
No
12. When was the last period of time when your mood was consistently "high", irritable, or manic for several days on end? Skip if not applicable.
Today M-D-Y
13. Are you currently feeling this way?
Yes
No
14. Have you ever been hospitalized or in a partial hospitalization for consistently high mood or manic episode?
Yes
No
14b. When were you last hospitalized for consistently high mood or manic episode?
Today M-D-Y
1. Has there ever been a time when you were feeling depressed or down most of the day?
Yes
No
1a. Was this nearly every day?
Yes
No
1b. Did this last two or more weeks?
Yes
No
1c. When was the last time your mood was consistently down or depressed?
Today M-D-Y
1d. Are you currently feeling down or depressed?
Yes
No
2. Has there ever been a time when you lost interest or pleasure in things you usually enjoy?
Yes
No
2a. Was this nearly every day?
Yes
No
2b. Did it last two or more weeks?
Yes
No
2c. When was the last time you consistently lacked interest or pleasure in things you usually enjoy?
Today M-D-Y
3. Have you ever been hospitalized or in a partial hospitalization for consistently depressed mood?
Yes
No
3b. When were you last hospitalized for consistently depressed mood?
Today M-D-Y
1. Have you recently had thoughts that life is not worth living or thoughts about death/suicide?
Yes
No
1a. Are these passive thoughts or do you have a plan?
Passive
Have a plan
2. Have you ever attempted to hurt or kill yourself?
Yes
No
PLEASE NOTE: No one will be reviewing these responses in real time. If you answered yes to questions 1 and 2 or you are feeling suicidal, you may need medical help. Please call 911, go to your local emergency room, or contact Boston Emergency Services Team (BEST) at 1-800-981-4357.
3. Have you ever had thoughts in the past that life is not worth living or thoughts about death/suicide?
Yes
No
4. Have you ever been hospitalized for suicidal thoughts or actions?
Yes
No
1. Are you seeing a psychiatrist?
Yes
No
More than weekly Weekly Monthly Every 3 months Less than every 3 months
2. Are you seeing a psychologist, social worker, or other therapist?
Yes
No
More than weekly Weekly Monthly Every 3 months Less than every 3 months
2b. What type of therapy are you currently doing?
Cognitive Behavioral Therapy
Dialectical Behavioral Therapy
Trauma-focused therapy
Other type of individual therapy
Supportive therapy
Family counseling
Group therapy
Other
Not Sure
3. Are you currently taking any psychiatric medications?
Yes
No
3a. Which of the following medications are you currently taking?
Antipsychotic medication (e.g., Abilify, Clozaril, Seroquel)
Antidepressant medication (e.g., Lexapro, Prozac, Zoloft)
Anticonvulsant medication (e.g., Depakote, Lamictal, Trileptal)
Anxiolytic medication (e.g., Xanax, Ativan, Valium)
Mood stabilizer (e.g., Lithium)
Other
4. How many alcoholic drinks do you have in an average week?
5. How many times do you use marijuana in an average week?
6. Have you used any other recreational drugs in the past month?
Yes
No
1. Do you currently have any other medical problems?
Yes
No
2. Have you had other major medical problems in the past?
Yes
No
3. Have you ever been diagnosed with PTSD (Post-Traumatic Stress Disorder)?
Yes
No
4. Have you ever been diagnosed with MDD (Major Depressive Disorder)?
Yes
No
5. Have you ever been diagnosed with an anxiety disorder?
Yes
No
6. Are you taking any sleep aid medications?
Yes
No
Format: (ft)' (in)"
8. What is your weight in lbs?
9. Are you right-handed or left-handed?
Right
Left
9a. Do you have any interest in studies involving fMRI?
Yes
No
10. Have you ever received electroconvulsive therapy (ECT)?
Yes
No
11. Do you have any metallic plates, implants, screws, or prostheses?
Yes
No
12. Have you ever had a concussion or any head trauma?
Yes
No
13. Are you pregnant or planning to become pregnant?
Yes
No
14. Have you ever had difficulties with the law?
Yes
No
15. When you are not feeling depressed, manic, or high, do you hear voices? Do you think people can read your mind, are out to get you, or put thoughts or messages in your head?
Yes
No
16. Would you be interested in joining our patient registry? This would allow us to contact you in the future should we begin a new study that may be a good fit for you.
Yes
No
The Mass General Brigham standard is to send "encrypted" email. This requires you to initially set up and activate an account with a password. You can then use the password to access secure emails sent to you from Mass General Brigham.
17. How would you like us to email you?
Encrypted
Unencrypted
18. What is your primary motivation for doing research?
Compensation Treatment Help others Learn more about my condition Doctor recommended it Other
Thank you for completing our survey! If you need support for your mental health, please visit our website (https://dautenbipolarcenter.org/node/18) to see a list of resources for individuals with mood disorders and their families:1-800-981-HELP (1-800-981-4357) 1-617-726-2994 1-877-870-HOPE (1-877-870-4673) 1-800-SUICIDE (1-800-784-2433) 1-800-723-TALK (1-800-723-8255)
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