The present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services pr... more The present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project examined whether symptoms that are not part of the DSM-IV definition of major depressive disorder (MDD) are better at discriminating depressed from nondepressed patients than the current criteria. Symptoms assessed included diminished drive, helplessness, hopelessness, nonreactive mood, psychic anxiety, somatic anxiety, subjective anger, and overtly expressed anger. A total of 1538 psychiatric outpatients were administered a semistructured diagnostic interview. We inquired about all of the symptoms of depression for all patients. Diminished drive exhibited stronger performance in differentiating MDD from non-MDD relative to all DSM-IV criteria except depressed mood, reduced interest/pleasure, and impaired concentration/indecisiveness. A compound criterion combining diminished drive with loss of energy was endorsed by nearly all MDD patients. Helplessness and hopelessness, when combined into a single criterion, performed more strongly than some of the DSM-IV criteria. Lack of reactivity, anxiety, and anger symptoms failed to differentiate more strongly than current DSM-IV criteria. The implications of these results for revising the diagnostic criteria for major depression are discussed.
In a previous article from the Rhode Island Methods to Improve Diagnostic Assessment and Services... more In a previous article from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we reported that bipolar disorder is often overdiagnosed in psychiatric outpatients. An important question not examined in that article was what diagnoses were given to the patients who had been overdiagnosed with bipolar disorder. In the present report from the MIDAS project, we examined whether there was a particular diagnostic profile associated with bipolar disorder overdiagnosis. Eighty-two psychiatric outpatients reported having been previously diagnosed with bipolar disorder that was not confirmed when they were interviewed with the Structured Clinical Interview for DSM-IV (SCID). Psychiatric diagnoses were compared in these 82 patients and in 528 patients who were not previously diagnosed with bipolar disorder. Patients were interviewed by a highly trained diagnostic rater who administered a modified version of the SCID for DSM-IV Axis I disorders and the Structured Interview for DSM-IV Personality for DSM-IV Axis II disorders. This study was conducted from May 2001 to March 2005. The most frequent lifetime diagnosis in the 82 patients previously diagnosed with bipolar disorder was major depressive disorder (82.9%, n = 68). The patients overdiagnosed with bipolar disorder were significantly more likely to be diagnosed with borderline personality disorder compared to patients who were not diagnosed with bipolar disorder (24.4% vs 6.1%; P < .001). A previous diagnosis of bipolar disorder was also associated with significantly higher lifetime rates of major depressive disorder (P < .01), posttraumatic stress disorder (P < .05), impulse control disorders (P < .05), and eating disorders (P < .05), although only the association with impulse control disorders remained significant after controlling for the presence of borderline personality disorder. Psychiatric outpatients overdiagnosed with bipolar disorder were characterized by more Axis I and Axis II diagnostic comorbidity in general, and borderline personality disorder in particular.
Specific diagnostic criteria for pathological gambling (PG) have been available for 25 years, sin... more Specific diagnostic criteria for pathological gambling (PG) have been available for 25 years, since the publication of DSM-III. Little research has examined the psychometric performance of the diagnostic criteria. The goal of the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project was to examine the sensitivity, specificity and predictive values of the DSM-IV PG criteria for psychiatric outpatients who screened positive for a gambling problem. A total of 1709 psychiatric outpatients were evaluated with a semistructured diagnostic interview for PG. Of all patients 88 screened positive for PG, 40 of whom met DSM-IV diagnostic criteria for a lifetime history of PG. All ten DSM-IV criteria were significantly more frequent in the PG group. The sensitivity of the criteria ranged from 25.0% to 90.0% (mean = 67.8%), whereas specificity ranged from 62.5% to 100% (mean = 81.9%). Positive predictive values ranged from 64.1% to 100% (mean = 78.9%), and negative predictive values ranged from 61.5% to 90.7% (mean = 77.1%). Guidelines are recommended for determining whether a diagnostic criterion should be retained as part of the set of diagnostic criteria, and our results suggested that two of the DSM-IV PG criteria are candidates for elimination (criterion 8—commitment of illegal acts; criterion 10—reliance on others for financial assistance to relieve a desperate financial problem).
Objectives: The Mood Disorders Questionnaire (MDQ) has been the most widely studied screening qu... more Objectives: The Mood Disorders Questionnaire (MDQ) has been the most widely studied screening questionnaire for bipolar disorder, though few studies have examined its performance in a heterogeneous sample of psychiatric outpatients. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined the operating characteristics of the MDQ in a large sample of psychiatric outpatients presenting for treatment.Methods: A total of 534 psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV and asked to complete the MDQ. Missing data on the MDQ reduced the number of patients to 480, 10.4% (n = 52) of whom were diagnosed with bipolar disorder.Results: Based on the scoring guidelines recommended by the developers of the MDQ, the sensitivity of the scale was only 63.5% for the entire group of bipolar patients. The specificity of the scale was 84.8%, and the positive and negative predictive values were 33.7% and 95.0%, respectively. When impairment was not required to define a case on the MDQ, then sensitivity increased to 75.0%, specificity dropped to 78.5%, positive predictive value was 29.8%, and negative predictive value was 96.3%.Conclusions: In a large sample of psychiatric outpatients, we found that the MDQ, when scored according to the developers’ recommendations, had inadequate sensitivity as a screening measure. After the threshold to determine MDQ caseness was lowered by not requiring moderate or severe impairment, the sensitivity of the scale increased, but specificity decreased, and positive predictive value remained below 30%. These results raise questions regarding the MDQ’s utility in routine clinical practice.
Reliable, valid, user-friendly measurement is necessary to successfully implement an outcomes eva... more Reliable, valid, user-friendly measurement is necessary to successfully implement an outcomes evaluation program in clinical practice. Self-report questionnaires, which generally correlate highly with clinician ratings, are a cost-effective assessment option. However, even self-administered questionnaires can be burdensome to patients because many are lengthy. Consequently, we developed and determined the reliability and validity of ultra-brief, single-item assessments of 3 domains important to consider when treating depressed patients: symptom severity, psychosocial functioning, and quality of life. In the first study (conducted June 1997 to March 2002), 1278 psychiatric outpatients with various DSM-IV diagnoses completed single-item assessments of psychosocial functioning and quality of life as well as more detailed measures of these constructs. In the second study (conducted August 2003 to July 2004), 562 psychiatric outpatients who were in ongoing treatment for a DSM-IV major depressive episode completed a depression symptom scale and a measure of global severity of depression. The test-retest reliability of the psychosocial functioning and quality-of-life items was high. The single-item measures of symptom severity, psychosocial functioning, and quality of life were significantly correlated with the total scores and individual item scores of longer measures of the same constructs (p < .001). The single-item measures significantly discriminated between depressed patients in full remission, in partial remission, and in a current depressive episode (p < .001). These studies provide evidence of the reliability and validity of single-item measures of symptom severity, psychosocial functioning, and quality of life. Very brief measures, such as the ones described in the present report, are not burdensome for patients to complete and can be easily incorporated into a busy clinical practice in order to collect data on treatment effectiveness.
The diagnostic criteria for depression were developed on the basis of clinical experience rather ... more The diagnostic criteria for depression were developed on the basis of clinical experience rather than empirical study. Although they have been available and widely used for many years, few studies have examined the psychometric properties of the DSM criteria for major depression. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we examined whether criteria such as insomnia, fatigue, and impaired concentration that are also diagnostic criteria for other disorders are less specific than the other DSM-IV depression symptom criteria. We also conducted a regression analysis to determine whether all criteria are independently associated with the diagnosis of major depressive disorder. A total of 1538 psychiatric outpatients were administered a semistructured diagnostic interview. We inquired about all of the symptoms of depression for all patients. All of the DSM-IV symptom criteria for major depressive disorder were significantly associated with the diagnosis. Contrary to our prediction, symptoms such as insomnia, fatigue, and impaired concentration, which are also criteria of other disorders, generally performed as well as the criteria that are unique to depression such as suicidality, worthlessness, and guilt. The results of the regression analysis, which controlled for symptom covariation, indicated that five symptoms (increased weight, decreased weight, psychomotor retardation, indecisiveness, and suicidal thoughts) were not independently associated with the diagnosis of depression. The implications of these results for revising the diagnostic criteria for major depression are discussed.
There are two practical problems with the DSM-IV symptom criteria for major depressive disorder (... more There are two practical problems with the DSM-IV symptom criteria for major depressive disorder (MDD)--they are somewhat lengthy and therefore difficult to remember, and there are difficulties in applying some of the criteria in patients with comorbid medical illnesses because of symptom nonspecificity. Therefore, in the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we attempted to develop a briefer definition of major depression that is composed entirely of mood and cognitive symptoms. Our goal was to develop an alternative set of diagnostic criteria for major depression that did not include somatic symptoms but would nonetheless demonstrate a high level of concordance with the current DSM-IV definition. We examined several alternative definitions of MDD. After eliminating the somatic criteria from the DSM-IV MDD criteria and adding the symptom "reduced drive," there was a very high level of concordance with DSM-IV classification (95%). This new definition thus offers two advantages over the current DSM-IV definition--it is briefer and it is free of somatic symptoms, thereby making it easier to apply with medically ill patients. We discuss using improvement in the clinical utility, rather than validity of diagnostic criteria, as the basis for making revisions in the nomenclature.
A reliable and valid instrument has yet to be developed that elicits antidepressant treatment his... more A reliable and valid instrument has yet to be developed that elicits antidepressant treatment history via patient interview. The goal of the present study was to establish the test-retest reliability of the Treatment Response to Antidepressant Questionnaire (TRAQ). The TRAQ is a semistructured interview that was designed to collect systematically information regarding previous antidepressant treatment, adequacy of trials, and nature of response. Fifty subjects who sought outpatient treatment as part of the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project participated in the study. Patients were interviewed initially by a psychologist, who administered the TRAQ. An average of 5 to 6 days later, a psychiatrist who was blind to the results of the initial evaluation readministered the TRAQ to each of these patients. Reliability of recall of antidepressant trials, trial adequacy, and nature of response were evaluated using the kappa statistic. The mean duration of the TRAQ interviews was 3.30 minutes (SD=2.03 minutes). The reliability of recall of antidepressant trials ranged from 0.81 to 0.95, with an overall kappa of 0.91. The kappa for trial adequacy, depending on the definition used, ranged from 0.72 to 0.84. The kappa for determining positive versus negative response was 0.72. Thus, the test-retest reliability of the TRAQ was found to be in the good to excellent range for each of the principal outcome measures. The TRAQ can be administered by non-MDs as a reliable measure for collecting standardized information regarding antidepressant treatment history via patient interview.
Bipolar disorder, a serious illness resulting in significant psychosocial morbidity and excess mo... more Bipolar disorder, a serious illness resulting in significant psychosocial morbidity and excess mortality, has been reported to be frequently underdiagnosed. However, during the past few years we have observed the emergence of an opposite phenomenon--the overdiagnosis of bipolar disorder. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we empirically examined whether bipolar disorder is overdiagnosed. Seven hundred psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV (SCID) and completed a self-administered questionnaire, which asked the patients whether they had been previously diagnosed with bipolar or manic-depressive disorder by a health care professional. Family history information was obtained from the patient regarding first-degree relatives. Diagnoses were blind to the results of the self-administered scale. The study was conducted from May 2001 to March 2005. Fewer than half the patients who reported that they had been previously diagnosed with bipolar disorder received a diagnosis of bipolar disorder based on the SCID. Patients with SCID-diagnosed bipolar disorder had a significantly higher morbid risk of bipolar disorder than patients who self-reported a previous diagnosis of bipolar disorder that was not confirmed by the SCID (p < .02). Patients who self-reported a previous diagnosis of bipolar disorder that was not confirmed by the SCID did not have a significantly higher morbid risk for bipolar disorder than the patients who were negative for bipolar disorder by self-report and the SCID. Not only is there a problem with underdiagnosis of bipolar disorder, but also an equal if not greater problem exists with overdiagnosis.
The present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services pr... more The present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project examined whether symptoms that are not part of the DSM-IV definition of major depressive disorder (MDD) are better at discriminating depressed from nondepressed patients than the current criteria. Symptoms assessed included diminished drive, helplessness, hopelessness, nonreactive mood, psychic anxiety, somatic anxiety, subjective anger, and overtly expressed anger. A total of 1538 psychiatric outpatients were administered a semistructured diagnostic interview. We inquired about all of the symptoms of depression for all patients. Diminished drive exhibited stronger performance in differentiating MDD from non-MDD relative to all DSM-IV criteria except depressed mood, reduced interest/pleasure, and impaired concentration/indecisiveness. A compound criterion combining diminished drive with loss of energy was endorsed by nearly all MDD patients. Helplessness and hopelessness, when combined into a single criterion, performed more strongly than some of the DSM-IV criteria. Lack of reactivity, anxiety, and anger symptoms failed to differentiate more strongly than current DSM-IV criteria. The implications of these results for revising the diagnostic criteria for major depression are discussed.
In a previous article from the Rhode Island Methods to Improve Diagnostic Assessment and Services... more In a previous article from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we reported that bipolar disorder is often overdiagnosed in psychiatric outpatients. An important question not examined in that article was what diagnoses were given to the patients who had been overdiagnosed with bipolar disorder. In the present report from the MIDAS project, we examined whether there was a particular diagnostic profile associated with bipolar disorder overdiagnosis. Eighty-two psychiatric outpatients reported having been previously diagnosed with bipolar disorder that was not confirmed when they were interviewed with the Structured Clinical Interview for DSM-IV (SCID). Psychiatric diagnoses were compared in these 82 patients and in 528 patients who were not previously diagnosed with bipolar disorder. Patients were interviewed by a highly trained diagnostic rater who administered a modified version of the SCID for DSM-IV Axis I disorders and the Structured Interview for DSM-IV Personality for DSM-IV Axis II disorders. This study was conducted from May 2001 to March 2005. The most frequent lifetime diagnosis in the 82 patients previously diagnosed with bipolar disorder was major depressive disorder (82.9%, n = 68). The patients overdiagnosed with bipolar disorder were significantly more likely to be diagnosed with borderline personality disorder compared to patients who were not diagnosed with bipolar disorder (24.4% vs 6.1%; P < .001). A previous diagnosis of bipolar disorder was also associated with significantly higher lifetime rates of major depressive disorder (P < .01), posttraumatic stress disorder (P < .05), impulse control disorders (P < .05), and eating disorders (P < .05), although only the association with impulse control disorders remained significant after controlling for the presence of borderline personality disorder. Psychiatric outpatients overdiagnosed with bipolar disorder were characterized by more Axis I and Axis II diagnostic comorbidity in general, and borderline personality disorder in particular.
Specific diagnostic criteria for pathological gambling (PG) have been available for 25 years, sin... more Specific diagnostic criteria for pathological gambling (PG) have been available for 25 years, since the publication of DSM-III. Little research has examined the psychometric performance of the diagnostic criteria. The goal of the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project was to examine the sensitivity, specificity and predictive values of the DSM-IV PG criteria for psychiatric outpatients who screened positive for a gambling problem. A total of 1709 psychiatric outpatients were evaluated with a semistructured diagnostic interview for PG. Of all patients 88 screened positive for PG, 40 of whom met DSM-IV diagnostic criteria for a lifetime history of PG. All ten DSM-IV criteria were significantly more frequent in the PG group. The sensitivity of the criteria ranged from 25.0% to 90.0% (mean = 67.8%), whereas specificity ranged from 62.5% to 100% (mean = 81.9%). Positive predictive values ranged from 64.1% to 100% (mean = 78.9%), and negative predictive values ranged from 61.5% to 90.7% (mean = 77.1%). Guidelines are recommended for determining whether a diagnostic criterion should be retained as part of the set of diagnostic criteria, and our results suggested that two of the DSM-IV PG criteria are candidates for elimination (criterion 8—commitment of illegal acts; criterion 10—reliance on others for financial assistance to relieve a desperate financial problem).
Objectives: The Mood Disorders Questionnaire (MDQ) has been the most widely studied screening qu... more Objectives: The Mood Disorders Questionnaire (MDQ) has been the most widely studied screening questionnaire for bipolar disorder, though few studies have examined its performance in a heterogeneous sample of psychiatric outpatients. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined the operating characteristics of the MDQ in a large sample of psychiatric outpatients presenting for treatment.Methods: A total of 534 psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV and asked to complete the MDQ. Missing data on the MDQ reduced the number of patients to 480, 10.4% (n = 52) of whom were diagnosed with bipolar disorder.Results: Based on the scoring guidelines recommended by the developers of the MDQ, the sensitivity of the scale was only 63.5% for the entire group of bipolar patients. The specificity of the scale was 84.8%, and the positive and negative predictive values were 33.7% and 95.0%, respectively. When impairment was not required to define a case on the MDQ, then sensitivity increased to 75.0%, specificity dropped to 78.5%, positive predictive value was 29.8%, and negative predictive value was 96.3%.Conclusions: In a large sample of psychiatric outpatients, we found that the MDQ, when scored according to the developers’ recommendations, had inadequate sensitivity as a screening measure. After the threshold to determine MDQ caseness was lowered by not requiring moderate or severe impairment, the sensitivity of the scale increased, but specificity decreased, and positive predictive value remained below 30%. These results raise questions regarding the MDQ’s utility in routine clinical practice.
The present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services pr... more The present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project examined whether symptoms that are not part of the DSM-IV definition of major depressive disorder (MDD) are better at discriminating depressed from nondepressed patients than the current criteria. Symptoms assessed included diminished drive, helplessness, hopelessness, nonreactive mood, psychic anxiety, somatic anxiety, subjective anger, and overtly expressed anger. A total of 1538 psychiatric outpatients were administered a semistructured diagnostic interview. We inquired about all of the symptoms of depression for all patients. Diminished drive exhibited stronger performance in differentiating MDD from non-MDD relative to all DSM-IV criteria except depressed mood, reduced interest/pleasure, and impaired concentration/indecisiveness. A compound criterion combining diminished drive with loss of energy was endorsed by nearly all MDD patients. Helplessness and hopelessness, when combined into a single criterion, performed more strongly than some of the DSM-IV criteria. Lack of reactivity, anxiety, and anger symptoms failed to differentiate more strongly than current DSM-IV criteria. The implications of these results for revising the diagnostic criteria for major depression are discussed.
In a previous article from the Rhode Island Methods to Improve Diagnostic Assessment and Services... more In a previous article from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we reported that bipolar disorder is often overdiagnosed in psychiatric outpatients. An important question not examined in that article was what diagnoses were given to the patients who had been overdiagnosed with bipolar disorder. In the present report from the MIDAS project, we examined whether there was a particular diagnostic profile associated with bipolar disorder overdiagnosis. Eighty-two psychiatric outpatients reported having been previously diagnosed with bipolar disorder that was not confirmed when they were interviewed with the Structured Clinical Interview for DSM-IV (SCID). Psychiatric diagnoses were compared in these 82 patients and in 528 patients who were not previously diagnosed with bipolar disorder. Patients were interviewed by a highly trained diagnostic rater who administered a modified version of the SCID for DSM-IV Axis I disorders and the Structured Interview for DSM-IV Personality for DSM-IV Axis II disorders. This study was conducted from May 2001 to March 2005. The most frequent lifetime diagnosis in the 82 patients previously diagnosed with bipolar disorder was major depressive disorder (82.9%, n = 68). The patients overdiagnosed with bipolar disorder were significantly more likely to be diagnosed with borderline personality disorder compared to patients who were not diagnosed with bipolar disorder (24.4% vs 6.1%; P < .001). A previous diagnosis of bipolar disorder was also associated with significantly higher lifetime rates of major depressive disorder (P < .01), posttraumatic stress disorder (P < .05), impulse control disorders (P < .05), and eating disorders (P < .05), although only the association with impulse control disorders remained significant after controlling for the presence of borderline personality disorder. Psychiatric outpatients overdiagnosed with bipolar disorder were characterized by more Axis I and Axis II diagnostic comorbidity in general, and borderline personality disorder in particular.
Specific diagnostic criteria for pathological gambling (PG) have been available for 25 years, sin... more Specific diagnostic criteria for pathological gambling (PG) have been available for 25 years, since the publication of DSM-III. Little research has examined the psychometric performance of the diagnostic criteria. The goal of the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project was to examine the sensitivity, specificity and predictive values of the DSM-IV PG criteria for psychiatric outpatients who screened positive for a gambling problem. A total of 1709 psychiatric outpatients were evaluated with a semistructured diagnostic interview for PG. Of all patients 88 screened positive for PG, 40 of whom met DSM-IV diagnostic criteria for a lifetime history of PG. All ten DSM-IV criteria were significantly more frequent in the PG group. The sensitivity of the criteria ranged from 25.0% to 90.0% (mean = 67.8%), whereas specificity ranged from 62.5% to 100% (mean = 81.9%). Positive predictive values ranged from 64.1% to 100% (mean = 78.9%), and negative predictive values ranged from 61.5% to 90.7% (mean = 77.1%). Guidelines are recommended for determining whether a diagnostic criterion should be retained as part of the set of diagnostic criteria, and our results suggested that two of the DSM-IV PG criteria are candidates for elimination (criterion 8—commitment of illegal acts; criterion 10—reliance on others for financial assistance to relieve a desperate financial problem).
Objectives: The Mood Disorders Questionnaire (MDQ) has been the most widely studied screening qu... more Objectives: The Mood Disorders Questionnaire (MDQ) has been the most widely studied screening questionnaire for bipolar disorder, though few studies have examined its performance in a heterogeneous sample of psychiatric outpatients. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined the operating characteristics of the MDQ in a large sample of psychiatric outpatients presenting for treatment.Methods: A total of 534 psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV and asked to complete the MDQ. Missing data on the MDQ reduced the number of patients to 480, 10.4% (n = 52) of whom were diagnosed with bipolar disorder.Results: Based on the scoring guidelines recommended by the developers of the MDQ, the sensitivity of the scale was only 63.5% for the entire group of bipolar patients. The specificity of the scale was 84.8%, and the positive and negative predictive values were 33.7% and 95.0%, respectively. When impairment was not required to define a case on the MDQ, then sensitivity increased to 75.0%, specificity dropped to 78.5%, positive predictive value was 29.8%, and negative predictive value was 96.3%.Conclusions: In a large sample of psychiatric outpatients, we found that the MDQ, when scored according to the developers’ recommendations, had inadequate sensitivity as a screening measure. After the threshold to determine MDQ caseness was lowered by not requiring moderate or severe impairment, the sensitivity of the scale increased, but specificity decreased, and positive predictive value remained below 30%. These results raise questions regarding the MDQ’s utility in routine clinical practice.
Reliable, valid, user-friendly measurement is necessary to successfully implement an outcomes eva... more Reliable, valid, user-friendly measurement is necessary to successfully implement an outcomes evaluation program in clinical practice. Self-report questionnaires, which generally correlate highly with clinician ratings, are a cost-effective assessment option. However, even self-administered questionnaires can be burdensome to patients because many are lengthy. Consequently, we developed and determined the reliability and validity of ultra-brief, single-item assessments of 3 domains important to consider when treating depressed patients: symptom severity, psychosocial functioning, and quality of life. In the first study (conducted June 1997 to March 2002), 1278 psychiatric outpatients with various DSM-IV diagnoses completed single-item assessments of psychosocial functioning and quality of life as well as more detailed measures of these constructs. In the second study (conducted August 2003 to July 2004), 562 psychiatric outpatients who were in ongoing treatment for a DSM-IV major depressive episode completed a depression symptom scale and a measure of global severity of depression. The test-retest reliability of the psychosocial functioning and quality-of-life items was high. The single-item measures of symptom severity, psychosocial functioning, and quality of life were significantly correlated with the total scores and individual item scores of longer measures of the same constructs (p < .001). The single-item measures significantly discriminated between depressed patients in full remission, in partial remission, and in a current depressive episode (p < .001). These studies provide evidence of the reliability and validity of single-item measures of symptom severity, psychosocial functioning, and quality of life. Very brief measures, such as the ones described in the present report, are not burdensome for patients to complete and can be easily incorporated into a busy clinical practice in order to collect data on treatment effectiveness.
The diagnostic criteria for depression were developed on the basis of clinical experience rather ... more The diagnostic criteria for depression were developed on the basis of clinical experience rather than empirical study. Although they have been available and widely used for many years, few studies have examined the psychometric properties of the DSM criteria for major depression. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we examined whether criteria such as insomnia, fatigue, and impaired concentration that are also diagnostic criteria for other disorders are less specific than the other DSM-IV depression symptom criteria. We also conducted a regression analysis to determine whether all criteria are independently associated with the diagnosis of major depressive disorder. A total of 1538 psychiatric outpatients were administered a semistructured diagnostic interview. We inquired about all of the symptoms of depression for all patients. All of the DSM-IV symptom criteria for major depressive disorder were significantly associated with the diagnosis. Contrary to our prediction, symptoms such as insomnia, fatigue, and impaired concentration, which are also criteria of other disorders, generally performed as well as the criteria that are unique to depression such as suicidality, worthlessness, and guilt. The results of the regression analysis, which controlled for symptom covariation, indicated that five symptoms (increased weight, decreased weight, psychomotor retardation, indecisiveness, and suicidal thoughts) were not independently associated with the diagnosis of depression. The implications of these results for revising the diagnostic criteria for major depression are discussed.
There are two practical problems with the DSM-IV symptom criteria for major depressive disorder (... more There are two practical problems with the DSM-IV symptom criteria for major depressive disorder (MDD)--they are somewhat lengthy and therefore difficult to remember, and there are difficulties in applying some of the criteria in patients with comorbid medical illnesses because of symptom nonspecificity. Therefore, in the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we attempted to develop a briefer definition of major depression that is composed entirely of mood and cognitive symptoms. Our goal was to develop an alternative set of diagnostic criteria for major depression that did not include somatic symptoms but would nonetheless demonstrate a high level of concordance with the current DSM-IV definition. We examined several alternative definitions of MDD. After eliminating the somatic criteria from the DSM-IV MDD criteria and adding the symptom "reduced drive," there was a very high level of concordance with DSM-IV classification (95%). This new definition thus offers two advantages over the current DSM-IV definition--it is briefer and it is free of somatic symptoms, thereby making it easier to apply with medically ill patients. We discuss using improvement in the clinical utility, rather than validity of diagnostic criteria, as the basis for making revisions in the nomenclature.
A reliable and valid instrument has yet to be developed that elicits antidepressant treatment his... more A reliable and valid instrument has yet to be developed that elicits antidepressant treatment history via patient interview. The goal of the present study was to establish the test-retest reliability of the Treatment Response to Antidepressant Questionnaire (TRAQ). The TRAQ is a semistructured interview that was designed to collect systematically information regarding previous antidepressant treatment, adequacy of trials, and nature of response. Fifty subjects who sought outpatient treatment as part of the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project participated in the study. Patients were interviewed initially by a psychologist, who administered the TRAQ. An average of 5 to 6 days later, a psychiatrist who was blind to the results of the initial evaluation readministered the TRAQ to each of these patients. Reliability of recall of antidepressant trials, trial adequacy, and nature of response were evaluated using the kappa statistic. The mean duration of the TRAQ interviews was 3.30 minutes (SD=2.03 minutes). The reliability of recall of antidepressant trials ranged from 0.81 to 0.95, with an overall kappa of 0.91. The kappa for trial adequacy, depending on the definition used, ranged from 0.72 to 0.84. The kappa for determining positive versus negative response was 0.72. Thus, the test-retest reliability of the TRAQ was found to be in the good to excellent range for each of the principal outcome measures. The TRAQ can be administered by non-MDs as a reliable measure for collecting standardized information regarding antidepressant treatment history via patient interview.
Bipolar disorder, a serious illness resulting in significant psychosocial morbidity and excess mo... more Bipolar disorder, a serious illness resulting in significant psychosocial morbidity and excess mortality, has been reported to be frequently underdiagnosed. However, during the past few years we have observed the emergence of an opposite phenomenon--the overdiagnosis of bipolar disorder. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we empirically examined whether bipolar disorder is overdiagnosed. Seven hundred psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV (SCID) and completed a self-administered questionnaire, which asked the patients whether they had been previously diagnosed with bipolar or manic-depressive disorder by a health care professional. Family history information was obtained from the patient regarding first-degree relatives. Diagnoses were blind to the results of the self-administered scale. The study was conducted from May 2001 to March 2005. Fewer than half the patients who reported that they had been previously diagnosed with bipolar disorder received a diagnosis of bipolar disorder based on the SCID. Patients with SCID-diagnosed bipolar disorder had a significantly higher morbid risk of bipolar disorder than patients who self-reported a previous diagnosis of bipolar disorder that was not confirmed by the SCID (p < .02). Patients who self-reported a previous diagnosis of bipolar disorder that was not confirmed by the SCID did not have a significantly higher morbid risk for bipolar disorder than the patients who were negative for bipolar disorder by self-report and the SCID. Not only is there a problem with underdiagnosis of bipolar disorder, but also an equal if not greater problem exists with overdiagnosis.
The present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services pr... more The present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project examined whether symptoms that are not part of the DSM-IV definition of major depressive disorder (MDD) are better at discriminating depressed from nondepressed patients than the current criteria. Symptoms assessed included diminished drive, helplessness, hopelessness, nonreactive mood, psychic anxiety, somatic anxiety, subjective anger, and overtly expressed anger. A total of 1538 psychiatric outpatients were administered a semistructured diagnostic interview. We inquired about all of the symptoms of depression for all patients. Diminished drive exhibited stronger performance in differentiating MDD from non-MDD relative to all DSM-IV criteria except depressed mood, reduced interest/pleasure, and impaired concentration/indecisiveness. A compound criterion combining diminished drive with loss of energy was endorsed by nearly all MDD patients. Helplessness and hopelessness, when combined into a single criterion, performed more strongly than some of the DSM-IV criteria. Lack of reactivity, anxiety, and anger symptoms failed to differentiate more strongly than current DSM-IV criteria. The implications of these results for revising the diagnostic criteria for major depression are discussed.
In a previous article from the Rhode Island Methods to Improve Diagnostic Assessment and Services... more In a previous article from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we reported that bipolar disorder is often overdiagnosed in psychiatric outpatients. An important question not examined in that article was what diagnoses were given to the patients who had been overdiagnosed with bipolar disorder. In the present report from the MIDAS project, we examined whether there was a particular diagnostic profile associated with bipolar disorder overdiagnosis. Eighty-two psychiatric outpatients reported having been previously diagnosed with bipolar disorder that was not confirmed when they were interviewed with the Structured Clinical Interview for DSM-IV (SCID). Psychiatric diagnoses were compared in these 82 patients and in 528 patients who were not previously diagnosed with bipolar disorder. Patients were interviewed by a highly trained diagnostic rater who administered a modified version of the SCID for DSM-IV Axis I disorders and the Structured Interview for DSM-IV Personality for DSM-IV Axis II disorders. This study was conducted from May 2001 to March 2005. The most frequent lifetime diagnosis in the 82 patients previously diagnosed with bipolar disorder was major depressive disorder (82.9%, n = 68). The patients overdiagnosed with bipolar disorder were significantly more likely to be diagnosed with borderline personality disorder compared to patients who were not diagnosed with bipolar disorder (24.4% vs 6.1%; P < .001). A previous diagnosis of bipolar disorder was also associated with significantly higher lifetime rates of major depressive disorder (P < .01), posttraumatic stress disorder (P < .05), impulse control disorders (P < .05), and eating disorders (P < .05), although only the association with impulse control disorders remained significant after controlling for the presence of borderline personality disorder. Psychiatric outpatients overdiagnosed with bipolar disorder were characterized by more Axis I and Axis II diagnostic comorbidity in general, and borderline personality disorder in particular.
Specific diagnostic criteria for pathological gambling (PG) have been available for 25 years, sin... more Specific diagnostic criteria for pathological gambling (PG) have been available for 25 years, since the publication of DSM-III. Little research has examined the psychometric performance of the diagnostic criteria. The goal of the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project was to examine the sensitivity, specificity and predictive values of the DSM-IV PG criteria for psychiatric outpatients who screened positive for a gambling problem. A total of 1709 psychiatric outpatients were evaluated with a semistructured diagnostic interview for PG. Of all patients 88 screened positive for PG, 40 of whom met DSM-IV diagnostic criteria for a lifetime history of PG. All ten DSM-IV criteria were significantly more frequent in the PG group. The sensitivity of the criteria ranged from 25.0% to 90.0% (mean = 67.8%), whereas specificity ranged from 62.5% to 100% (mean = 81.9%). Positive predictive values ranged from 64.1% to 100% (mean = 78.9%), and negative predictive values ranged from 61.5% to 90.7% (mean = 77.1%). Guidelines are recommended for determining whether a diagnostic criterion should be retained as part of the set of diagnostic criteria, and our results suggested that two of the DSM-IV PG criteria are candidates for elimination (criterion 8—commitment of illegal acts; criterion 10—reliance on others for financial assistance to relieve a desperate financial problem).
Objectives: The Mood Disorders Questionnaire (MDQ) has been the most widely studied screening qu... more Objectives: The Mood Disorders Questionnaire (MDQ) has been the most widely studied screening questionnaire for bipolar disorder, though few studies have examined its performance in a heterogeneous sample of psychiatric outpatients. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined the operating characteristics of the MDQ in a large sample of psychiatric outpatients presenting for treatment.Methods: A total of 534 psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV and asked to complete the MDQ. Missing data on the MDQ reduced the number of patients to 480, 10.4% (n = 52) of whom were diagnosed with bipolar disorder.Results: Based on the scoring guidelines recommended by the developers of the MDQ, the sensitivity of the scale was only 63.5% for the entire group of bipolar patients. The specificity of the scale was 84.8%, and the positive and negative predictive values were 33.7% and 95.0%, respectively. When impairment was not required to define a case on the MDQ, then sensitivity increased to 75.0%, specificity dropped to 78.5%, positive predictive value was 29.8%, and negative predictive value was 96.3%.Conclusions: In a large sample of psychiatric outpatients, we found that the MDQ, when scored according to the developers’ recommendations, had inadequate sensitivity as a screening measure. After the threshold to determine MDQ caseness was lowered by not requiring moderate or severe impairment, the sensitivity of the scale increased, but specificity decreased, and positive predictive value remained below 30%. These results raise questions regarding the MDQ’s utility in routine clinical practice.
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Papers by Diane Young