Procedural validity of the computerized version of the Composite International Diagnostic Interview (CIDI-Auto) in the anxiety disorders

The procedural validity of the computerized version of the Composite International Diagnostic Interview (CIDI-Auto) was examined against the consensus diagnoses of two clinicians for six anxiety disorders (agoraphobia, panic disorder (+/- agoraphobia), social phobia, simple phobia, obsessive compulsive disorder (OCD), generalized anxiety disorder (GAD) and major depressive episode (MDE)). Clinicians had available to them all data obtained over a 2- to 10-month period. Subjects were 98 patients accepted for treatment at an Anxiety Disorders Clinic, thus, all subjects had at least one of the diagnoses being examined. While the CIDI-Auto detected 88.2% of the clinician diagnoses, it identified twice as many diagnoses as did the clinicians. The sensitivity of the CIDI-Auto was above 0.85 except for GAD, which had a sensitivity of 0.29. The specificity of the CIDI-Auto was lower (range: 0.47-0.99). The agreement between the CIDI-Auto and the clinician diagnoses, as measured by intraclass kappas, ranged from poor (kappa = 0.02; GAD) to excellent (kappa = 0.81; OCD), with a fair level of agreement overall (kappa = 0.40). Canonical correlation analysis suggested that the discrepancies between the CIDI-Auto and clinicians were not due to different diagnostic distinctions being made. It is suggested that the CIDI-Auto may have a lower threshold for diagnosing anxiety disorders than do experienced clinicians. It is concluded that, in a sample where all subjects have at least one anxiety disorder diagnosis, the CIDI-Auto has acceptable validity.

Workforce deployment: reconciling demands and resources

OBJECTIVE

The purpose of the study was to review the information in a Consultancy prepared for the National Mental Health Policy which suggested that half of the people with serious mental illnesses were untreated, while persons with "mental problems" were being overserviced by the specialist mental health services. The fate of the large group of persons with mental disorders of mid-range severity was not addressed.

METHOD

Epidemiological data was reconciled with the service patterns of the clinical workforce and the extent of the unmet need estimated.

RESULTS

It was estimated that 25-30% of the Australian population meet criteria for a mental disorder in any year, yet less than one third will receive treatment. Of those that are treated, three quarters will receive their treatment from general practitioners and the remaining quarter will be treated by either the public mental health services, the addition services, or private psychiatrists. The problem is that less than one half of those with serious mental disorders and only two thirds of those with chronic and disabling disorders appear to be being treated by anyone. Even if there were no slippage of services away from these serious and chronic groups of patients, there would still be a workforce shortfall, especially in rural and remote areas.

CONCLUSIONS

Strategies to remedy this shortfall that involve psychiatrists, clinical psychologists and general practitioners are noted, and the need for a National Mental Health Survey to provide accurate data is stressed.

A Psychological Profile of the Bariatric Patient with Implications for Treatment

BACKGROUND: Psychological testing of the bariatric patient utilizing instruments such as the MMPI have not proven useful in predicting successful weight loss following bariatric surgery. This has led many physicians and professionals who treat bariatric patients to believe that psychological testing is of no value. This paper discusses three instruments and the psychological profile of the average bariatric patient that they provide, and how the profile may be of benefit to the bariatric patient and to professionals who treat them. METHODS: The profile to be presented was obtained from the statistical analysis of the tests of 70 patients selected by random sample from a population of 695 patients. RESULTS: Results suggest that the average bariatric patient is mentally healthy and free of any psychological disorders contraindicating surgery. Although mentally healthy, the results suggest that the average bariatric patient does have a number of attitudes, behaviors, and personality traits which may sabotage weight lost following surgery. CONCLUSIONS: The psychological profile obtained from the data provides valuable information toward the development of a comprehensive treatment program designed to improve these potentially sabotaging attitudes, behaviors, and personality traits, in order to facilitate successful weight loss following bariatric surgery.

Continuities between psychiatric disorders in adolescents and personality disorders in young adults

OBJECTIVE

Personality disorders are a major mental health problem, but little information about their etiology and natural history is available. This study examined continuities between axis I disorders in adolescents and personality disorders in young adults.

METHOD

The authors interviewed 145 young adults (mean age, 19.6 years) who had been diagnosed with a variety of DSM-III emotional and disruptive disorders during adolescence (mean age, 13.7 years). The Personality Disorder Examination was used to establish whether the subjects currently suffered from personality disorders.

RESULTS

Subjects who had had disruptive disorders during adolescence showed high rates of all types of personality disorders (40% had a personality disorder at follow-up), while subjects who had had emotional disorders had a lower rate of personality disorders (12%). Men were more likely to have cluster A personality disorders, and women were more likely to have cluster C personality disorders. Disruptive diagnoses were associated with cluster B personality disorders, but emotional disorders did not show an association with cluster C personality disorders. Oppositional disorder did not increase the likelihood of passive-aggressive personality disorder. There was an association between attention deficit disorder with hyperactivity and borderline personality disorder.

CONCLUSIONS

The rate of personality disorders was lower among young adults who had had emotional disorders during adolescence than among those who had had disruptive disorders, suggesting either that treatment for emotional disorders is more effective or that the personality psychopathology in these adolescents is not as severe as that in adolescents with disruptive disorders.

Best practices for implementing outcomes management. More science, more art, worldwide

Based on his own and other large-scale studies, the author explains that the current push to measure treatment outcomes and develop outcomes management programs is a worldwide phenomenon in behavioral healthcare. He presents a model showing outcomes measurement as the cornerstone of good clinical practice, from intake through diagnosis and treatment to outcomes management and clinical information systems.

A comparison of two structured diagnostic interviews: CIDI and SCAN

The relationship between and the inter-rater reliability of the Composite International Diagnostic Interview (CIDI) and the Schedules for Clinical Assessment in Neuropsychiatry (SCAN) for anxiety and depressive disorders were explored. The CIDI and the SCAN were administered by trained interviewers in counterbalanced order. A subsample of interviews was observed to determine the inter-rater reliability of the instruments. Subjects were 101 patients accepted for treatment at an Anxiety Disorders Clinic; 29 of the 101 patients participated in the inter-rater reliability study. Concordance between the instruments as measured by canonical correlation analysis was moderate for current (r = 0.69, p = 0.05) and for lifetime (r = 0.66, p = 0.05) diagnoses. Inter-rater reliability of the CIDI was perfect (overall intraclass kappa = 1.00), and of the SCAN was good (overall intraclass kappa = 0.67). It is concluded that although the two instruments made similar diagnostic distinctions, the clinical judgment involved in administering the SCAN resulted in the more moderate levels of agreement between the interviewer and observer than those found for the CIDI.

Potent activation of phosphatidylinositol 3'-kinase by simple phosphotyrosine peptides derived from insulin receptor substrate 1 containing two YMXM motifs for binding SH2 domains

The phosphotyrosine form of the major substrate for the insulin receptor tyrosine kinase, insulin receptor substrate 1 (IRS-1), associates with and activates the enzyme phosphatidylinositol 3'-kinase (PtdIns 3'-kinase). IRS-1 contains nine potential tyrosine phosphorylation sites within YMXM or YXXM sequences known to bind to the two SH2 domains on the 85-kDa regulatory subunit of PtdIns 3'-kinase. We used sequences within IRS-1 as a model for synthesizing phosphotyrosine and nonhydrolyzable phosphonotyrosine peptides containing two YMXM motifs and tested them for their ability to bind to the SH2 domains of PtdIns 3'-kinase and stimulate its activity. We demonstrated for the first time that IRS-1-derived peptides containing two tyrosine phosphorylated YMXM motifs are capable of stimulating PtdIns 3'-kinase activity in the cytosol of 3T3-L1 adipocytes at nanomolar concentrations, similar to that required by purified phosphoryl-IRS-1 [Lamphere, M., Carpenter, C. L., Sheng, Z., Kallen, R. G., & Lienhard, G. E. (1994) Am. J. Physiol. 266 (Endocrinol. Metab. 29), E486-E489] and the extent of activation by these peptides was similar to that seen by maximal stimulation of cells with insulin. In contrast, those phosphotyrosine peptides containing only a single YMXM motif were able to stimulate PtdIns 3'-kinase activity only at concentrations over 10 microM. We conclude from these results that the high-affinity activation of PtdIns 3'-kinase requires the simultaneous binding of two phosphorylated YMXM motifs on IRS-1 to the two SH2 domains of PtdIns 3'-kinase.

Appraisal of danger and proximity in social phobics

A central tenet in Beck's theory of anxiety and phobias is that appraisal of danger in phobic individuals increases with increasing proximity to a feared situation. Appraisal of danger in social phobics and a control group of stutterers was compared before, during and following a challenging task (pubic speech). Support for Beck's theory was not found. Social phobics danger appraisals were greatest in anticipation of a speech. In contrast, the control group's danger appraisals were highest when in the situation. State anxiety paralleled the pattern observed for danger appraisal. The implications of these results are discussed in relation to current theories of maintenance of phobias.

Proximity and anticipation of a negative outcome in phobias

Thirty-five patients being treated for one of three anxiety disorders were asked to rate the likelihood of a negative outcome prior to entering a feared situation, while in the situation and after leaving the situation. Ratings made in anticipation were consistently higher than ratings made either in the situation or after leaving it. In contrast, normal Ss, about to undertake tourist rides perceived as being mildly dangerous, rated the likelihood of negative outcome as highest when actually in the situation.

Constructive advice for a poorly understood problem: treatment and management of premenstrual syndrome

While women are increasingly seeking therapeutic help for premenstrual syndrome, lack of understanding of its aetiology means treatment focuses more on the symptoms than the underlying cause. A sympathetic approach based on counselling, practical advice and reassurance, however, can help many women to tackle the symptoms before they become more severe.

Oral health status and treatment needs of non-institutionalized persons aged 60+ in Adelaide, South Australia

There has been a growing recognition of the need to obtain information about the oral health of older Australians. The aim of this report is to provide descriptive epidemiological information about the oral health and treatment needs of non-institutionalized older adults in Adelaide. Data from interviews with 178 persons aged 60+ were obtained from a pilot study. Clinical data were available for 106 persons who participated in oral examinations. Among the 52.9 per cent of dentate persons, the prevalence of root decay (27.1 per cent) was slightly higher than coronal decay (23.6 per cent). Some 28.1 per cent of dentate persons had a serious periodontal condition, defined as the presence of four or more teeth with at least 5 mm or more of periodontal attachment loss and periodontal pocketing of 4 mm or more at one or more of those teeth. The majority of persons (83.8 per cent) wore one or two dentures. Disorders associated with dentures were frequent, affecting 77.4 per cent of upper denture wearers and 72.5 per cent of lower denture wearers. Persons who were older, who had lower educational attainment or lower household incomes were disadvantaged in aspects of oral health status and dental caries. However, there were no consistent associations between chronic medical conditions and oral disorders. Despite the high prevalence of oral impairment, reflecting extensive disease activity in the past, high levels of untreated disease were relatively uncommon. Instead, a high prevalence of oral disorders created a substantial need for basic forms of dental treatment in this group.

Property issues in practice

This article discusses legal issues relating to property ownership. The primary focus is on land use control laws such as zoning ordinances. Cases involving legal questions over the location and operation of veterinary clinics are discussed. An explanation of how land use contracts work and how veterinarians may encounter them is included. The application of nuisance law is reviewed, and representative cases are discussed. Also included is a discussion of property liability issues and what veterinarians can do to avoid litigation.

Sending your teenagers away. Controlled stress decreases neurotic vulnerability

OBJECTIVE

To study the effect of a controlled stressor on the rate of personality maturity.

DESIGN

Eighteen-month prospective controlled study.

SETTING

General community.

INTERVENTION

EXPERIMENTAL

Exposed to the stress of 12 months' intercultural experience.

CONTROL

Remained in usual environment.

MAIN OUTCOME MEASURE

A measure of personality vulnerability/maturity derived from a canonical correlational combination of trait anxiety, locus of control, and defense style.

RESULTS

Exchange students exposed to the stressor made significantly greater gains in personality maturity (0.28 vs 0.03 SD: P < or = .01) than did the control students matched on this measure at baseline.

CONCLUSION

Exchange students exposed to the stress of living abroad showed a substantial decrease in vulnerability, which should decrease the risk of future neurotic disorders in this group.

The essential psychotherapies

Psychiatry is becoming increasingly confident about defining the benefits to be expected from each treatment (World Health Organization, 1991). The World Health Organization has published a list of essential drug treatments, but neither it nor any national regulatory body has ever examined non-drug treatments. This article examines the utility of the psychotherapies as treatments for persons with psychiatric disorders, and within a health service, whether supported by private insurance or by public taxation. It is not about the utility of psychotherapy paid for by an individual, for what people do with their own money is their own business. However, when deciding how to apportion a limited health budget, one should choose treatments that are more effective, safer, and cheaper than competing alternatives. Precisely how effectiveness, safety, and cost efficiency should be traded off against each other is a moot point, but there is agreement that treatments that are ineffective, harmful, and costly should not be used.

The Defense Style Questionnaire

The Defense Style Questionnaire has proven of interest as the first questionnaire to reliably describe defense styles. The 72-item DSM-III-R-labeled Defense Style Questionnaire was administered to 388 controls and 324 patients. Eight statistical and two a priori criteria were used in choosing two items to represent each of the 20 defenses. A new 40-item Defense Style Questionnaire is published together with normative and reliability data on a normal population, patients with anxiety disorders, and child-abusing parents. The scores are unaffected by the sex of the respondent, but the endorsement of immature defense styles decreases with age.

Parental 'affectionless control' as an antecedent to adult depression: a risk factor refined

It has been well established that individuals with a history of depression report their parents as being less caring and more overprotective of them than do controls. 'Affectionless control' in childhood has thus been proposed as a risk factor for depression. Evidence is presented from a logistic regression analysis of data from a volunteer community sample that lack of care rather than over-protection is the primary risk factor. No evidence for an interaction effect of low care and over-protection was found.

Drop-out rate as a performance indicator in psychotherapy

Many large studies of psychotherapy show that the median patient drops out by the 5th session and most before the 10th session. Data from an effective behavior therapy clinic for the anxiety disorders showed that only 17% of patients failed to complete a median of 60 h of therapy. Patient characteristics were not associated with attrition. We examined 5 meta-analytic treatment reviews and found the median drop-out rate was 8% after 20 h of therapy. We suggest that low attrition is associated with effective, standardized treatment and as such, drop-out rate may be a proxy variable that can indicate effective service delivery.