Psychiatric diagnosis in clinical practice: is comorbidity being missed?

Potential Mental Disorder Symptoms in the Prophet Elijah: An Exegetical and Psychological Analysis of Selected Episodes from 1 Kings 18-19

This interdisciplinary study examines the prophet Elijah's experiences as depicted in 1 Kings 18-19 through a multidisciplinary lens, combining theological, literary, and psychological perspectives. Drawing on literary and historical-critical methods, a biblical scholar analyzes the narrative's linguistic and cultural dimensions, while a psychologist evaluates these findings using contemporary mental health frameworks, including the DSM-5 and models of spiritual struggle. By synthesizing these approaches, the study explores Elijah's emotional challenges, highlighting their resonance with modern understandings of mental health and spirituality. The findings suggest that Elijah's profound struggles-marked by triumph, despair, and renewal-offer valuable insights into the interplay of faith, vulnerability, and resilience. These insights illuminate how ancient narratives continue to address contemporary questions of human experience and psychological struggle.

Time Trends in Adolescent Diagnoses of Major Depressive Disorder and Co-occurring Psychiatric Conditions in Electronic Health Records

Major depressive disorder (MDD) is highly prevalent in youth and generally characterized by psychiatric comorbidities. Secular trends in co-occurring diagnoses remain unclear, especially in healthcare settings. Using large-scale electronic health records data from a major U.S. healthcare system, we examined the prevalence of MDD diagnoses and co-occurring psychiatric conditions during adolescence (12-18 years; N = 133,753) across four generations (birth years spanning 1985 to 2002) and by sex. Then using a phenome-wide association analysis, we explored which of 67 psychiatric conditions were associated with adolescent MDD diagnosis in earlier versus recent generations. Adolescent MDD diagnosis prevalence increased (8.9 to 11.4%) over time. Over 60% with an MDD diagnosis had co-occurring psychiatric diagnoses, especially neurodevelopmental and anxiety disorders. Co-occurring diagnoses generally increased over time, especially for anxiety disorders (14 to 50%) and suicidal behaviors (6 to 23%), across both sexes. Eight comorbidities interacted with generation, showing stronger associations with MDD diagnosis in earlier (e.g., conduct disorder) versus more recent (e.g., suicidal ideation and behaviors) generations. The findings underscore the importance of assessing psychiatric complexity in adolescents diagnosed with MDD, applying transdiagnostic approaches to address co-occurring presentations, and further investigating potential causes for generational increases.

Psychometric evaluation of the patient health questionnaire stress scale

The "Patient Health Questionnaire (PHQ)" is a screening instrument, designed for time-efficient detection and severity assessment of depression, anxiety, and other syndromes in medical settings. Besides the questions on psychological symptoms, there are items on psychosocial functioning, on stressors and critical life events. However, for the stress items there are no psychometric properties available until now. The present study is thought to investigate item characteristics, internal consistency as well as factorial and construct validity of the stress scale of the PHQ. A representative sample of the general population of Germany was collected by a demography consulting company (USUMA, Berlin). Per random-route procedure, households and members of the households were selected. The sample was representative for the German community regarding age, gender, and education. In this investigation the following questionnaires were administered: PHQ-Stress, Questions on Life Satisfaction Modules (FLZ-M), Type-D Scale-14 (DS14). The sample included N = 2396 participants with mean age of 48.50 (SD = 17.75; range = 14 to 92) and 55.2 % being female. Reliability of the PHQ stress scale was acceptable (ω = 0.776), but some factor loadings were comparatively low. Model fit indices showed mixed results, some indicating unacceptable and some indicating acceptable fit of the 10-item stress scale of the PHQ. Correlations with related constructs demonstrated the scale's convergent validity. The results of this validation study indicate that the PHQ stress scale, which provides a one-dimensional total stress score, is a valid, good practical and reliable self-report instrument for assessing the severity of psychosocial stress.

Psychotic-like experiences and multimorbid psychopathology: The relationship between the 16-item prodromal questionnaire and DSM-IV classifications in a help-seeking population

AIM

Identifying multimorbid psychopathology is necessary to offer more adequate treatment and ultimately reduce the prevalence of persistent mental illnesses. Psychotic symptoms are increasingly seen as a transdiagnostic indicator of multimorbidity, severity and complexity of non-psychotic psychopathology. This study aims to investigate whether psychotic-like experiences and subclinical psychotic symptoms as measured by the 16-item Prodromal Questionnaire are also associated with multimorbid psychopathology.

METHODS

Participants were help-seeking individuals from outpatient mental healthcare settings and intensive home-treatment teams, aged 17-35. Assessment included the 16-item Prodromal Questionnaire to measure psychotic-like experiences, the Structured Clinical Interview for DSM-IV Axis I, and three sections of the Structured Clinical Interview for DSM-IV Axis II Disorders to determine DSM-IV-TR classifications. The final sample comprised of 160 participants who scored above a cutoff of 6 items on the 16-item Prodromal Questionnaire (HIGH-score) and 60 participants who scored below cutoff (LOW-score). A Poisson Regression was executed to determine the association between the PQ-16 and DSM-IV-TR classifications.

RESULTS

The HIGH-score group had a mean of 2.76 multimorbid disorders (range 0-7), while the LOW-score group had a mean of 1.45 disorders (range 0-3). Participants with four to seven disorders scored high on the 16-item Prodromal Questionnaire.

CONCLUSIONS

Our results suggest that psychotic-like experiences are associated with multimorbidity and severity of psychopathology. Screening for psychotic-like experiences via the PQ-16 in a help-seeking population may help prevent under-diagnosis and under-treatment of comorbid psychopathology.

Identifying the DSM-5 mixed features specifier in depressed patients: A comparison of measures

BACKGROUND

A commonly used measure to assess mixed features in depressed patients is the Young Mania Rating Scale (YMRS), which only partially aligns with the DSM-5 criteria. Different algorithms on the YMRS have been used to approximate the DSM-5 mixed features criteria. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined the agreement and validity of different approaches towards assessing the mixed features specifier.

METHODS

Three hundred nine depressed psychiatric patients were interviewed with the Structured Clinical Interview for DSM-IV, the DSM-5 Mixed Features Specifier Interview (DMSI) and the YMRS. Seven definitions of mixed features were examined, two based on the DMSI and five from the YMRS.

RESULTS

The prevalence of mixed features varied 8-fold amongst the 7 definitions. The level of agreement between the YMRS definitions and the DMSI was poor. For each definition, mixed features were significantly more common in patients with bipolar disorder than major depressive disorder. A family history of bipolar disorder was significantly associated with the DMSI assessment of mixed features but none of the YMRS approaches.

LIMITATIONS

The ratings on the measures were not independent of each other. The sample size was too small to compare the patients with bipolar I and bipolar II disorder.

CONCLUSIONS

While there was evidence of validity for both the DSM-5 and YMRS approaches towards identifying mixed features, the 2 approaches are not interchangeable. The algorithm on the YMRS used to classify patients has a significant impact on prevalence.

Incidence and Predictors of Low Sexual Desire and Hypoactive Sexual Desire Disorder in Women: A Systematic Review and Meta-Analysis

Determining the true incidence and identifying the risk factors of low sexual desire (LSD) and hypoactive sexual desire disorder (HSDD) are essential to prevent sexual dysfunctions and provide adequate treatment resources. This systematic review and meta-analysis were performed on research articles reporting women with LSD and HSDD in PsycArticles, Scopus, MEDLINE, Web of Science databases, and reference lists till October 2021. All cross-sectional studies published in English that assessed both sexual desire and sexual distress were included. Of 891 full-text articles identified, 24 were eligible, all of which had a low risk of overall bias. We did separate random-effects meta-analyses for LSD and HSDD outcomes. The incidence of LSD and HSDD were 29% and 12%, respectively. Studies that used the convenience sampling method reported a higher incidence of HSDD than studies that used the probability sampling method. No differences were found between the assessment method and across cultures in LSD and HSDD. A majority of studies reviewed addressed demographic (e.g. age, education), physiological (e. g. menopausal status, body mass index), psychological (e.g. depression, daily internal stress), relational (e.g. relationship length, relationship satisfaction), and sexual predictors (e.g. sexual activity, sexual pleasure) between LSD and HSDD. This systematic review may inform researchers, guideline developers, and policy-makers about LSD associated with distress and help health professionals to identify women most at risk.

Revisiting the intake policy at the mental child and adolescent clinics

BACKGROUND

The psychiatric intake interview is crucial for the delivery of quality care. Currently, the interview in most public clinics varies in nature. It often consists of a clinical face-to-face interview (structured/unstructured) with or without self-report questionnaires (systematic/non-systematic). By integrating structured computerized self-report questionnaires into the intake, the assessment process could be shortened, and diagnostic accuracy increased.

OBJECTIVES

The study aims to assess whether adding structured computerized questionnaires will increase the efficacy of the intake process, as indicates by shortened intakes and a higher level of diagnostic accuracy, for children and adolescents in mental health clinics in Israel.

METHODOLOGY

Patients (M_age = 8.62, SD_age = 1.86; 33.8% females) referred to the youth mental health clinic of Maccabi HaSharon district, were included in either the CIA group (Comprehensive Intake Assessment - with questionnaires) or IAU group (Intake as Usual - without questionnaires).

RESULTS

In terms of accuracy and time measurements, the CIA group had higher diagnostic accuracy and a shorter intake duration of 6.63 min, almost 15% of an intake meeting, compared to the IAU group. No differences were found in satisfaction and therapeutic alliance between the groups.

CONCLUSIONS AND IMPLICATIONS

More accurate diagnosis is essential to tailor the appropriate treatment for the child's needs. Moreover, reducing intake time by a few minutes contributes significantly to the ongoing activities of mental health clinics. With this reduction, more intakes can be scheduled at a given time, optimizing the intake process, and reducing long wait times, which are increasing due to the growing demand for psychotherapeutic and psychiatric care.

The Brief Adolescent Depression Screen: A Brief Screening Tool for Depression and Suicidal Behavior in Inpatient Adolescents

Background

In clinical settings, there is significant need for brief, easily-administered assessment tools for adolescent depression that can be used by mental health clinicians from a variety of training backgrounds. Existing depression screening tools do not assess for duration and consistency of symptoms, two key indicators of pathological depression.

Objective

The Brief Adolescent Depression Screen (BADS) was developed to screen for major and persistent depressive disorders in adolescents in order to meet the assessment needs in an inpatient setting, and the validity of this tool was tested.

Method

The current study used a sample of 396 inpatient adolescents to assess the screening utility of the BADS for detecting whether the adolescent meets criteria for a depressive diagnosis according to a well-validated semi-structured interview, as well as detecting a positive history of suicidal behavior. Further, the screening utility of this measure was compared to the utility of an established depression rating scale.

Results

Analyses first determined the duration of depressive symptoms on the BADS that optimally screened for the presence of Major Depressive Disorder and Persistent Depressive Disorder. Findings indicated that, using these optimal screening cut-offs, the BADS showed a strong screening utility, resulting in a sensitivity and specificity for identifying full depressive diagnoses and a positive history of suicidal behavior with similar or greater accuracy than an established rating scale.

Conclusions

These findings provide initial evidence to suggest that the BADS may be a helpful screening tool for adolescent depressive disorders in inpatient settings.

Development and Preliminary Evaluation of a Rapid Screening Tool for Detecting Borderline Personality Disorder in People Aged over 60 Years

OBJECTIVES

Screening and diagnostic instruments for Borderline Personality Disorder (BPD) are not validated in people aged over 60. We report a pilot study examining the sensitivity and specificity of a de-novo screening instrument in older adults.

METHODS

The BPD-OA screening tool incorporates DSM 5 and literature describing the expression of BPD in older adults. This study was conducted using a case control design. The Diagnostic Interview for Borderlines-Revised (DIB-R) and the McLean Screening Instrument for BPD (MSI-BPD) were used as comparators. Comprehensive assessment by psychiatric teams determined participants to be (i) BPD-positive (n = 22) or (ii) BPD-negative (gender matched; n = 21).

RESULTS

The BPD-OA was the most sensitive instrument for discriminating older adult BPD from non-BPD participants (sensitivity = 0.82). No significant relationship was found between the BPD-OA score and age in BPD-diagnosed participants (r = -0.181, n = 21, p = .432). Participant age explained 3.2% of the variance in BPD-OA scores. Of the 21 BPD-negative participants, eight false positives experienced prominent mood disorders (specificity = 0.62).

CONCLUSIONS

The BPD-OA screening tool is clearly superior to instruments validated for use in younger people. Further refinement and evaluation will enhance its sensitivity and specificity.

CLINICAL IMPLICATIONS

Detection of BPD in older adult care settings will improve outcomes for patients, families, and staff through better understanding and appropriate management and treatment strategies.

The psychometric properties of the of the Persian version of the Screen for adult anxiety related disorders (SCAARED) in patients with anxiety disorders

BACKGROUND

The aim of this study was to investigate the psychometric properties of the Persian version of the Screen for adult anxiety related disorders (SCAARED) in Tehran.

METHOD

The present study was a descriptive-survey method and a cross-sectional method. The present research population consists of patients referring to hospitals and psychiatric clinics in Tehran, as well as male and female students in Tehran. The sample of the present study included 300 participants (150 patients with a diagnosis of anxiety disorders and 150 non-clinical samples), who were selected by random sampling method. Inclusion criteria included age 18 to 50, minimum diploma, lack of mental retardation, and lack of acute physical illnesses such as cancer or severe pain. The participants, after completing the demographic questionnaire and conducting a Structured Clinical Interview for DSM-5 Disorders-Clinical Version (SCID-5-CV), completed the SCAARED and the Personal Wellbeing Index-Adults (PWI-A). Finally, face and content validity and construct validity, test-retest reliability, Cronbach's alpha, and factor analysis were used.

RESULTS

The results of the present study confirmed the face validity and content of the present scale. A review of Cronbach's standardized alpha showed that SCAARED has a reliability of 0.966, and therefore, the Persian version of these questionnaires is a reliable tool. Also, the results showed a correlation between the two implementations of the questionnaire; in addition to the strong correlation at the level (p < .01) between the factors of the questionnaire and the factors with the total score, there was a strong correlation between the first and second implementation in four factors and the overall score. Therefore, it can be concluded that the SCAARED has good test-retest reliability. Also, there is a positive correlation between the factors and the overall score of the SCAARED with anxiety disorders based on Structured Clinical Interview for DSM-5 Disorders (p < .01), which indicates the favorable convergent validity of the SCAARED questionnaire. There is a negative correlation between the factors and the overall score of the SCAARED with the PWI-A at the level (p < .01), which indicates the favorable divergent validity of the SCAARED, and the results of exploratory factor analysis of the questionnaire were confirmed.

CONCLUSION

The Persian version of the SCAARED is a tool with appropriate validity and reliability.

Factors associated with a borderline personality disorder diagnosis in the emergency department

INTRODUCTION

Research on borderline personality disorder (BPD) has shown that less intensive care is especially effective when patients have been told about their condition. However, problems with diagnosing the disorder are also described in the literature. This study thus aims to explore the factors associated with the challenges of identifying and then communicating a BPD diagnosis to patients.

METHODS

We analyzed a database of 202 patients of Toulouse University Hospital (France) who had a CIM-10 F60.3 diagnosis. This data was used to identify the sociodemographic and clinical benchmarks associated with patients who had received an established BPD diagnosis prior to their attendance at the hospital's emergency department (ED) in the study period.

RESULTS

Sixty-three percentage of the patients admitted to our psychiatric ED had been given an earlier diagnosis of BPD. Those who had not been diagnosed were more likely to: not have undergone any psychiatric follow-up; not have been hospitalized in the psychiatry department; and not have previously attended at the ED. Patients with BPD and a comorbidity of MDD were also less likely to have received a BPD diagnosis before their ED admission.

CONCLUSION

This study found that patients without an established BPD diagnosis who present at the ED are more likely to not be known to the psychiatric care system. This suggests that EDs have a specific role to play in making a diagnosis and the subsequent orientation of care.

Computing schizophrenia: ethical challenges for machine learning in psychiatry

Recent advances in machine learning (ML) promise far-reaching improvements across medical care, not least within psychiatry. While to date no psychiatric application of ML constitutes standard clinical practice, it seems crucial to get ahead of these developments and address their ethical challenges early on. Following a short general introduction concerning ML in psychiatry, we do so by focusing on schizophrenia as a paradigmatic case. Based on recent research employing ML to further the diagnosis, treatment, and prediction of schizophrenia, we discuss three hypothetical case studies of ML applications with view to their ethical dimensions. Throughout this discussion, we follow the principlist framework by Tom Beauchamp and James Childress to analyse potential problems in detail. In particular, we structure our analysis around their principles of beneficence, non-maleficence, respect for autonomy, and justice. We conclude with a call for cautious optimism concerning the implementation of ML in psychiatry if close attention is paid to the particular intricacies of psychiatric disorders and its success evaluated based on tangible clinical benefit for patients.

Patients with borderline personality disorder and bipolar disorder: a descriptive and comparative study

BACKGROUND

Bipolar disorder and borderline personality disorder (BPD) are each significant public health problems. It has been frequently noted that distinguishing BPD from bipolar disorder is challenging. Consequently, reviews and commentaries have focused on differential diagnosis and identifying clinical features to distinguish the two disorders. While there is a burgeoning literature comparing patients with BPD and bipolar disorder, much less research has characterized patients with both disorders. In the current report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compare psychiatric outpatients with both BPD and bipolar disorder to patients with BPD without bipolar disorder and patients with bipolar disorder without BPD.

METHODS

Psychiatric outpatients presenting for treatment were evaluated with semi-structured interviews. The focus of the current study is the 517 patients with both BPD and bipolar disorder (n = 59), BPD without bipolar disorder (n = 330), and bipolar disorder without BPD (n = 128).

RESULTS

Compared to patients with bipolar disorder, the patients with bipolar disorder and BPD had more comorbid disorders, psychopathology in their first-degree relatives, childhood trauma, suicidality, hospitalizations, time unemployed, and likelihood of receiving disability payments. The added presence of bipolar disorder in patients with BPD was associated with more posttraumatic stress disorder in the patients as well as their family, more bipolar disorder and substance use disorders in their relatives, more childhood trauma, unemployment, disability, suicide attempts, and hospitalizations.

CONCLUSIONS

Patients with both bipolar disorder and BPD have more severe psychosocial morbidity than patients with only one of these disorders.

Predictors of diagnostic delay: Assessment of psychiatric disorders in the clinic

BACKGROUND

Diagnostic delay contributes to morbidity in psychiatric disorders.

METHODS

Patients in an ambulatory psychiatry clinic were given patient-reported outcome measures at an initial visit, and a subset (N = 493) were given a structured interview (MINI International Neuropsychiatric Interview, MINI), in addition to the clinical encounter (CLIN). Diagnostic agreement between MINI and CLIN was assessed at an initial and follow-up visit. Diagnostic delay was identified if diagnostic disagreement between MINI and CLIN occurred at the initial visit and changed to an agreement at a follow-up visit. Registry data was compiled by an honest broker.

RESULTS

Significant agreement occurred between MINI and CLIN diagnoses for major depressive disorder (MDD), bipolar disorder (BD), generalized anxiety disorder, and panic disorder. Diagnostic agreement for MDD occurred at initial visit for 63% of patients, and at follow-up for 87% of those with initial diagnostic disagreement; for BD, 75% at initial visit and 28% at follow-up. No demographic, socioeconomic, symptom severity or functioning measures predicted diagnostic agreement for the MDD group at the first visit, however initial psychopathological symptom complexity predicted diagnostic agreement in the diagnostic delay group. Initial diagnostic agreement for BD was predicted by lower symptom burden and better social, physical, and occupational functioning. No factors predicted additional diagnostic agreement at the second visit in the diagnostic delay group.

CONCLUSION

Initial assessment by a structured interview aided physicians in identifying MDD by the second visit in patients with complex psychopathology. Patients with high complexity/severity of symptoms and more difficulty with functioning were less commonly identified with BD even with the assistance of a structured interview. Use of structured assessment tools may improve the detection of psychiatric illness by clinicians at the first visit.

Poor Separation of Clinical Symptom Profiles by DSM-5 Disorder Criteria

Assessment of mental illness typically relies on a disorder classification system that is considered to be at odds with the vast disorder comorbidity and symptom heterogeneity that exists within and across patients. Patients with the same disorder diagnosis exhibit diverse symptom profiles and comorbidities creating numerous clinical and research challenges. Here we provide a quantitative analysis of the symptom heterogeneity and disorder comorbidity across a sample of 107,349 adult individuals (aged 18-85 years) from 8 English-speaking countries. Data were acquired using the Mental Health Quotient, an anonymous, online, self-report tool that comprehensively evaluates symptom profiles across 10 common mental health disorders. Dissimilarity of symptom profiles within and between disorders was then computed. We found a continuum of symptom prevalence rather than a clear separation of normal and disordered. While 58.7% of those with 5 or more clinically significant symptoms did not map to the diagnostic criteria of any of the 10 DSM-5 disorders studied, those with symptom profiles that mapped to at least one disorder had, on average, 20 clinically significant symptoms. Within this group, the heterogeneity of symptom profiles was almost as high within a disorder label as between 2 disorder labels and not separable from randomly selected groups of individuals with at least one of any of the 10 disorders. Overall, these results quantify the scale of misalignment between clinical symptom profiles and DSM-5 disorder labels and demonstrate that DSM-5 disorder criteria do not separate individuals from random when the complete mental health symptom profile of an individual is considered. Greater emphasis on empirical, disorder agnostic approaches to symptom profiling would help overcome existing challenges with heterogeneity and comorbidity, aiding clinical and research outcomes.

The Use of Evidence-Based Assessment for Anxiety Disorders in an Australian Sample

Anxiety disorders are common and cause considerable functional impairment. Fortunately, evidence-based treatments are available, however, treatment effectiveness is often reliant on the provision of an accurate diagnosis. Accurate diagnosis requires a multi-method evidence-based assessment (EBA). Assessment techniques available to clinicians include a clinical interview, semi-structured diagnostic interview, self-report/clinician-administered rating scales and direct observation. Research demonstrates that only a small number of therapists utilize EBA, and to date this has not been investigated in an Australian sample. One hundred and two registered Australian psychologists (M_age = 40.98; SD = 12.67; 83.6% female) participated in an online study investigating assessment practices. Participants were asked to indicate EBA frequency of use and the obstacles they face to using EBA. The majority of participants (69% working with adult patients and 51% working with pediatric patients) reported partial use of EBA. Few psychologists (21% working with adult patients and 11% working with child patients) indicated complete use of EBA. Thirty-six percent of participants indicated negative beliefs about the usefulness or helpfulness of EBA. Multiple obstacles to the use of EBA were reported including concerns with the time required to complete assessment (27%), and a lack of access to assessment tools (10%). Implications for training and clinical practice are discussed.

Understanding the severity of depression: do nondepressive symptoms influence global ratings of depression severity?

OBJECTIVE

Almost all depression measures have been developed without discussing how to best conceptualize and assess the severity of depression. It is therefore not surprising that measures differ in both how items are rated and item content. The question that we address in the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project is whether a measure of depression severity should include symptoms that are frequent in depressed patients but are defining features of other disorders (eg, anxiety, irritability).

METHODS

Patients were evaluated with a semi-structured interview and severity ratings were made of each symptom of major depressive disorder (MDD) as well as anxiety, irritability, and somatization. Patients were also rated on the Clinical Global Index of severity (CGI).

RESULTS

Three of the 5 nondepressive symptoms (psychic anxiety, somatic anxiety, and subjective anger) were significantly correlated with the CGI. The correlation between the sum of all 5 nondepressive symptoms and the CGI was significantly lower than the correlation between the sum of the depressive symptom severity ratings (0.12 vs 0.52, z = 11.0, p < .001). The partial correlation between the CGI and the nondepressive symptom severity ratings (after controlling for the total depressive symptom ratings) was nonsignificant.

DISCUSSION

After accounting for the severity of depressive symptoms, the severity of the nondepressive symptoms was not associated with global ratings of depressive severity. These findings raise questions regarding the appropriateness of including ratings of anxiety, irritability, and somatization on a measure that purportedly assesses the severity of depression.

Have Treatment Studies of Depression Become Even Less Generalizable? Applying the Inclusion and Exclusion Criteria in Placebo-Controlled Antidepressant Efficacy Trials Published over 20 Years to a Clinical Sample

BACKGROUND

Antidepressants are amongst the most frequently prescribed medications. More than a decade ago, our clinical research group applied a prototypic set of inclusion/exclusion criteria used in an antidepressant efficacy trial (AET) to patients presenting for treatment in our outpatient practice and found that most patients would not qualify for the trial. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we apply the psychiatric inclusion/exclusion criteria used in 158 placebo-controlled studies to a large sample of depressed patients who presented for outpatient treatment to determine the range and extent of the representativeness of samples treated in AETs and whether this has changed over time.

METHOD

We applied the inclusion and exclusion criteria used in 158 AETs to 1,271 patients presenting to an outpatient practice who received a principal diagnosis of major depressive disorder. The patients underwent a thorough diagnostic evaluation.

RESULTS

Across all 158 studies, the percentage of patients that would have been excluded ranged from 44.4 to 99.8% (mean = 86.1%). The percentage of patients that would have been excluded was significantly higher in the studies published in 2010 through 2014 compared to the studies published from 1995 to 2009 (91.4 vs. 83.8%, t(156) = 3.74, p < 0.001).

CONCLUSIONS

Only a minority of depressed patients seen in clinical practice are likely to be eligible for most AETs. The generalizability of AETs has decreased over time. It is unclear how generalizable the results of AETs are to patients treated in real-world clinical practice.

Is the DSM-5 Anxious Distress Specifier Interview a valid measure of anxiety in patients with generalized anxiety disorder: A comparison to the Hamilton Anxiety Scale

DSM-5 includes criteria for an anxious distress specifier for major depressive disorder, and measures have been developed to assess these criteria. The validity of measures of the severity of anxious distress has been established in depressed patients. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined whether a severity measure of anxious distress was as valid as the Hamilton Anxiety Scale (HAMA) as a measure of the severity of anxiety in patients with generalized anxiety disorder (GAD). Eighty-five patients with GAD were interviewed by trained raters who administered the DSM-5 Anxious Distress Specifier Interview (DADSI), HAMA, and Hamilton Depression Rating Scale (HAMD). The patients completed self-report measures of depression, anxiety, and irritability. The DADSI and HAMA were significantly correlated (r  0.52, p < .001). Both the DADSI and HAMA were more highly correlated with measures of anxiety than with measures of the other symptom domains. The HAMD was significantly more highly correlated with the HAMA than with the DADSI. Both measures were significantly correlated with measures of positive mental health, functioning, life satisfaction, and general well-being. Both measures were sensitive to change in response to treatment. Both the DADSI and HAMA were valid measures of anxiety severity in patients with GAD, though the HAMA was more highly confounded with the HAMD than the DADSI. The DADSI is briefer than the HAMA, and thus may be more practical to use in research studies as well as clinical practice.

Recognition of personality disorder and anxiety disorder comorbidity in patients treated for depression in secondary psychiatric care

OBJECTIVES

Depression is a common illness with substantial economic consequences for society and a great burden for affected individuals. About 30% of patients with depression do not respond to repeated treatments. Psychiatric comorbidity is known to affect duration, recurrence and treatment outcome of depression. However, there is a lack of knowledge on the extent to which psychiatric comorbidity is identified in the clinical setting for depressed patients in secondary psychiatric care. Therefore, the aim of this study was to compare the agreement between traditional diagnostic assessment (TDA) and a structured and comprehensive diagnostic procedure (SCDP) for identification of personality and anxiety disorder comorbidity in depressed patients in secondary psychiatric care.

METHODS

274 patients aged 18-77 were referred from four secondary psychiatric care clinics in Sweden during 2012-2017. ICD-10 diagnoses according to TDA (mostly unstructured by psychiatric specialist and residents in psychiatry), were retrieved from medical records and compared to diagnoses resulting from the SCDP in the study. This included the Mini International Neuropsychiatric Interview, the Structured Interview for DSM Axis II Personality Disorders and semi-structured questions on psychosocial circumstances, life-events, psychiatric symptoms, psychiatric treatments, substance use, and suicidal and self-harm behaviour. The assessment was carried out by psychiatric specialists or by residents in psychiatry with at least three years of psychiatric training.

RESULTS

SCDP identified personality disorder comorbidity in 43% of the patients compared to 11% in TDA (p<0,0001). Anxiety disorder comorbidity was identified in 58% with SCDP compared to 12% with TDA (p<0,0001).

CONCLUSIONS

Important psychiatric comorbidity seems to be unrecognized in depressive patients when using TDA, which is routine in secondary psychiatric care. Comorbidities are better identified using the proposed model involving structured and semi-structured interviews together with clinical evaluations by clinical experts.

Applying the inclusion/exclusion criteria in placebo-controlled studies to a clinical sample: A comparison of medications

BACKGROUND

We previously compared the inclusion/exclusion criteria in the studies of vortioxetine to other antidepressants and found that they were significantly more restrictive in the vortioxetine studies. In the present study, we tested the hypothesis that the differences in psychiatric inclusion/exclusion criteria used in the studies of some antidepressants resulted in differences in generalizability to clinical samples.

METHODS

We applied the inclusion and exclusion criteria used in 161 antidepressant efficacy trials to 1,271 patients presenting to an outpatient practice who received a principal diagnosis of major depressive disorder. The patients underwent a thorough diagnostic evaluation. We compared the percentage of patients that would be excluded in studies of different medications.

RESULTS

The percentage of patients that would have been excluded was significantly higher in the vortioxetine studies than other medications. For the 15 medications that were included in at least 5 trials, we computed the mean percentage of patients that would be excluded. The values ranged from 76.0% (for fluoxetine) to 99.1% (for quetiapine).

LIMITATIONS

While our calculations were based on the exclusion criteria stated in the published articles, we have no way of knowing how these criteria were actually applied.

CONCLUSION

Studies of different medications vary in how representative the samples are of patients in clinical practice. The variability in the inclusion/exclusion criteria used to select samples for antidepressant efficacy trials, and the evidence that studies of different medications vary in their generalizability, makes it more difficult to interpret network analyses comparing the relative efficacy of medications.

Symptom presence versus symptom intensity in understanding the severity of depression: Implications for documentation in electronic medical records

BACKGROUND

Data mining efforts have been applied to research data bases to develop statistical models for predicting outcomes. Electronic medical records have the potential to enable efforts to apply statistical techniques to mine large clinical data bases. Of course, such prediction algorithms will only be as good as the data that is available to input. The question that we address in the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project is how much information might be gained from dimensional ratings of symptom severity over and above that which is accounted for when determining symptom presence. Such results could have implications for how medical record documentation should be established.

METHODS

Patients were evaluated with a semi-structured interview, and the presence of each symptom of major depressive disorder (MDD) was recorded. Patients were also rated on the Clinical Global Index of Severity (CGI-S).

RESULTS

A multiple regression analysis entering the presence of MDD symptoms as predictors of the CGI had a cumulative R² of 0.26. A multiple regression analysis entering all symptom severity ratings as predictors of the CGI had a cumulative R² of 0.40.

LIMITATIONS

The study was based on patients presenting for outpatient treatment to a single clinical practice. Symptoms that are not diagnostic criteria for MDD were not examined.

DISCUSSION

Research institutions interested in using data mining statistical approaches of electronic medical records should consider having the clinicians rate whether symptoms are mild, moderate or severe and not just whether they are present or absent.

PTSD in mental health outpatient settings: highly prevalent and under-recognized

OBJECTIVES

To estimate the current prevalence of posttraumatic stress disorder (PTSD) and the diagnosis rate of this disorder ascertained by psychiatrists in training.

METHODS

We interviewed 200 adults under treatment in a university mental health outpatient clinic. The PTSD diagnoses obtained using the Structured Clinical Interview for DSM-IV (SCID-IV) were compared with the patients' medical records.

RESULTS

Forty-one patients (20.5%) were diagnosed with current PTSD, but only one of them (2.4%) had previously received this diagnosis. This study confirms that although PTSD is highly prevalent among mental health outpatients, it is remarkably underdiagnosed in teaching hospitals.

CONCLUSIONS

These findings suggest that psychiatrists in training may be failing to investigate traumatic events and their consequences and strongly indicate that trauma-related issues should be given more prominence in psychiatry curricula and psychiatrist training.

Depressive symptoms carry an increased risk for suicidal ideation and behavior in bipolar disorder without any additional contribution of mixed symptoms

OBJECTIVES

To determine whether the risk of suicidal ideation or behavior during mixed states exceeds that attributable to the depressive components of these states alone in bipolar disorder.

METHODS

We utilized real-world, longitudinal clinical data collected on 290 patients with bipolar disorders (bipolar I, bipolar II, and bipolar not otherwise specified (NOS)) from the National Network of Depression Centers (NNDC) Clinical Care Registry (CCR) seen for 891 visits over a mean of 27.5 weeks. Depressive symptoms were measured with the Patient Health Questionnaire-9 (PHQ-9), manic symptoms with the Altman Self-Rating Mania (ASRM), and suicidal ideation and behavior with the Columbia-Suicide Severity Rating Scale (C-SSRS), obtained as part of the routine, measurement-based care provided across the NNDC. The relations between depressive symptoms, manic symptoms, and the interaction thereof (mixed symptoms) on coinciding suicidal ideation and behavior were modeled in generalized linear mixed models.

RESULTS

Depressive symptoms, as measured by the PHQ-9, were strongly associated with suicidal ideation and behavior (p < 0.0001), while there was no significant association with manic symptoms as measured by the ASRM or the interaction between depressive and manic symptoms. Similar results were observed when the outcome was restricted to suicidal behavior and when mood was modeled categorically. There was evidence of a gender by ASRM interaction (p = 0.011) and risk of suicidal ideation or behavior was significant for women, but not men with manic symptoms.

LIMITATIONS

Diagnoses were based on clinician assessment and not structured interview. Mood assessments were self-reported rather than clinician-administered. Suicidal ideation was more frequently observed than suicidal behavior (23/272 visits where outcome positive).

CONCLUSIONS

Depression represents the primary mood state accounting for suicide risk in bipolar disorder. Co-occurring symptoms of mania (mixed symptoms) do not appear to convey an elevated risk for suicidal ideation or behavior beyond that explained by the depressive symptoms alone.

Clinicians' attitudes toward standardized assessment and diagnosis within child and adolescent psychiatry

BACKGROUND

There is a strong call for clinically useful standardized assessment tools in everyday child and adolescent psychiatric practice. The attitudes of clinicians have been raised as a key-facilitating factor when implementing new methods. An explorative study was conducted aimed to investigate the clinicians' attitudes regarding standardized assessments and usefulness of diagnoses in treatment planning.

METHODS

411 mental health service personnel working with outpatient and inpatient assessment and treatment within the specialist child and adolescent mental health services, Stockholm County Council were asked to participate in the study, of which 345 (84%) agreed answer a questionnaire. The questionnaire included questions regarding Attitudes toward Standardized Assessment and Utility of Diagnosis. Descriptive analyses were performed and four subscales were compared with information from a similar study in US using the same instruments. The demographic and professional characteristics (age, working years, gender, education, profession, management position, involvement in assessment, level of service) in terms of prediction of attitudes were studied by univariate and multivariate linear regressions.

RESULTS

Overall, the clinicians had quite positive attitudes and were more positive compared to a similar study conducted in the US earlier. There were differences in attitudes due to several characteristics but the only characteristic predicting all subscales was type of profession (counselor, nurse, psychiatrist, psychologist, other), with counselors being less positive than other groups.

CONCLUSION

The overall positive attitudes toward standard assessment are of importance in the development of evidence-based practice and our study implies that clinicians in general value and are willing to use standardized assessment. Nevertheless, there are specific issues such as adequate training and available translated assessment instrument that need to be addressed. When implementing new methods in practice, there are general as well as specific resistances that need to be overcome. Studies in different cultural settings are of importance to further extend the knowledge of what is general and what is specific barriers.

Prevalence and clinicians' awareness of psychiatric comorbidities among first-episode schizophrenia

BACKGROUND

To explore the prevalence and clinicians' awareness of psychiatric comorbidities, and to identify factors associated with current psychiatric comorbidities in first-episode schizophrenia (FES) patients.

METHOD

In this cross-sectional study, 128 patients with FES, who were in symptomatic remission, were consecutively recruited from a local early intervention clinic. All patients were interviewed using the Chinese bilingual version of the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Axis I Disorders, Positive and Negative Syndrome Scales, Scale to Assess Unawareness of Mental Disorder, Social and Occupational Functioning Assessment Scale, Simpson-Angus Scale, Barnes Akathisia Rating Scale and Abnormal Involuntary Movement Scale. Bivariate and multivariate analyses were performed to investigate factors associated with psychiatric comorbidities in FES patients.

RESULTS

The lifetime and point prevalence of psychiatric comorbidities among FES patients were 47.7% and 27.3%, respectively. Current psychiatric comorbidities were documented on the medical records of 39.3% of the patients. The FES patients with current psychiatric comorbidities had a lower level of functioning. Depression in FES was also associated with akathisia.

CONCLUSION

Psychiatric comorbidities are prevalent among community FES patients. In addition to achieving symptomatic remission in schizophrenia, both treating psychiatric comorbidities and minimizing the side-effects of treatment, particularly akathisia, are fundamental for supporting FES patients in their journey to recovery.

Screening for psychiatric disorders with self-administered questionnaires

Given the time demands of clinical practice it is not surprising that diagnoses are sometimes missed. To improve diagnostic recognition, self-administered screening scales have been recommended. A problem with much of the research effort on screening scales is the confusion between diagnostic testing and screening. It is important for a screening test to have high sensitivity because the more time intensive/expensive follow-up diagnostic inquiry will presumably only occur in patients who are positive on the initial screen. Investigators vary in how they analyze their data in determining the recommended cutoff score on a self-administered screening questionnaire. To illustrate this, in the present report we examined how often each of the different approaches towards determining a cutoff score on bipolar disorder screening scales were used. We reviewed 68 reports of the performance of the 3 most commonly researched bipolar disorder screening scales to determine how the recommended cutoff on the scale was derived. Most studies recommended a cutoff point on the screening scale that optimized the level of agreement with the diagnostic gold standard. Only 11 (16.2%) studies recommended a cutoff that prioritized the scale's sensitivity. It is important for clinicians to understand the difference between screening and diagnostic tests. The results of the present study indicate that most studies of the performance of the 3 most commonly studied bipolar disorder screening measures have taken the wrong approach in deriving the cutoff score on the scale for the purpose of screening.

Community and Clinical Epidemiology of Borderline Personality Disorder

Several studies of the prevalence of borderline personality disorder in community and clinical settings have been carried out to date. Although results vary according to sampling method and assessment method, median point prevalence is roughly 1%, with higher or lower rates in certain community subpopulations. In clinical settings, the prevalence is around 10% to 12% in outpatient psychiatric clinics and 20% to 22% among inpatient clinics. Further research is needed to identify the prevalence and correlates of borderline personality disorder in other clinical settings (eg, primary care) and to investigate the impact of demographic variables on borderline personality disorder prevalence.

Understanding the severity of depression: Which symptoms of depression are the best indicators of depression severity?

BACKGROUND

In DSM-5, all symptoms of depression are considered equal representations of severity. In ICD-10, the type of symptom is considered in classifying severity. It is important to better understand if the defining symptoms of depression are differentially associated with overall severity so that severity categorization in diagnostic systems is most valid. In the present study from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project we examined the association between the individual diagnostic criteria for major depressive disorder (MDD) and global ratings of depression severity. We thus examined whether there is support for the ICD-10 approach in which some symptoms are better indicators of severity than are other symptoms.

METHODS

Patients were evaluated with a semi-structured interview and the presence of each symptom of MDD was recorded. Patients were also rated on the Clinical Global Index of severity (CGI-S).

RESULTS

All 9 DSM-5 criteria were significantly correlated with the CGI with suicidality having the highest correlation. A regression analysis found that all 9 criteria were significant predictors of the CGI. At the symptom level, 15 of the 17 symptoms were significantly correlated with the CGI (all except increased appetite and increased weight).

DISCUSSION

There were differences between the symptoms of depression in their association with severity with suicidal ideation, depressed mood, and anhedonia having the highest correlations with severity whereas some symptoms were not significantly associated with severity distinctions. Future descriptions of the severity of depression should not consider all criteria as equal representations of severity.

The clinical correlates of comorbid anxiety symptoms and syndromal anxiety in patients with major depressive disorder

This study explored the magnitude and clinical correlates of anxiety in three groups of patients with major depressive disorder (MDD): those with comorbid anxiety disorders (the COM group), those with subthreshold core anxiety disorder symptoms that are the screening items for anxiety disorders on the MINI (the SUB group), and those with neither anxiety disorders nor subthreshold core anxiety disorder symptoms (the NON group). Anxiety symptomatology of 1052 patients from 8 psychiatric settings in mainland China, who met DSM-IV TR criteria for MDD, was assessed using the MINI. The presence of core anxiety symptoms was determined by patient endorsement of any screening item of panic disorder, agoraphobia, social anxiety disorder, or generalized anxiety disorder. The prevalences of comorbid subthreshold core anxiety symptoms and anxiety disorders were 13% and 28.7%, respectively. The SUB and COM cases showed similar patterns of clinical presentation. Both were more likely than the NON cases to be characterized by younger age, concurrent dysthymia and OCD, suicidal ideation and attempted suicides. These findings highlight the importance of assessing both anxiety symptoms and anxiety disorders in the presence of MDD, and suggest the need for novel assessments capable of addressing different levels of anxiety in depressed patients.

Asenapine in the management of impulsivity and aggressiveness in bipolar disorder and comorbid borderline personality disorder: an open-label uncontrolled study

Borderline personality disorder (BPD) often co-occurres with bipolar disorder (BD). Impulsivity and aggressiveness represent core shared features and their pharmacological management is mainly based on mood stabilizers and antipsychotics, although scarce evidence is available for this context of comorbidity. The aim of the present study was to evaluate the role of Asenapine as an adjunctive drug for reducing aggressiveness and impulsivity in a sample of Italian BD type I outpatients with or without a comorbid BPD. This was an observational 12-week open-label uncontrolled clinical study carried out from April to October 2014 in two psychiatric clinics in Sicily. Each patient was treated with asenapine at two dose options, 5 mg (twice daily) or 10 mg (twice daily), and concomitant ongoing medications were not discontinued. We measured impulsivity using the Barratt Impulsiveness Scale (BIS) and aggressiveness using the Aggressive Questionnaire (AQ). For the analysis of our outcomes, patients were divided into two groups: with or without comorbid BPD. Adjunctive therapy was associated with a significant decrease of BIS and AQ overall scores in the entire bipolar sample. Yet, there was no significant difference in BIS and AQ reductions between subgroups. Using a regression model, we observed that concomitant BPD played a negative role on the Hostility subscale and overall AQ score variations; otherwise, borderline co-diagnosis was related positively to the reduction of physical aggression. According to our post-hoc analysis, global aggressiveness scores are less prone to decrease in patients with a dual diagnosis, whereas physical aggressiveness appears to be more responsive to the add-on therapy in patients with comorbidity.

Rapid and Accurate Behavioral Health Diagnostic Screening: Initial Validation Study of a Web-Based, Self-Report Tool (the SAGE-SR)

Background

The Structured Clinical Interview for DSM (SCID) is considered the gold standard assessment for accurate, reliable psychiatric diagnoses; however, because of its length, complexity, and training required, the SCID is rarely used outside of research.

Objective

This paper aims to describe the development and initial validation of a Web-based, self-report screening instrument (the Screening Assessment for Guiding Evaluation-Self-Report, SAGE-SR) based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and the SCID-5-Clinician Version (CV) intended to make accurate, broad-based behavioral health diagnostic screening more accessible within clinical care.

Methods

First, study staff drafted approximately 1200 self-report items representing individual granular symptoms in the diagnostic criteria for the 8 primary SCID-CV modules. An expert panel iteratively reviewed, critiqued, and revised items. The resulting items were iteratively administered and revised through 3 rounds of cognitive interviewing with community mental health center participants. In the first 2 rounds, the SCID was also administered to participants to directly compare their Likert self-report and SCID responses. A second expert panel evaluated the final pool of items from cognitive interviewing and criteria in the DSM-5 to construct the SAGE-SR, a computerized adaptive instrument that uses branching logic from a screener section to administer appropriate follow-up questions to refine the differential diagnoses. The SAGE-SR was administered to healthy controls and outpatient mental health clinic clients to assess test duration and test-retest reliability. Cutoff scores for screening into follow-up diagnostic sections and criteria for inclusion of diagnoses in the differential diagnosis were evaluated.

Results

The expert panel reduced the initial 1200 test items to 664 items that panel members agreed collectively represented the SCID items from the 8 targeted modules and DSM criteria for the covered diagnoses. These 664 items were iteratively submitted to 3 rounds of cognitive interviewing with 50 community mental health center participants; the expert panel reviewed session summaries and agreed on a final set of 661 clear and concise self-report items representing the desired criteria in the DSM-5. The SAGE-SR constructed from this item pool took an average of 14 min to complete in a nonclinical sample versus 24 min in a clinical sample. Responses to individual items can be combined to generate DSM criteria endorsements and differential diagnoses, as well as provide indices of individual symptom severity. Preliminary measures of test-retest reliability in a small, nonclinical sample were promising, with good to excellent reliability for screener items in 11 of 13 diagnostic screening modules (intraclass correlation coefficient [ICC] or kappa coefficients ranging from .60 to .90), with mania achieving fair test-retest reliability (ICC=.50) and other substance use endorsed too infrequently for analysis.

Conclusions

The SAGE-SR is a computerized adaptive self-report instrument designed to provide rigorous differential diagnostic information to clinicians.

External validity of the Psychiatric Diagnostic Screening Questionnaire (PDSQ) in a clinical sample

This study contributes to the convergent and discriminant validity of the Psychiatric Diagnostic Screening Questionnaire (PDSQ) by investigating its correlations with the relevant clinical scales of the Personality Assessment Inventory (PAI) and life space variables, such as relationship status, education level, job loss, and history of suicide attempts. Bivariate correlations were calculated for a sample of 254 psychiatric outpatients. The results indicated that the PDSQ scales demonstrated good to excellent convergent and discriminant validity with target scales from the PAI. They were also found to be meaningfully associated with a variety of life space variables. For example, five of the subscales and the Total Score correlated positively with a recent job loss, and eight of the subscales were negatively associated with education and/or employment status. Some incongruence with hypothesized relationships was discovered for life correlates classified as markers of psychiatric severity. Overall, these findings add to the emerging body of evidence corroborating the convergent and discriminant validity of the PDSQ.

Relationship Between the DSM-5 Anxious Distress Specifier and the Hamilton Depression Rating Scale Anxiety/Somatization Factor

We examined the association between the Hamilton Depression Scale (HAMD) approach to classifying depressed patients into anxious and nonanxious subgroups and the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) anxious distress specifier subtyping. Two hundred two depressed patients were interviewed with semistructured diagnostic interviews. Patients were rated on the 17-item HAMD and the Hamilton Anxiety Rating Scale and completed the Clinically Useful Anxiety Outcome Scale. Both approaches toward identifying anxiety in depressed patients resulted in most of the patients meeting the anxiety subtype. Both subtyping methods were significantly correlated with clinician-rated and self-report measures of anxiety, and scores on the anxiety scales were higher in the patients who met the anxious subtype. However, DSM-5 anxious distress subtyping was only marginally associated with the HAMD anxiety/somatization factor subtyping approach (k = 0.21), and dimensional scores were only moderately correlated (r = 0.50). These findings indicate that the DSM-5 and HAMD approaches toward identifying an anxious subtype of depression are not interchangeable.

The Mini-International Neuropsychiatric Interview is useful and well accepted as part of the clinical assessment for depression and anxiety in primary care: a mixed-methods study

BACKGROUND

Psychiatric complaints are common among primary care patients, with depression and anxiety being the most frequent. Diagnosis of anxiety and depression can be difficult, potentially leading to over- as well as under-diagnosis. The diagnostic process can be facilitated by incorporating structured interviews as part of the assessment. One such instrument, the Mini-International Neuropsychiatric Interview (MINI), has been established and accepted in psychiatric care. The purpose of this study was to explore the experiences and perceptions of the paper-and-pen version of MINI version 6.0 among patients and staff in primary care centers in Sweden.

METHODS

The MINI was introduced at three primary care centers and was conducted by either therapists or general practitioners. Patients presented with symptoms that could suggest depression or anxiety disorders. The duration of the interview was recorded. The experiences and perceptions of 125 patients and their interviewers were collected using a structured questionnaire. Global satisfaction was measured with a visual-analog scale (0-100). Semi-structured interviews were conducted with 24 patients and three therapists, and focus groups were held with 17 general practitioners. Qualitative content analysis was used for the interviews and focus groups. The findings across the groups were triangulated with results from the questionnaires.

RESULTS

The median global satisfaction with the MINI was 80 for patients and 86 for interviewers. General practitioners appreciated that the MINI identified comorbidities, as one-third of the patients had at least two psychiatric diagnoses. The MINI helped general practitioners attain a more accurate diagnosis. Patients appreciated that the MINI helped them recognize and verbalize their problems and did not find it intrusive. Patients and interviewers had mixed experiences with the yes-no format of the MINI, and the risk of subjective interpretations was acknowledged. Patients, general practitioners and therapists stated that the MINI contributed to appropriate treatment. The MINI assessment lasted 26 min on average (range 12 to 60 min).

CONCLUSIONS

The paper-and-pen version of the MINI could be useful in primary care as part of the clinical assessment of patients with problems suggestive of depression or anxiety disorders. The MINI was well accepted by patients, general practitioners and therapists.

Measuring anxiety in depressed patients: A comparison of the Hamilton anxiety rating scale and the DSM-5 Anxious Distress Specifier Interview

DSM-5 included criteria for an anxious distress specifier for major depressive disorder (MDD). In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project we examined whether a measure of the specifier, the DSM-5 Anxious Distress Specifier Interview (DADSI), was as valid as the Hamilton Anxiety Scale (HAMA) as a measure of the severity of anxiety in depressed patients. Two hundred three psychiatric patients with MDD were interviewed by trained diagnostic raters who administered the Structured Clinical Interview for DSM-IV (SCID) supplemented with questions to rate the DADSI, HAMA, and Hamilton Depression Rating Scale (HAMD). The patients completed self-report measures of depression, anxiety, and irritability. Sensitivity to change was examined in 30 patients. The DADSI and HAMA were significantly correlated (r = 0.60, p < 0.001). Both the DADSI and HAMA were more highly correlated with measures of anxiety than with measures of the other symptom domains. The HAMD was significantly more highly correlated with the HAMA than with the DADSI. For each anxiety disorder, patients with the disorder scored significantly higher on both the DADSI and HAMA than did patients with no current anxiety disorder. A large effect size of treatment was found for both measures (DADSI: d = 1.48; HAMA: d = 1.37). Both the DADSI and HAMA were valid measures of anxiety severity in depressed patients, though the HAMA was more highly confounded with measures of depression than the DADSI. The DADSI is briefer than the HAMA, and may be more feasible to use in clinical practice.

Reliability and validity of the DSM-5 Anxious Distress Specifier Interview

BACKGROUND

To acknowledge the clinical significance of anxiety in depressed patients, DSM-5 included an anxious distress specifier for major depressive disorder (MDD). In the present report we describe the reliability and validity of a semi-structured interview assessing the features of the anxious distress specifier. Our goal was to develop an instrument that could be used for both diagnostic and outcome measurement purposes.

METHODS

One hundred seventy-three psychiatric patients with MDD were interviewed by a trained diagnostic rater who administered the Structured Clinical Interview for DSM-IV (SCID) supplemented with questions from the DSM-5 Anxious Distress Specifier Interview (DADSI). Inter-rater (n=25) and test-retest (n=25) reliability of the DADSI was examined in separate groups of patients. The patients were rated on clinician rating scales of depression, anxiety and irritability, and patients completed self-report measures of these constructs. Sensitivity to change was examined in 16 patients.

RESULTS

Approximately three-quarters of the depressed patients met the criteria for the anxious distress specifier (78.0%, n=135). The DADSI had excellent joint-interview reliability and good test-retest reliability. DADSI total scores were more highly correlated with other clinician-rated and self-report measures of anxiety than with measures of depression and anger. DADSI scores were significantly higher in depressed outpatients with a current anxiety disorder than depressed patients without a comorbid anxiety disorder. The DADSI was sensitive to improvement.

CONCLUSION

The DADSI is a reliable and valid measure of the presence of the DSM-5 anxious distress specifier for MDD as well as the severity of the features of the specifier.

Psychometrics of the screen for adult anxiety related disorders (SCAARED)- A new scale for the assessment of DSM-5 anxiety disorders

OBJECTIVE

To examine the psychometrics of the Screen for Adult Anxiety Related Disorders (SCAARED).

METHODS

The SCAARED was adapted from the Screen for Child Anxiety Related Emotional Disorders. Participants (N=336) ages 18-27 years old were evaluated using the Structured Clinical Interview for DSM-IV Disorders (SCID). The SCAARED was completed at or within two-weeks before the SCID. The psychometrics of the SCAARED were analyzed using standard statistical analyses including principal components, and Receiver Operant Curve analyses. A replication was performed in an age/sex matched independent sample (N=158).

RESULTS

The SCAARED showed four factors: somatic/panic/agoraphobia, generalized anxiety, separation anxiety, and social anxiety. The total and each factor scores demonstrated good internal consistency (α=0.86-0.97) and good discriminant validity between anxiety and other disorders and within anxiety disorders for generalized and social anxiety. Area Under the Curve for the total and each of the factor scores ranged between 0.72 and 0.84 (p<0.0001). These results were replicated in the independent sample.

CONCLUSIONS

The SCAARED showed excellent psychometric properties supporting its use to screen adults for anxiety disorders, longitudinal studies following youth into adulthood and studies comparing child and adult populations. Further replication studies in larger community and clinical samples are indicated.

Pre- and post-surgical psychiatric assessments and intervention by major epilepsy centers in Japan - Nationwide survey

BACKGROUND

Although psychiatric issues following epilepsy surgery are now widely recognized as a major problem, actual awareness of these issues by epilepsy centers remains to be elucidated. This is the first known report regarding the use of psychiatric assessments and interventions by epilepsy centers throughout Japan.

PARTICIPANTS AND METHODS

At the beginning of 2016, we sent a questionnaire regarding psychiatric assessments performed before and after epilepsy surgery, psychiatric intervention after surgery, and future plans for dealing with psychiatric issues in relation to epilepsy surgery, which consisted of a total of 24 items, to all members of the Japan Epilepsy Center Association (JEPICA). Nearly all major epilepsy centers in Japan are included in JEPICA, which had 31 members in 2016. Twenty-four (77%) of the 31 centers responded to the questionnaire.

RESULTS

Seventeen (70.8%) centers answered that a psychiatrist was incorporated as part of their epilepsy surgery unit. In addition, 17 (70.8%) noted that psychiatric assessments were obtained prior to surgery, which were performed by psychiatrists in 8 (33.3%) centers and psychologists in 11 (45.8%). In 23 (95.8%) of the centers, the risk of occurrence of psychiatric illness following surgery was routinely explained prior to surgery, at least to surgical candidates with high susceptibility. In total, cases of psychiatric illness following surgery had been experienced in 16 (66.7%) centers, with depression as the most commonly encountered (41.7%), followed by anxiety (33.3%), psychosis (25.0%), and psychogenic non-epileptic seizures (8.3%).

DISCUSSION

Strong points of epilepsy centers in Japan include serious concern regarding post-surgical psychiatric illness by nearly all members of JEPICA and explanation of the risk of psychiatric adverse events provided beforehand to their patients. On the other hand, the small size of some epilepsy centers, along with lack of a standardized method for evaluation of psychiatric symptoms as well as dependence on the individual willingness of psychiatrists assigned as members of the epilepsy units, seem to have led to significant diagnostic and therapeutic gaps among epilepsy centers regarding psychiatric issues related to epilepsy surgery.

Has the symptom severity inclusion requirement narrowed the definition of major depressive disorder in antidepressant efficacy trials?

BACKGROUND

The inclusion criteria of all placebo-controlled studies of antidepressants have required a minimum level of severity on standardized measures of symptoms of depression. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project we examined the association between scores on the Hamilton Depression Rating Scale (HAMD) and the number of criteria met for MDD, as well as the impact of different HAMD cutoff scores on the distribution of the number of DSM-IV criteria met. We speculated that the use of a minimum symptom severity score (MSSS) for inclusion in an antidepressant efficacy trial (AETs) disproportionately excludes patients who are at or just above the diagnostic threshold for MDD, whereas patients who are well above the diagnostic threshold are not excluded.

METHODS

Seven hundred forty outpatients with current MDD were evaluated with a semi-structured diagnostic interview. We compared the distribution of DSM-IV MDD criteria scores in patients who scored at or above or below the 3 cutoff scores on the HAMD most commonly used for inclusion in an AET.

RESULTS

The distribution of the number of DSM-IV MDD symptom criteria met was significantly associated with HAMD scores. Compared to patients scoring below 18 on the HAMD the patients scoring 18 and above were less likely to report 5 MDD criteria (13.9% vs. 43.7%, χ²=82.2, p<0.001; RR 0.32 [95% C.I. 0.24-0.41]) and more likely to report 9 criteria (9.3% vs. 0.3%, χ²=27.6, p<0.001; RR 28.7 [95% C.I. 4.0-207.5]). The pattern was similar when comparing patients scoring above and below the cutoffs of 20 and 22. At a cutoff of 22 on the HAMD more than 85% of the patients meeting 5 or 6 MDD criteria would be excluded from a trial. In contrast, less than 10% of the patients meeting 8 or 9 criteria would be excluded based on a HAMD cutoff of 18.

LIMITATIONS

The present study was conducted in a single outpatient practice in which the majority of patients were white, female, and had health insurance. Although the study was limited to a single site, a strength of the recruitment procedure was that the sample was not selected for participation in a treatment study, and exclusion and inclusion criteria did not reduce the representativeness of the patient groups.

CONCLUSIONS

While there is not a perfect relationship between the HAMD score and the number of DSM MDD criteria present, the results of the current study suggest that HAMD scores can be thought of as a proxy for the number of DSM diagnostic criteria. Thus, the recruitment strategy for AETs has increasingly redefined the MDD diagnostic category by requiring a greater number of criteria than that required in the DSM.

Subjective anger and overt aggression in psychiatric outpatients

BACKGROUND

The attention given to anger and aggression in psychiatric patients pales in comparison to the attention given to depression and anxiety. Most studies have focused on a limited number of psychiatric disorders, and results have been inconsistent. The present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project sought to replicate and extend prior findings examining which psychiatric disorders and demographic characteristics were independently associated with elevated levels of anger and aggression.

METHOD

3800 individuals presenting to the Rhode Island Hospital Department of Psychiatry outpatient practice underwent a semi-structured interview to determine current Axis I (N=3800) and Axis II (N=2151) pathology. Severity of subjective anger and overt aggression within the past week were also assessed for each patient, and odds ratios were determined for each disorder. Multiple regression analyses were conducted to determine which diagnoses independently contributed to increased levels of anger and aggression.

RESULTS

Almost half of the sample reported moderate-to-severe levels of current subjective anger, and more than 20% endorsed moderate-to-severe levels of current overt aggression. The frequency of anger was similar to the frequencies of depressed mood and psychic anxiety. Anger and aggression were elevated across all diagnoses except adjustment disorder. Anger and aggression were most elevated in patients with major depressive disorder, panic disorder with agoraphobia, post-traumatic stress disorder, intermittent explosive disorder, and cluster B personality disorders.

CONCLUSIONS

Anger is as common as depressed mood and psychic anxiety amongst psychiatric outpatients, and problems with anger cut across diagnostic categories. Given the high prevalence of problems with anger in psychiatric patients, more research should be directed towards its effective treatment.

An Investigation of Diagnostic Accuracy and Confidence Associated with Diagnostic Checklists as Well as Gender Biases in Relation to Mental Disorders

This study examines the utility of checklists in attaining more accurate diagnoses in the context of diagnostic decision-making for mental disorders. The study also aimed to replicate results from a meta-analysis indicating that there is no association between patients’ gender and misdiagnoses. To this end, 475 psychotherapists were asked to judge three case vignettes describing patients with Major Depressive Disorder (MDD), Generalized Anxiety Disorder, and Borderline Personality Disorder. Therapists were randomly assigned to experimental conditions in a 2 (diagnostic method: with using diagnostic checklists vs. without using diagnostic checklists) × 2 (gender: male vs. female case vignettes) between-subjects design. Multinomial logistic and linear regression analyses were used to examine the association between the usage of diagnostic checklists as well as patients’ gender and diagnostic decisions. The results showed that when checklists were used, fewer incorrect co-morbid diagnoses were made, but clinicians were less likely to diagnose MDD even when the criteria were met. Additionally, checklists improved therapists’ confidence with diagnostic decisions, but were not associated with estimations of patients’ characteristics. As expected, there were no significant associations between gender and diagnostic decisions.

Diagnostic profiles of adult psychiatric outpatients with and without attention deficit hyperactivity disorder

OBJECTIVE

Despite growing recognition that attention deficit/hyperactivity disorder (ADHD) is a highly prevalent, impairing, and comorbid disorder that persists into adulthood, reports on the nature and extent of its psychiatric comorbidities have been mixed to date. This study compared the prevalence rates of all major Axis I disorders as well as borderline personality disorder in an unselected sample of adult psychiatric outpatients with and without ADHD.

METHODS

As part of the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we administered a DSM-IV-based semi-structured diagnostic interview assessing ADHD and other psychiatric disorders to 1134 patients presenting for initial evaluation at an outpatient psychiatric practice. Logistic regression analyses were used to compare the rates of each disorder in patients with versus without an ADHD diagnosis (both overall and by Combined and Inattentive type).

RESULTS

Patients with (versus without) any ADHD diagnosis had significantly higher rates of bipolar disorder, social phobia, impulse control disorders, eating disorders, and BPD, and significantly lower rates of major depressive disorder and adjustment disorder (all p<.05). Patients with (versus without) ADHD-Inattentive type had significantly higher rates of social phobia and eating disorders, whereas those with (versus without) the ADHD-Combined type had significantly higher rates of bipolar disorder, alcohol dependence, and BPD (all p<.05).

CONCLUSION

In this novel investigation of the psychiatric profiles of an unselected sample of treatment-seeking adult outpatients with versus without ADHD, a distinct pattern of comorbidities emerged across subtypes, with implications for the accurate assessment and treatment of patients presenting for psychiatric care.

Reliability and validity of a semi-structured DSM-based diagnostic interview module for the assessment of Attention Deficit Hyperactivity Disorder in adult psychiatric outpatients

Despite growing recognition that the symptoms and functional impairments of Attention Deficit/Hyperactivity Disorder (ADHD) persist into adulthood, only a few psychometrically sound diagnostic measures have been developed for the assessment of ADHD in adults, and none have been validated for use in a broad treatment-seeking psychiatric sample. The current study presents the reliability and validity of a semi-structured DSM-based diagnostic interview module for ADHD, which was administered to 1194 adults presenting to an outpatient psychiatric practice. The module showed excellent internal consistency and interrater reliability, good convergent and discriminant validity (as indexed by relatively high correlations with self-report measures of ADHD and ADHD-related constructs and little or no correlation with other, non-ADHD symptom domains), and good construct validity (as indexed by significantly higher rates of psychosocial impairment and self-reported family history of ADHD in individuals who meet criteria for an ADHD diagnosis). This instrument is thus a reliable and valid diagnostic tool for the detection of ADHD in adults presenting for psychiatric evaluation and treatment.