Detecting differences in diagnostic assessment of bipolar disorder.

During the past 25 years, semistructured diagnostic interviews have been the standard for diagnostic evaluations in research relying on reliable and valid psychiatric assessment and diagnosis. However, the use of semistructured interviews still requires interpretation of the diagnostic criteria and does not preclude the application of different diagnostic thresholds. The goal of this report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project is to illustrate how a self-report scale can be used to detect systematic differences in the application of diagnostic criteria for bipolar disorder and to demonstrate the wide variation in how broadly different groups tend to diagnose bipolar disorder.

Screening for bipolar disorder and finding borderline personality disorder.

Objective: Bipolar disorder and borderline personality disorder share some clinical features and have similar correlates. It is, therefore, not surprising that differential diagnosis is sometimes difficult. The Mood Disorder Questionnaire (MDQ) is the most widely used screening scale for bipolar disorder.

Performance of the mood disorders questionnaire in a psychiatric outpatient setting.

Objectives: The Mood Disorders Questionnaire (MDQ) has been the most widely studied screening questionnaire for bipolar disorder, though few studies have examined its performance in a heterogeneous sample of psychiatric outpatients. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined the operating characteristics of the MDQ in a large sample of psychiatric outpatients presenting for treatment.

Methods: A total of 534 psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV and asked to complete the MDQ.

Why don't psychiatrists use scales to measure outcome when treating depressed patients?

Objective: A survey of psychiatrists in the United Kingdom found that only a minority routinely used standardized measures to assess outcome when treating depression and anxiety disorders. The goals of the present study were to determine how frequently psychiatrists in the United States use scales to measure outcome when treating depressed patients and, for those clinicians who do not regularly use such scales, to ascertain the reasons for the lack of use.

Method: The subjects were 314 psychiatrists who attended a continuing medical education conference in California, Massachusetts, New York, or Wisconsin in 2006 or 2007.

Depressed patients' acceptability of the use of self-administered scales to measure outcome in clinical practice.

Background: Self-report questionnaires are a cost-effective option to monitor the outcome of clinical care. Even when using self-report scales, consideration should be given to how much time they take to complete and how burdensome they are perceived to be. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compared the acceptability of completing two depression scales-the Beck Depression Inventory (BDI) and the Clinically Useful Depression Outcome Scale (CUDOS).

Clinical significance and remission in treating major depressive disorder: parallels between related outcome constructs.

Over the last several years, research has increasingly focused on how to meaningfully characterize treatment outcome, with different terminologies emerging. In the psychotherapy and behavioral assessment research, clinical significance has emerged as the dominant term to describe the assessment of meaningful change due to treatment, whereas for certain psychiatric disorders remission is the term most commonly used to represent the posttreatment assessment of clinically meaningful change. In the treatment of major depressive disorder, these two constructs exhibit parallels in terms of methodology and conceptual themes, though the two lines of outcomes research using these terms have proceeded along largely isolated paths with little acknowledgment of their shared concerns.

A clinically useful depression outcome scale.

If the optimal delivery of mental health treatment ultimately depends on examining outcome, then precise, reliable, valid, informative, and user-friendly measurement is the key to evaluating the quality and efficiency of care in clinical practice. Self-report questionnaires are a cost-effective option because they are inexpensive in terms of professional time needed for administration, and they correlate highly with clinician ratings. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we describe the reliability and validity of the Clinically Useful Depression Outcome Scale (CUDOS).

Remission in depressed outpatients: more than just symptom resolution?

Objective: In treatment studies of depression remission is defined according to scores on symptom severity scales. Normalization of functioning has often been mentioned as an important component of the definition of remission, though it is not used to identify remitted patients in studies of treatment efficacy. Conceptually, the return of normal functioning should be as fundamental to the concept of remission as is symptom resolution because the presence of both symptoms and impaired functioning are core constructs in the diagnosis of mental disorders.

Examining a dimensional representation of depression and anxiety disorders' comorbidity in psychiatric outpatients with item response modeling.

The current study replicated, in a sample of 2,300 outpatients seeking psychiatric treatment, a previous study (R. F. Krueger & M.

Diagnosing major depressive disorder XII: can a self-report depression questionnaire be used to examine questions about the DSM-IV diagnostic criteria?

This paper is the final one in our series examining the DSM-IV diagnostic criteria for major depressive disorder. The data collected were part of the Rhode Island Methods to Improve Diagnostic Assessment and Services project, a unique integration of a research assessment protocol into a community-based clinical practice. We were able to examine a number of psychometric and conceptual issues in the diagnosis of depression because we modified the diagnostic interview to inquire about all diagnostic criteria, as well as additional associated features, of all patients.

Diagnosing major depressive disorder XI: a taxometric investigation of the structure underlying DSM-IV symptoms.

Psychopathologists have long debated the latent structure of mental disorders, and a number of researchers have suggested that depression may be best characterized as a continuous, rather than categorical, phenomenon. Nonetheless, attention has been drawn to limitations permeating existing research and the need for studies using more appropriate statistical methods developed expressly to tease apart taxonic (categorical) and dimensional (continuous) structural models. The present study examined the structure underlying the DSM-IV symptoms of major depressive disorder in a large outpatient sample rigorously assessed using semistructured clinical interviews.

Diagnosing major depressive disorder X: can the utility of the DSM-IV symptom criteria be improved?

There are two practical problems with the DSM-IV symptom criteria for major depressive disorder (MDD)--they are somewhat lengthy and therefore difficult to remember, and there are difficulties in applying some of the criteria in patients with comorbid medical illnesses because of symptom nonspecificity. Therefore, in the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we attempted to develop a briefer definition of major depression that is composed entirely of mood and cognitive symptoms. Our goal was to develop an alternative set of diagnostic criteria for major depression that did not include somatic symptoms but would nonetheless demonstrate a high level of concordance with the current DSM-IV definition.

Diagnosing major depressive disorder IX: are patients who deny low mood a distinct subgroup?

A dysphoric mood is not required for the diagnosis of DSM-IV major depressive disorder. Individuals who deny depression, sadness, or feeling blue may nonetheless be diagnosed with major depressive disorder if they have lost interest or pleasure in all, or almost all, of their usual activities, and experienced at least four other symptoms of depression. The underlying assumption is that depressed patients without low mood are no different than depressed patients who report dysphoric mood.

Diagnosing major depressive disorder VIII: are some symptoms better than others?

The present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project examined whether symptoms that are not part of the DSM-IV definition of major depressive disorder (MDD) are better at discriminating depressed from nondepressed patients than the current criteria. Symptoms assessed included diminished drive, helplessness, hopelessness, nonreactive mood, psychic anxiety, somatic anxiety, subjective anger, and overtly expressed anger. A total of 1538 psychiatric outpatients were administered a semistructured diagnostic interview.

Diagnosing major depressive disorder VII: family history as a diagnostic criterion.

Eliciting information about a patient's family history is a component of a standard diagnostic evaluation. Since depression runs in families, a question arises as to whether family history information should be considered when diagnosing depression. The text of DSM-IV indicates that a family history of a mood disorder should sometimes be considered when trying to distinguish between major depressive disorder and other conditions such as catatonic schizophrenia.

Diagnosing major depressive disorder VI: performance of an objective test as a diagnostic criterion.

Considerable research has evaluated biological and psychological tests for various psychiatric disorders; however, few objective tests are included in DSM-IV as diagnostic criteria. It was recently suggested that existing tests are insufficiently accurate to be included as diagnostic criteria. While it is true that there are limitations in the sensitivity and/or specificity of such tests, this should not rule them out as effective diagnostic criteria.

Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression.

Antidepressant medication is considered the current standard for severe depression, and cognitive therapy is the most widely investigated psychosocial treatment for depression. However, not all patients want to take medication, and cognitive therapy has not demonstrated consistent efficacy across trials. Moreover, dismantling designs have suggested that behavioral components may account for the efficacy of cognitive therapy.

Diagnosing major depressive disorder V: applying the DSM-IV exclusion criteria in clinical practice.

To be diagnosed with DSM-IV major depressive disorder (MDD), a patient must meet five out of nine symptom criteria, one of which is depressed mood or pervasive loss of interest or pleasure. Once a patient has reached this symptom threshold, there are several exclusionary criteria that need to be passed to receive the diagnosis. The symptoms must cause significant distress or impairment in functioning, the symptoms cannot be caused by substance use or a general medical condition, and the symptoms cannot be better accounted for by bereavement.

Diagnosing major depressive disorder IV: relationship between number of symptoms and the diagnosis of disorder.

The symptom inclusion criteria for DSM-IV major depressive disorder (MDD) consist of a list of nine characteristic features of depression, at least five of which must be present. Two of the criteria for MDD, low mood and loss of interest or pleasure, are accorded greater importance than the remaining seven criteria in that one of these two features is required for the diagnosis. The implicit assumption underlying this organization of the criteria is that some individuals might meet five of the nine criteria without experiencing low mood or loss of interest or pleasure and thus be inappropriately diagnosed with major depression.

The impact of gender, age and depressed state on patients' perspectives of remission.

Background: Current standards for treatment outcome from major depression assess remission solely from the vantage point of symptom resolution. Recent evidence, however, suggests that depressed patients consider factors beyond symptom resolution as important for defining remission. The goal of this study was to examine the influence of three predictors on patients' views of factors important for achieving remission: gender, age and current depressed state (i.

Diagnosing major depressive disorder III: can some symptoms be eliminated from the diagnostic criteria?

All criteria used to diagnose a psychiatric disorder should contribute to distinguishing cases from noncases. The principal of parsimony argues for defining a disorder with as few criteria as possible. Thus, criteria that do not contribute to the case-noncase distinction should be eliminated from the list of defining features because they unnecessarily increase the complexity of the definition of the disorder.

Validity of a self-report depression symptom scale for identifying remission in depressed outpatients.

In treatment studies of depression, remission is usually defined by scoring less than a threshold value on an interview-based measure of depression severity such as the Hamilton Rating Scale for Depression (HRSD). Although it has been recommended that measures such as the HRSD be used by clinicians in clinical practice to evaluate remission status, the time demands of clinical practice limit the feasibility of this suggestion. Self-report questionnaires are a cost-effective option to thoroughly, systematically, reliably, and validly evaluate clinical status because they are inexpensive in terms of professional time needed for administration and do not require special training for administration.

Diagnosing major depressive disorder: II: is there justification for compound symptom criteria?

The DSM-IV symptom inclusion criteria for the diagnosis of major depressive disorder (MDD) are constructed in three ways: single symptom criteria, compound criteria encompassing opposite variants of the same disturbance, and compound criteria encompassing related problems. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we tested the following three hypotheses: (1) the components of compound-opposite criteria rarely occur simultaneously, (2) the components of the compound-related criteria frequently occur simultaneously, and (3) the components of the compound-related criteria more frequently co-occur than other pairs of the MDD criteria. We also examined how many patients would be rediagnosed if the compound criteria were split into separate items.

Diagnosing major depressive disorder I: A psychometric evaluation of the DSM-IV symptom criteria.

The diagnostic criteria for depression were developed on the basis of clinical experience rather than empirical study. Although they have been available and widely used for many years, few studies have examined the psychometric properties of the DSM criteria for major depression. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we examined whether criteria such as insomnia, fatigue, and impaired concentration that are also diagnostic criteria for other disorders are less specific than the other DSM-IV depression symptom criteria.

Diagnosing major depressive disorder introduction: an examination of the DSM-IV diagnostic criteria.

During the past 3 decades, more research has been conducted on depression than any other psychiatric disorder. While there are numerous studies on depression in the areas of epidemiology, biopsychosocial correlates, genetics, course, and treatment, remarkably little research has focused on the criteria used to diagnose major depressive disorder. Nearly 10 years ago, we began the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, an integration of a comprehensive assessment protocol into a community-based psychiatry outpatient practice.