Moving toward DSM-5: the field trials.

Commentary accepted for publication July 2010.
American Journal of Psychiatry (Impact Factor: 14.72). 10/2010; 167(10):1158-60. DOI: 10.1176/appi.ajp.2010.10070962
Source: PubMed
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    ABSTRACT: How different ways of assessing suicidal ideation influence its prevalence, correlates and predictive validity among patients with major depressive disorder (MDD) remains unclear. Within the Vantaa Primary Care Depression Study (PC-VDS, 91 patients) and the Vantaa Depression Study (VDS, 153 psychiatric out-and 41 inpatients), suicidal ideation was assessed with the Scale for Suicidal Ideation (SSI), Hamilton Depression Scale (HAM-D) item 3 and Beck Depression Inventory (BDI) item 9, and by asking whether patients had seriously considered suicide during the episode. The positive and negative predictive values (PPV, NPV) for suicide attempts during a six-month follow-up were investigated. Depending on the setting, 56-88% of patients had suicidal ideation in some of the assessments, but only 8-44% in all of them. Agreement ranged from negligible to moderate (kappa 0.06-0.64), being lowest among primary care patients. The correlates of suicidal ideation overlapped. No assessment had optimal sensitivity, specificity, PPV and NPV. Nevertheless, PPVs ranged up to 43%. Which MDD patient is classified as having suicidal ideation depends strongly on the method of assessment, with the greatest variation likely in primary care. Differences in assessments may cause inconsistency in risk factors. Predicting suicide attempts is difficult, but not futile.
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    ABSTRACT: Background Diagnostic reliability or inter-rater accuracy, defined as the concordance between diagnoses assigned to a patient by different psychiatrists, was found to be very low in the first studies devoted to the subject since the 1950s. To resolve these inaccuracies, sources of bias in scientific studies, a few psychiatrists from the American Psychiatric Association decided to change the principles of nosography in order to optimise the reliability of psychiatric diagnoses. These days, a scientific study that does not use this official standard will have very little chance of being cited in the international literature, but the scientific basis of the increase in inter-rater accuracy thanks to the DSM-III and following is however lacking: very few studies have compared a diagnosis established in relation to the DSM with a diagnosis established as a result of a non-standardised clinical interview. Method This editorial poverty seems to us to convey a confession of failure that we aim to overcome with a return to theory by precisely differentiating the concepts of diagnostic accuracy and validity, the latter considering the existence of the diagnosis itself by integrating its etiopathogenic origins, its clinical “verity” and finally its interest in terms of the therapeutic treatment. Results The “atheoretical” notions are no longer relevant in the DSM-V: the validity of the diagnoses should increase through the precise definition of psychopathological and sociological determinants associated with the characterisation of biological and/or neuroradiological markers which will build an etiopathogenic theory of each psychic phenomenon. Discussion Classification like this will remain, by definition, reductive: a diagnostic code will never be a subject in that it is not enough just to provide our subjective clinical. Conclusion As with our clinical approach, taking into account our individual and societal subjectivities in defining a new nosography seems to us fundamental for the future of psychiatry.
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