Systematic Study of Structured Diagnostic Procedures in Outpatient Psychiatric Rehabilitation: A Three-year, Three-cohort Study of the Stability of Psychiatric Diagnoses

Abstract

Background. Psychiatric diagnoses are important for treatment planning. There are a number of current challenges in the area of psychiatric diagnosis with important treatment implications. In this study, we examined the differential usefulness of two semi-structured interviews of differing length compared to clinical diagnoses for generation of diagnoses that did not require modification over the course of treatment. Methods. We performed a three-year, three-cohort study at an outpatient psychiatric rehabilitation facility, comparing the stability of admission diagnoses when generated by unstructured procedures relying on referring clinician diagnosis, the SCID, and the MINI. We examined changes in diagnoses from admission to discharge (averaging 13 weeks) and, during the second two years, convergence between referring clinician diagnoses and those generated by structured interviews. The same three interviewers examined all patients in all three phases of the study. Results. Admission and discharge diagnoses were available for 313 cases. Diagnoses generated with the unstructured procedure were changed by discharge 74 percent of the time, compared to four percent for SCID diagnoses and 11 percent for MINI diagnoses. Referring clinician diagnoses were disconfirmed in Years 2 and 3 in 56 percent of SCID cases and 44 percent of MINI cases. The distinctions between unipolar and bipolar disorders were particular points of disagreement, with similar rates of under and over-diagnosis of bipolar disorder. The rate of confirmation of referring clinician diagnoses of schizoaffective disorder was 10 percent with the SCID and 11 percent with the MINI. Discussion. In this setting, there appears to be a reasonable trade-off between brevity and accuracy through the use of the MINI compared to the SCID, with substantial improvements in stability of diagnoses compared to clinician diagnoses. Clinical diagnoses were minimally overlapping with the results of structured diagnoses, suggesting that structured assessment, particularly early in the illness or in short term treatment settings, may improve treatment planning.

Full text

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ABSTRACT
Background. Psychiatric
diagnoses are important for
treatment planning. There are a
number of current challenges in the
area of psychiatric diagnosis with
important treatment implications. In
this study, we examined the
differential usefulness of two semi-
structured interviews of differing
length compared to clinical diagnoses
for generation of diagnoses that did
not require modification over the
course of treatment.
Methods. We performed a three-
year, three-cohort study at an
outpatient psychiatric rehabilitation
facility, comparing the stability of
admission diagnoses when generated
by unstructured procedures relying
on referring clinician diagnosis, the
SCID, and the MINI. We examined
changes in diagnoses from admission
to discharge (averaging 13 weeks)
and, during the second two years,
convergence between referring
clinician diagnoses and those
generated by structured interviews.
The same three interviewers
examined all patients in all three
phases of the study.
Results. Admission and discharge
diagnoses were available for 313
cases. Diagnoses generated with the
unstructured procedure were
changed by discharge 74 percent of
the time, compared to four percent
for SCID diagnoses and 11 percent
for MINI diagnoses. Referring
clinician diagnoses were disconfirmed
in Years 2 and 3 in 56 percent of
SCID cases and 44 percent of MINI
cases. The distinctions between
unipolar and bipolar disorders were
particular points of disagreement,
with similar rates of under and over-
diagnosis of bipolar disorder. The rate
of confirmation of referring clinician
diagnoses of schizoaffective disorder
was 10 percent with the SCID and 11
percent with the MINI.
Discussion. In this setting, there
appears to be a reasonable trade-off
between brevity and accuracy
through the use of the MINI
compared to the SCID, with
substantial improvements in stability
of diagnoses compared to clinician
Systematic Study of
Structured Diagnostic
Procedures in Outpatient
Psychiatric Rehabilitation:
A Three-year, Three-cohort
Study of the Stability of
Psychiatric Diagnoses
by RAYMOND KOTWICKI, MD, AND PHILIP D. HARVEY, PhD
Dr. Kotwicki is with Skyland Trail and Emory University in Atlanta, Georgia; and Dr. Harvey is
with the University of Miami Miller School of Medicine, Miami, Florida.
Innov Clin Neurosci. 2013;10(5–6):14–19
FUNDING: This research was funded by
Skyland Trail.
FINANCIAL DISCLOSURES: Dr. Kotwicki is the
Medical Director of Skyland Trail. He reports
no other conflicts of interest. Dr. Harvey is a
member of the National Advisory board of
Skyland Trail and is compensated for this
service.
ADDRESS CORRESPONDENCE TO: Raymond
Kotwicki, MD; E-mail:
rkotwicki@skylandtrail.org
KEY WORDS: Bipolar disorder, psychosis,
structured diagnoses, validity
[ORIGINAL RESEARCH]

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diagnoses. Clinical diagnoses were
minimally overlapping with the
results of structured diagnoses,
suggesting that structured
assessment, particularly early in the
illness or in short term treatment
settings, may improve treatment
planning.
INTRODUCTION
The reliability of psychiatric
diagnoses has improved markedly
since the introduction of structured
psychiatric interviews.1These
interviews were first developed in the
late 1960s2and were fine tuned3up
through the time of the introduction
of the the Diagnostic and Statistical
Manual of Mental Disorders, Third
Edition (DSM-III)4 in 1980. At the
same time, the use of these
structured interviews is still not
common in everyday clinical practice,
with most use in research settings. It
is not clear how much the application
of such interviews would impact the
reliability and validity of diagnoses in
clinical practice settings, but it seems
likely that there are certain
circumstances where the increase in
validity would be quite substantial.
The importance of collection of valid
assessment data through structured
assessment procedures is
compounded by the problems in self-
report seen in multiple psychiatric
conditions;5–7 questionnaire or
checklist methods that do not contain
interaction and observation with an
interviewer are clearly subject to
these concerns.
While we have recently shown in a
literature review8that established
schizophrenia can be diagnosed by
clinicians with high degrees of
concordance with the results of
structured psychiatric interviews,
there are still multiple diagnostic
challenges. Patients with multiple,
early-course conditions, even
schizophrenia, often have diagnoses
that change even when initially
generated with structured
procedures.9,10 Psychiatric interviews
vary in their focus (Axis-I vs. Axis-II),
in their length, and in their
assessment of the patient alone
versus symptoms in their relatives.
Structured interviews can require
substantial time commitments and
can require considerable training in
order to be accurately employed.
Secular trends and patient
expectations may also impact
presumed diagnoses when new
patients present for treatment in
community mental health settings.
Some of this variation may be due to
exposure of potential patients to
media or internet information, which
may shape their opinions of their
diagnoses. Bipolar disorder, for
instance, has seen a marked increase
in terms of its diagnosed prevalence
in the last 20 years, after 40 years of
stability in diagnostic prevalence,11
with this increase corresponding with
multiple, newly indicated treatments
and associated advertising. In
addition, an increased appreciation of
the fact that bipolar disorders can be
marked by brief episodes of
hypomania rather than full manic
episodes has increased the challenge
in discrimination between bipolar and
unipolar mood disorders. We know
that distinguishing unipolar
depression and bipolar illness has
socioeconomic and functional
implications.12 Correspondingly,
contemporary diagnostic trends may
also incorrectly shape referring
diagnoses when patients initially
present for treatment. For instance,
in previous years the concept of
schizophrenia was expanded to
include a variety of conditions
outside the current boundaries, such
as “pseudo-neurotic schizophrenia;”13
there is a controversy about whether
current concepts of mood spectrum
conditions are overly broad as well.
There are several benefits of
systematic collection of diagnostic
data in everyday practice. There are
suggestions that certain conditions,
such as bipolar disorder, are both
over-diagnosed14,15 and frequently
missed16,17 in clinical settings. The
most frequent suggestion to remedy
this situation is a structured
psychiatric interview. In fact, in the
Pogge et al14 and Zimmerman et al15
studies, using a structured interview
revealed over-diagnosis of bipolar
disorder in adolescent and adults
found to have major depression.
Presumptive diagnoses of
posttraumatic stress disorder (PTSD)
are often generated on the basis of
trauma exposure, without a
systematic assessment of the other
required symptoms.18 Schizoaffective
disorder is commonly diagnosed in
clinical practice,19 but the diagnosis
has been argued to lack reliability20
and intrinsic clinical validity.21
Managed care companies are
often interested in matching
treatments to diagnoses and may
refuse to reimburse for treatments
that are not approved for specific
indications, suggesting that in order
to offer suitable treatments to
patients accurate diagnosis is
important. This is particularly
relevant to time-limited treatment. As
interventions such as day treatment
or other rehabilitation therapies may
be approved by insurance payers for
delivery only for finite periods,
inaccurate targeting of treatment
interventions early on could lead to
therapeutic interventions being
applied for relatively abbreviated and
potentially inefficacious periods.
Thus, early identification of the
eventual diagnosis can lead to
enhanced ability to deliver
appropriate treatments for a larger
proportion of the time allowed. In
this context, stability of diagnoses
over time reflects an important
component of the validity of these
diagnoses while it is admittedly not
the only important aspect.
This paper presents the results of
a systematic study of the usefulness
of structured psychiatric interviews.
In a three-year, three-cohort,
consecutive-admission study, we
examined psychiatric diagnoses that
were generated through unstructured
clinical interviews and reliance on
referral source diagnoses (Year 1),
and two different psychiatric
interviews that varied in their length
of administration (Years 2 and 3).
This study was performed at an
outpatient psychiatric rehabilitation
center that largely focuses on early

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course patients (mean age=24) and
included three years of consecutive
admissions from similar referral
sources, where the assessment
procedure was systematically
changed at one-year periods with the
same admission staff in place across
the three years. We used the
Structured Clinical Interview for the
DSM (SCID)22 for the second year of
the study and the MINI International
Neuropsychiatric Interview (MINI)23
for the third. Stability of diagnoses
was indexed through the number of
changes in diagnosis suggested by the
clinical staff during the course of the
patient’s treatment based on real-
time observations and the results of
the therapeutic process. For cases in
Years 2 and 3, we also compared the
referral source diagnosis for the
patients to the diagnosis generated
with a structured psychiatric
interview. Our hypothesis was that
both of the structured interviews
would be superior for generating
stable diagnoses to both clinical
judgments and referral diagnoses
based on unstructured clinical
observation. We were particularly
interested in whether the
considerably more abbreviated MINI
would yield the same diagnostic
stability, compared to the lengthier
SCID, in these patients.
METHODS
Participants. Research
participants consisted of three years
of consecutive admissions to a
private, nonprofit, psychiatric
rehabilitation facility. All admissions
were examined; cases who were
screened for admission but who did
not receive services were not
analyzed. All data were archived in a
database and examined anonymously.
Patients signed a general consent
form for their data to be examined
anonymously and the Emory
University Internal Review Board
approved this study with expedited
review and did not require signed
informed consent for the analyses
performed in this study. Patients with
a primary diagnosis of a substance
use disorder or personality disorders
were excluded from admission due to
regulatory issues during this time
period. Dual-diagnoses patients as
well as patients who had concomitant
(but not primary) personality
disorders were included in analyses.
The same three experienced,
master-level, admission staff
members participated over all three
years. At the beginning of the study,
these staff members had a minimum
of three years of experience and an
average of 5. Cases were distributed
sequentially across the three raters
after referral to the treatment facility.
These staff members were not
involved in the treatment of the
patients and did not have input into
any subsequent treatment decisions.
Further, the clinical staff members
treating the patients were not
informed of the plans to evaluate
diagnostic stability as an outcome
measure in the study. The reporting
of the diagnoses consisted of the axis
I and axis II diagnostic impressions
which were entered into the
electronic medical records. For this
study, we focused on axis I diagnoses,
as they were primary. Demographic
data, including admission diagnoses,
are presented in Table 1. As can be
seen in the table, the ages of the
cases declined slightly each year and
there was a slight shift in the
diagnostic distribution.
Procedure. The same three
admission staff members participated
in all three years of this study, which
started October 1, 2008. In year one,
all referrals for admission to the
treatment center received a clinical
diagnosis based on an interview at
admission and information provided
by the referral source. Throughout
that year, the presumed “working
diagnosis” was the referral diagnosis
accompanied by an unstructured
interview that occurred within 48
hours of the patients’ admission. In a
pre-planned study, the three staff
members were trained by an
experienced psychiatric
diagnostician. During Year 2, these
same staff members, after training,
interviewed all candidates for
admission with the SCID. Interview
training consisted of observed
interviews, joint ratings, and
consensus discussion of a series of
cases not included in these analyses.
After one year of use of the SCID, a
third year of admissions were all
interviewed and diagnosed with the
MINI interview using identical
training procedures.
TABLE 1. Diagnoses at admission over a three-year, three-cohort prospective study
N
DIAGNOSTIC METHOD (YEAR)
CLINICAL (ONE) SCID (TWO) MINI (THREE)
110 101 110
M SD M SD M SD
Age 36.4 12.6 34.1 13.4 31.9 11.8
Length of stay (days) 90.6 66.6 86.7 75.2 81.8 51.2
Gender (% male) 62 59 50
Axis-I admission diagnosis
Bipolar 46 38 50
Major depression 30 38 40
Schizoaffective 11 11
Schizophrenia 6 16 7
Anxiety (includes PTSD) 6410
Other 1 4 2

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There are several other important
features of this design. In order for
the procedure to simulate the reality
of clinical practice, we did not
perform extensive assessment of
inter-rater reliability after the
initiation of the project. Instead, our
goal was to determine if using a semi-
structured interview and a trained
rater would generate stable
diagnoses. To examine this question,
we compared the rate of clinician
change of rater-generated admission
diagnoses across the three raters.
Thus, the outcome was diagnostic
stability across raters within rating
method and not agreement on a
specific diagnosis such as bipolar
disorder or schizophrenia. Patients
were treated at this facility on
average over three months, with
regular therapist and psychiatric
consultations and round-the-clock
clinical observation.
Primary axis-I diagnoses were
examined during the entire period of
treatment for each case during the
three year period. Changes in the
original admission diagnosis prior to
discharge from treatment were
recorded as the primary outcome
measure. As a secondary outcome in
Years 2 and 3, the original clinician
diagnosis was compared to the
admission diagnosis assigned
following the structured diagnostic
interview. In the calculation of
“change in diagnosis,” we used the
following rules: 1) We generated
global categories in order to avoid
characterizing minor changes in
diagnoses as discrepant. For instance,
we considered a diagnosis of bipolar
II and bipolar I disorder to be
consistent, although a change in
diagnosis from bipolar depression to
major depression was considered a
change. 2) We did not consider
schizophrenia subtypes as part of the
diagnostic agreement, but considered
schizophrenia to be different from
schizoaffective disorder. 3) Changes
in clinical state codes (i.e., severe to
remission) during the course of
treatment within the same diagnosis
were not considered as a difference
in diagnosis.
RESULTS
As can be seen in Table 1, the
overall pattern of admission
diagnoses changed slightly over the
study period. Diagnoses of major
depressive disorder became more
common and diagnoses of psychosis
became less so. When the primary
outcome, change in diagnosis from
admission to discharge, was
examined there were clear
differences across the methods. In
the year prior to the implementation
of the SCID, 74 percent of admission
diagnoses based on referral diagnosis
and unstructured interview were
changed over the course of the
treatment period, with the most
common changes being that an
admission diagnosis of major
depression was changed to a
diagnosis of bipolar disorder or vice
versa. In marked contrast, the rates
of change of diagnoses generated by
the SCID during similarly lengthy
stays was four percent and the rates
of changes in MINI diagnoses was 11
percent. Chi-square tests were used
to compare the differences in rate of
change in diagnoses across
procedures. The difference in rates of
change between the clinical
diagnostic assessment procedure and
the SCID was significant,
chi2(1)=19.09, p<0.001, as was the
difference between clinical diagnoses
and the MINI, chi2(1)=7.50, p<0.005.
However, the difference in rates of
changes in diagnoses between SCID
and MINI procedures was not
significant, chi2(1)= 2.01, p=0.16.
In order to determine whether
there were differences across the
three raters in the extent to which
their diagnoses were changed over
the course of treatment for the
patients, we performed a 3 (rater) x
2 (changed or not changed) Chi-
square test for each of the three
years. All three years suggested no
differences across the three raters in
the extent to which their diagnoses
were changed by the clinicians (all
chi2(2 df)<1.47, all p>0.48).
In the analyses of data from Years
2 and 3, we compared clinical
diagnosis provided by the referring
source to the diagnoses generated
with the structured procedures.
These data are presented in Table 2.
See Figure 1 for a graphic depiction
of these results. There were
substantial discrepancies between
these diagnoses. Of the cases
interviewed with the SCID, 56
percent of the cases were assigned a
diagnosis that was different from that
provided by the referral source and
for the MINI the number of cases
whose diagnosis was different was 42
percent. Diagnostic confirmation
rates for bipolar were 40 percent and
50 percent for the two years, and
confirmation of major depressive
disorder were somewhat higher. Most
diagnostic discrepancies were
TABLE 2. Changes in referral source diagnoses across during Years 2 and 3 of the study after
application of structured diagnostic interviews
REFERRAL DIAGNOSIS YEAR 2, % CONFIRMED YEAR 3, % CONFIRMED
Bipolar 40 50
Major depression 50 65
Schizoaffective 10 11
Schizophrenia 50 57
Anxiety 75 50
Overall confirmation rate 44 58

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interview-based diagnoses of major
depression in cases referred as
bipolar and bipolar depression in
cases referred as major depression.
Diagnostic confirmation of
schizoaffective disorder was also very
low at 10 percent and 11 percent
across the two years.
DISCUSSION
Given the importance of matching
appropriate diagnosis with evidence-
based pharmacologic,
psychotherapeutic, and psychosocial
interventions, identifying an accurate
working diagnosis quickly and
efficiently in community mental
health settings is essential. Relying
on referring diagnoses and self-
report of previous diagnoses may
yield a diagnosis that requires
modification, even in the context of
an initial unstructured psychiatric
diagnostic assessment by experts.
Implementing structured interviews
in such settings may be prudent, as
rates of diagnostic changes were
significantly reduced in our study
using both the SCID and MINI.
Length of administration of the MINI
is shorter than administering the
SCID (20 minutes compared to over
90 minutes), and diagnostic stability
was not notably different between
these two structured interviews in
our cohorts.
Themes of modifications in
referral diagnoses in our study
mirrored data from other community
diagnostic studies. In our Year-2 and
Year-3 cohorts, patients who
presented initially with diagnoses of
bipolar illness, unipolar depression,
and schizoaffective disorder had
significant rates of re-diagnosis of
their primary mental illness using a
structured diagnostic tool. Bipolar
illness prior to admission seemed to
be both over-diagnosed and under-
recognized within patients referred
to this treatment facility. While the
origin of the pattern of such
diagnostic changes is unclear, there
was both a bias toward over-
diagnosis of bipolar disorder in the
absence of symptomatic evidence in
patients eventually diagnosed with
major depression and tendencies to
miss euphoric bipolar symptoms.
Unsystematic assessment may
produce both types of diagnostic
errors: inadequate knowledge of the
signs of a manic or hypomanic
episode may lead to a false positive
bipolar diagnosis and failure to
assess for manic episodes may lead
to false negatives. Schizoaffective
disorder seems to be more often
found in the diagnostic opinions of
clinicians than in the results of
structured assessments.
There are some limitations to
these data and these analyses.
Stability is not the only element of
validity; we did not examine
treatment response, biomarkers, or
course of illness as validity
indicators. We could not quantify the
reasons why clinicians changed
admission diagnoses, and there may
be several reasons for these changes.
It also is possible that clinicians were
less likely to change diagnoses
generated by structured interviews,
but the clinicians were not aware we
planned to examine changes in
diagnosis as an outcome variable in a
research study. Discrepancies
between referring clinician diagnoses
and the results of structured
assessments cannot be attributed to
bias on the part of clinicians toward
not modifying a diagnosis. The
facility at which these analyses
occurred is a private, non-profit
treatment program that does not bill
Medicaid or Medicare. A selection
bias in referred patients may limit
generalizability of these outcomes to
other treatment settings in which
patients from more varied economic
groups are assessed and the
applicability to inpatient settings
cannot be determined. The very
short stays typical in current
inpatient treatment make the use of
structured diagnostic assessments
less useful. A relatively younger age
of the patients in this study may limit
generalizability of the findings to
older patients who have had longer
experiences with serious, persistent
mental illnesses. Neither the SCID
nor the MINI was designed for the
purpose of diagnosing axis-II
pathology and as a result, these
diagnoses could not be systematically
assessed in this study. The required
investment in training clinicians and
administering the standardized
assessments may similarly limit the
practicality of assessment of these
outcomes in busy community mental
health treatment centers, where
resources tend to be limited.
FIGURE 1. Confirmation of referral source diagnoses across during Years 2 and 3 of the study
after application of structured diagnostic interviews

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Although the study participants
were on average quite young,
patients were typically not recovering
from their first episode of illness,
during which time actual changes in
symptomatology and presentation
might account for diagnostic
uncertainty. As treatment options for
mental illnesses continue to improve,
diagnostic stability and reliability
become even more important in
community mental health settings.
Pharmacologic, psychotherapeutic,
and social interventions used to treat
patients with bipolar illness are
significantly different than similar
classes of interventions for patients
with personality disorders or even
unipolar depression. This study
suggests that the up-front investment
of effort and time to use a structured
diagnostic assessment at the time of
admission to residential, partial
hospitalization, and intensive out-
patient programs may be a wise
course of action for patients and
payers alike. Matching specific and
timely treatment to the appropriate
diagnosis makes sense for all
stakeholders, despite the requisite
time involved in administering the
assessments.
Future directions for efficiently
diagnosing mental illness in
community psychiatric facilities
should include assessing variables
related to patients’ socioeconomic
factors, referral sources, age of
patients, and stigma. Although
currently limited in application,
including biomarkers and imaging
data to make clinical diagnoses will
also help determine cost-effective
and practical structured diagnostic
tools that busy community clinicians
may implement in their treatment
planning for patients.
REFERENCES
1. Beck AT, Ward CH, Mendelson M, et
al. Reliability of psychiatric diagnosis
2: a study of consistency of clinical
judgments and ratings. Am J
Psychiatry. 1962;119:351–357.
2. Wing JK, Birley JL, Cooper JE, et al.
Reliability of a procedure for
measuring and classifying "present
psychiatric state. Br J Psychiatry.
1967;113:499–515.
3. Spitzer RL, Endicott J. Current and
Past Psychopathology Scales. New
York: New York State Psychiatric
Institute, Biometrics Research
Division; 1968.
4. American Psychiatric Association.
Diagnostic and Statistical Manual
of Mental Disorders, 3rd edition.
Washington, DC: American
Psychiatric Press, Inc.; 1980.
5. Amador XF, Flaum M, Andreasen
NC, et al. Awareness of illness in
schizophrenia and schizoaffective
and mood disorders. Arch Gen
Psychiatry. 1994;51:826–836.
6. Bowie CR, Twamley EW, Anderson
H, et al. Self-assessment of
functional status in schizophrenia. J
Psychiatr Res. 2007; 41:1012–1018.
7. Burdick KE, Endick CJ, Goldberg JF.
Assessing cognitive deficits in bipolar
disorder: are self-reports valid?
Psychiatry Res. 2005;136:43–50.
8. Harvey PD, Heaton RK, Carpenter,
WT, Jr., et al. Diagnosis of
schizophrenia: consistency across
information sources and stability of
the condition. Schizophr Res.
2012;140:9–14.
9. Schwartz JE, Fennig S, Tanenberg-
Karant M, et al. Congruence of
diagnoses 2 years after a first-
admission diagnosis of psychosis.
Arch Gen Psychiatry.
2000;57:593–600.
10. Bromet EJ, Naz B, Fochtmann LJ, et
al. Long-term diagnostic stability and
outcome in recent first-episode
cohort studies of schizophrenia.
Schizophr Bull. 2005;31:639–664.
11. Yutzy SH, Woofter CR, Abbott CC, et
al. The increasing frequency of
mania and bipolar disorder: causes
and potential negative impacts. J
Nerv Ment Dis. 2012;200:380–387.
12. Keck PE Jr, Kessler RC, Ross R.
Clinical and economic effects of
unrecognized or inadequately
treated bipolar disorder J Psychiatr
Pract. 2008;14(Suppl 2):31–38.
13. Hoch P, Pollatin P. Pseudoneurotic
forms of schizophrenia. Psychiatric
Q. 1949;23:248–276.
14. Pogge DL, Wayland-Smith D,
Zaccario M, et al. Diagnosis of manic
episodes in adolescent inpatients:
structured diagnostic procedures
compared to clinical chart diagnoses.
Psychiatry Res. 2001;101:47–54.
15. Zimmerman M, Ruggero CJ,
Chelminski I, Young D. Is bipolar
disorder overdiagnosed? J Clin
Psychiatry. 2008;69:935–940.
16. Hirschfeld RM, Vornik LA.
Recognition and diagnosis of bipolar
disorder. J Clin Psychiatry.
2004;65(Suppl 15):5–9.
17. Leboyer M, Kupfer DJ. Bipolar
disorder: new perspectives in health
care and prevention. J Clin
Psychiatry. 2010;71:1689–1695.
18. Harvey PD, Yehuda R. Strategies to
study risk for Post-traumatic stress
disorder. In Yehuda R (ed). Risk
Factors for Post-traumatic Stress
Disorder. Washington, DC: American
Psychiatric Press, Inc.;1999:1–22.
19. Jäger M, Haack S, Becker T, Frasch
K. Schizoaffective disorder: an
ongoing challenge for psychiatric
nosology. Eur Psychiatry.
2011;26:159–165.
20. Malhi GS, Green M, Fagiolini A, et al.
Schizoaffective disorder: diagnostic
issues and future recommendations.
Bipolar Disord. 2008;10:215–230.
21. Lake CR, Hurwitz N. Schizoaffective
disorder merges schizophrenia and
bipolar disorders as one disease:
there is no schizoaffective disorder.
Curr Opin Psychiatry.
2007;20:365–379.
22. First MB, Spitzer RL, Gibbon M, et
al. User’s guide for the Structured
Clinical Interview for DSM-IV Axis
I (SCID-I). Washington, DC:
American Psychiatric Press,
Inc.;1995.
23. Sheehan DV, Lecrubier Y,
Harnett‐Sheehan K, et al. The Mini
International Neuropsychiatric
Interview (M.I.N.I.): the
development and validation of a
structured diagnostic psychiatric
interview. J Clin Psychiatry.
1998;59(Suppl 20):22–33.