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


Abstract and Figures

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.
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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
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.
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
Kotwicki, MD; E-mail:
KEY WORDS: Bipolar disorder, psychosis,
structured diagnoses, validity
[VOLU ME 10, NU MBER 5–6, M AY–JUNE 2013] Innovations in CLINICAL NEUROSCIENCE 15
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
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
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.
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
110 101 110
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
[VOLU ME 10, NU MBER 5–6, M AY–JUNE 2013] Innovations in CLINICAL NEUROSCIENCE 17
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.
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
Bipolar 40 50
Major depression 50 65
Schizoaffective 10 11
Schizophrenia 50 57
Anxiety 75 50
Overall confirmation rate 44 58
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.
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
[VOLU ME 10, NU MBER 5–6, M AY–JUNE 2013] Innovations in CLINICAL NEUROSCIENCE 19
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
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.
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... Finally, the unexplained heterogeneity may jeopardize the interpretation of metaanalysis results. However, the overall estimated kappa aligns with two prior metaanalyses [9,17] as well as what is usually measured in single reports of very wellconducted studies, like Kottwicki [73] longitudinal study of reliability between SDI and NSDI. Moreover, our study used best practices for conducting systematic reviews, including PRISMA guidelines. ...
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Unlabelled: We aimed to find agreement between diagnoses obtained through standardized (SDI) and non-standardized diagnostic interviews (NSDI) for schizophrenia and Bipolar Affective Disorder (BD). Methods: A systematic review with meta-analysis was conducted. Publications from 2007 to 2020 comparing SDI and NSDI diagnoses in adults without neurological disorders were screened in MEDLINE, ISI Web of Science, and SCOPUS, following PROSPERO registration CRD42020187157, PRISMA guidelines, and quality assessment using QUADAS-2. Results: From 54231 entries, 22 studies were analyzed, and 13 were included in the final meta-analysis of kappa agreement using a mixed-effects meta-regression model. A mean kappa of 0.41 (Fair agreement, 95% CI: 0.34 to 0.47) but high heterogeneity (Î2 = 92%) were calculated. Gender, mean age, NSDI setting (Inpatient vs. Outpatient; University vs. Non-university), and SDI informant (Self vs. Professional) were tested as predictors in meta-regression. Only SDI informant was relevant for the explanatory model, leaving 79% unexplained heterogeneity. Egger's test did not indicate significant bias, and QUADAS-2 resulted in "average" data quality. Conclusions: Most studies using SDIs do not report the original sample size, only the SDI-diagnosed patients. Kappa comparison resulted in high heterogeneity, which may reflect the influence of non-systematic bias in diagnostic processes. Although results were highly heterogeneous, we measured a fair agreement kappa between SDI and NSDI, implying clinicians might operate in scenarios not equivalent to psychiatry trials, where samples are filtered, and there may be more emphasis on maintaining reliability. The present study received no funding.
... Auch erwies sich, dass die Diagnosen, die auf einem unstrukturierten diagnostischen Prozess basieren, über mehrere Jahre teilweise sehr stark schwanken bzw. sich verändern (74,0%), während dies bei semi-strukturieren diagnostischen Interviews nicht der Fall ist (4,0-11,0%) (Kotwicki & Harvey, 2013). Außerdem wurden Hinweise darauf gefunden, dass Patientinnen und Patienten häufig für psychische Probleme psychotherapeutische Hilfe in Anspruch nehmen möchten, die in semi-strukturierten diagnostischen Interviews eher als komorbide Störungen identifiziert werden (Zimmerman & Mattia, 2000). ...
This thesis focuses on misdiagnoses and diagnostic processes and methods in clinical psychology research and practice.
... These data were collected from May 2016 to December 2017, during which time all admissions to treatment services were administered a battery of assessments as part of the standard admissions process. All patients received a diagnosis with a structured procedure that has been previously published (Kotwicki and Harvey, 2013). This procedure included a structured interview with the MINI International Neuropsychiatric Inventory (MINI; Sheehan et al., 1998). ...
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Computerized cognitive training (CCT) interventions are increasing in their use in outpatient mental health settings. These interventions have demonstrated efficacy for improving functional outcomes when combined with rehabilitation interventions. It has recently been suggested that patients with more cognitive impairment have a greater therapeutic response and that reduced engagement in training can identify cases who manifest low levels of benefit from treatment. Participants were psychiatric rehabilitation clients, with diagnoses of major depression, bipolar disorder and schizophrenia. Newly admitted cases received CCT, delivered via Brain HQ, with cognitive functioning divided into groups on the basis of a BACS t-score of 40 or less vs. more. Training engagement was indexed by the number of training levels achieved per day trained. Forty-nine cases trained on average for 17 days and completed a mean of 150 levels. Overall, patients improved by an average of 4.4 points (0.44 SD) in BACS t-scores (p < .001). Improvements were positively correlated with training engagement (r = 0.30, p < .05), but not with days trained (r = 0.09) or levels earned (r = 0.03) alone. Patients with higher levels of baseline cognitive performance had reduced cognitive gains (p < .003), but did not have less training engagement (p = .97). Diagnoses did not predict cognitive gains (p = .93) or target engagement (p = .74). Poorer performance at baseline and higher levels of training engagement accounted for >10% in independent variance in cognitive gains. The mean level of cognitive improvement far exceeded practice effects. The index of engagement, levels achieved per training day, is easily extracted from the training records of patients, which would allow for early and continuous monitoring of treatment engagement in CCT activities and therapist intervention as needed to improve engagement.
... Any differences between the primary and generalizability samples seem to be sample-specific, rather than reflecting a difference due to race, as we obtained the same pattern of relations in both Black and White participants in the latter. Although two different clinical interviews were used in the primary versus the generalizability sample, the SCID-IV and MINI interviews have been shown to have comparable diagnostic stability (Kotwicki & Harvey, 2013). Nonetheless, replication using the SCID-5 (First, Williams, Karg, & Spitzer, 2015) would confirm the present findings. ...
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Depressive and anxiety disorders are severe and disabling conditions that result in substantial cost and global societal burden. Accurate and efficient identification is thus vital to proper diagnosis and treatment of these disorders. The Inventory of Depression and Anxiety Symptoms (IDAS) is a reliable and well-validated measure that provides dimensional assessment of both mood and anxiety disorder symptoms. The current study examined the clinical utility of the IDAS by establishing diagnostic cutoff scores and severity ranges using a large mixed sample (N = 5,750). Results indicated that the IDAS scales are good to excellent predictors of their associated Structured Clinical Interview for DSM-IV diagnoses. These findings were replicated using Diagnostic and Statistical Manual of Mental Disorders–Fifth edition(DSM-5) criteria assessed via the Mini-International Neuropsychiatric Interview. We provide three cutoff scores for each scale that can be used differentially depending on the goal of their use: screening, efficiency, or diagnosis confirmation. The identified severity ranges allow users to characterize individuals as mild, moderate, or severe, providing clinical information beyond diagnostic status. Finally, the 10-item IDAS Dysphoria scale and 20-item General Depression scale demonstrate strong ability to predict internalizing diagnoses and may represent an efficient way to screen for the presence of internalizing psychopathology.
... We did not interview patients, in contrast to Ogloff et al. (2015) who conducted SCID interviews, making the present study not directly comparable to theirs. Several previous studies have reported moderate to poor agreement between unstructured clinical diagnosis and SCID-based diagnoses (e.g., Kotwicki & Harvey, 2013;Miller, Dasher, Collins, Griffiths, & Brown, 2001;Ramirez Basco et al., 2000;Samuel, 2015;Samuel et al., 2013;Shear et al., 2000), and the present study adds a similar observation regarding agreement between clinical diagnosis and the evidence available on the medical record (as in Hansen et al., 2000) among forensic inpatients. Because we did not conduct interviews, we were unable to compare structured assessment with the unstructured clinical assessment conducted by clinicians, and therefore cannot draw conclusions about differences between unstructured and structured clinical assessment. ...
Research suggests that co-occurring substance use disorder (SUD) is prevalent among adults with psychiatric illness. Studies with forensic patients in Australia indicate that co-occurring disorders (CD) are underdiagnosed. To help determine how widespread CD underdiagnosis is in forensic populations internationally, we compared current diagnoses recorded in the clinical record with clinical evidence gathered during forensic assessment meeting DSM-IV criteria for SUD, in a Canadian sample of 638 male forensic inpatients. Among 491 with a major mental illness diagnosis, most (61%) met criteria for CD but only 19% were diagnosed as such. CD was associated with longer hospitalization, and with greater evidence of criminal history, antisociality, and risk of violent recidivism, regardless of how CD was defined. Identifying CD based on documented evidence, though, allowed for slightly greater detection of group differences. Underdiagnosing SUD has a potential impact on understanding substance use as a criminogenic treatment need in forensic mental health.
... We then developed multilevel models using clients' moving average SMORS scores and time since admission as predictor variables, categorizing them by the type of discharge, selecting the model having the best goodness of fit. We also compared initial engagement scores across diagnoses that were generated for all cases with a highly systematic assessment procedure (Kotwicki and Harvey 2013) and compared patients who were receiving financial aid based on income consideration to those who cost of care was covered by their family. Figure 1 presents the course of eligibility for the financial incentive as a function of three different possible moving average cut-off scores. ...
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Significant numbers of individuals with severe mental illnesses are difficult to engage in treatment services, presenting challenges for care. To be able to assess the relationship between engagement and discharge outcomes, we modified the ?Milestones of Recovery Scale?. This scale was modified for content to match the current clinical setting, evaluated for inter-rater reliability after modification in a sample of 233 cases receiving psychiatric rehabilitation, and then was administered to 423 additional psychiatric rehabilitation clients over a 24-month study period. In an effort to determine whether provision of financial incentives lead to sustained increases in client engagement, a cut off for client eligibility for financial incentives was evaluated on the basis of the reliability study and the course of engagement was related to receipt of this incentive and successful completion of treatment in a new sample of 423 patients. Of this sample, 78?% received an initial financial incentive during treatment (were initially engaged), and 93.3?% of that subgroup sustained this level of engagement it over their entire course of treatment. Of the 22?% of cases not receiving an initial incentive, only 5.4?% improved in their engagement to levels required for the incentive. Longitudinal analysis demonstrated that individuals who maintained or increased their level of engagement over time were more likely to complete treatment in accordance with planned treatment goals. The initial engagement and the course of engagement in treatment predicted successful completion, but incentives did not lead to increased engagement in initially poorly engaged patients. These data are interpreted in terms of the likely success of extrinsic rewards to increase engagement in mental health services.
... If the participant responded yes to any of these first questions, follow-up questions, according to the specific criteria, were asked in order to assess whether they met criteria for the relevant condition. Kotwicki and Harvey (2013) report that the MINI substantially improves upon the stability of diagnoses compared to unstructured procedures relying on clinician diagnoses. Further, the authors report that the differences in rates of changes in diagnoses between the Structured Clinical Interview for DSM disorders are nonsignificant (chi 2 (1)=2.01, ...
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The serotonin (5-HT) system has been implicated in both depression and reward and punishment processing. This thesis presents data from four studies designed to better understand the role of serotonin in decision-making and mood. Following the general introduction and description of the main experimental methods, the first experimental chapter presents a study that examined the relationship between naturally-varying 5-HT1A receptor availability, measured using positron emission tomography, and decision-making in healthy volunteers. This study identified correlations between 5-HT1A receptor availability in the hippocampal complex and both impulsivity and sensitivity to the probability of an outcome during decision-making. The second experimental chapter examined decision-making in healthy volunteers 3 days following MDMA (3,4-methylenedioxymethamphetamine) administration, when serotonin transmission is thought to be reduced. A specific type of decision-making process, “pruning” (the reflexive avoidance of aversive outcomes when searching through a tree of potential decisions), was significantly attenuated 3 days following MDMA administration. However, the expected positive relationship between the attenuation in this decision-making process and low mood was not observed. The third experimental chapter attempted to extend this finding using the acute tryptophan depletion method, which removes tryptophan (the precursor to serotonin) from the diet and is thought to reduce serotonin synthesis. Performance on three decision making tasks (pruning, gambling and impulsivity) was examined in healthy volunteers following tryptophan depletion. Results revealed that treatment decreased participants’ choosing of high probability gambles. The final chapter examined pruning in unmedicated depressed patients, and found that they behaved very similarly to healthy volunteers when evaluating aversive outcomes in the context of a tree of potential decisions, despite the hypothesised disruption to the serotonin system in this disorder. These experiments provide a more complete understanding of the relationship between serotonin, decision-making and mood, and are discussed in relation to theories of depression that pose a central role for disrupted decision-making.
Background: Early life adversity such as childhood emotional, physical, and sexual trauma is associated with later-life psychiatric and chronic medical conditions, including elevated inflammatory markers. Although previous research suggests a role for chronic inflammatory dysfunctions in several disease etiologies, specific associations between childhood trauma types and later life inflammation and health status are poorly understood. Methods: We studied patients (n=280) admitted to a psychiatric rehabilitation center. Self-reported histories of childhood emotional, physical, and sexual trauma were collected with a standard instrument. At the time of admission, we also assessed individuals' body mass index (BMI) and collected blood samples used to examine inflammatory marker C-reactive protein (CRP) levels. Results: The prevalence of all three types of abuse was relatively high, at 21% or more. 50% of the sample had elevations in CRP, with clinically significant elevations in 26%. We found that compared to a history of emotional or physical abuse, a history of childhood sexual trauma was more specifically associated with elevated CRP. This result held up when using linear regressions to examine the contribution of BMI. Limitation: Our sample is relatively young, with an average age of 27.2 years and minimal representation of ethnic and racial minority participants. Conclusion: Relative to childhood emotional and physical trauma, childhood sexual trauma may lead to elevated inflammatory responses, confirmed in our finding of an association between CRP and sexual abuse. Future studies need to assess the causal link between childhood sexual trauma and poorer health outcomes later in life.
This study analyzes the performance of the Center for Epidemiologic Studies Depression Scale (CES-D) to screen for major depressive disorder (MDD) in adults. We divided adults into three groups such as community-indwelling adults, patients with chronic diseases, and psychiatric patients. Electronic searches were performed on the MEDLINE, EMBASE, CINAHL, and PsycINFO database using the following keywords: depression, depressive disorder, major, and CES-D scale. The Quality Assessment of Diagnostic Accuracy Studies-2 was applied to assess the risk of bias in diagnostic studies. We reviewed 33 studies, including 18,271 adults that met the selection criteria. In meta-analysis, the pooled sensitivity was 0.86 on community-indwelling adults, 0.85 on patients with chronic diseases and 0.85 on psychiatric patients. The pooled specificity was 0.74, 0.84, and 0.88, respectively, and the summary receiver-operating characteristic curves were 0.88, 0.91, and 0.93, respectively. The RE correlation was a negative value (-0.394) only in patients with chronic diseases, showing no heterogeneity between studies. The CES-D, which has shown high diagnostic accuracy in adults, can be recommended for use as a first-stage screener for MDD. As a result, the early application of the CES-D can lead to disease prevention in adults at risk for depression.
Introduction: Patients with Major Depressive Disorder (MDD) referred for electroconvulsive therapy (ECT) have poorer Health Related Quality of Life (HRQOL), compared with other patients with MDD, but ECT is associated with significant and durable improvement in HRQOL. However, no prior research has focused exclusively on elderly patients with MDD receiving ECT. Methods: HRQOL data from 240 depressed patients over the age of 60 was measured with the Medical Outcomes Study Short Form 36 (SF-36). The SF-36 was measured before and after a course of acute ECT. Predictors of change in HRQOL scores were identified by generalized linear modeling. Results: At baseline, participants showed very poor HRQOL. After treatment with ECT, the full sample showed marked and significant improvement across all SF-36 measures, with the largest gains seen in dimensions of mental health. Across all participants, the Physical Component Summary (PCS) score improved by 2.1 standardized points (95% CI, 0.61,3.56), while the Mental Component Summary (MCS) score improved by 12.5 points (95% CI, 7.2,10.8) Compared with non-remitters, remitters showed a trend toward greater improvement in the PCS summary score of 2.7 points (95%CI, -0.45, 5.9), while the improvement in the MCS summary score was significantly greater (8.5 points, 95% CI, 4.6,12.3) in the remitters than non-remitters. Post-ECT SF-36 measurements were consistently and positively related to baseline scores and remitter/non-remitter status or change in depression severity from baseline. Objective measures of cognitive function had no significant relationships to changes in SF-36 scores. Limitations: This study's limitations include that it was an open label study with no comparison group, and generalizability is limited to elderly patients. Discussion: ECT providers and elderly patients with MDD treated with ECT can be confident that ECT will result in improved HRQOL in the short-term. Attaining remission is a key factor in the improvement of HRQOL. Acute changes in select cognitive functions were outweighed by improvement in depressive symptoms in determining the short term HRQOL of the participants treated with ECT.
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High rates of misdiagnosis, delayed diagnosis, and lack of recognition and treatment of comorbid conditions often lead patients with bipolar illness to have a chronic course with high disability, unemployment rates, and mortality. Despite the recognition that long-term outcome of bipolar disorder depends on systematic assessment of both interepisodic dysfunctional domains and comorbid psychiatric and medical conditions, treatment of bipolar disorder still focuses primarily on alleviation of acute symptoms and prevention of future recurrences. We propose here to review the evidence offering a modern view of bipolar disorder defined as a chronic and progressive multisystem disorder, taking into account characteristics of each patient as well as biosignatures in order to help design personalized treatments. We conducted a systematic PubMed search of all English-language articles, published between 2000 and 2010, focusing on the English and French literature with bipolar disorder cross-referenced with the following search terms: emotional dysregulation, sleep and circadian rhythm disturbances, cognitive impairment, age at onset, comorbid medical and psychiatric conditions, psychosocial and medical interventions, outcome, remission, and personalized medicine. The search was conducted between July 2009 and July 2010. The literature on bipolar disorder was reviewed to provide supporting evidence that the assessment of various symptom domains that are dysfunctional between episodes should all be considered as core dimensions of the disorder. Forty-one articles were identified through the PubMed search described above and selected on the basis of addressing any combination of the search terms in conjunction with bipolar disorder. Current guidelines advocate the use of more or less similar treatment algorithms for all patients, ignoring the clinical, pathophysiological, and lifetime heterogeneity of bipolar disorder. Systematic assessment of interepisodic dimensions, along with comorbid medical and psychiatric risk factors, should be performed along the life cycle in order to plan specific and personalized pharmacologic, medical, and psychosocial interventions tailored to the needs of each patient and ready-to-test biosignatures to serve as risk factors or diagnostic or prognostic tools. Medical and research findings, along with health economic data, support a more modern view of bipolar disorder as a chronic, progressive, multisystem disorder. This new comprehensive framework should guide the search to identify biomarkers and etiologic factors and should help design a new policy for health care, including prevention, diagnosis, treatment, and training.
The Structured Clinical Interview for DSM-III-R [Diagnostic and Statistical Manual, Revised] (SCID) is a semistructured interview for making the major Axis I and Axis II diagnoses. It is administered by a clinician or trained mental health professional who is familiar with the DSM-III-R classification and diagnostic criteria (1). The subjects may be either psychiatric or general medical patients or individuals who do not identify themselves as patients, such as subjects in a community survey of mental illness or family members of psychiatric patients. The language and diagnostic coverage make the SCID most appropriate for use with adults (age 18 or over), but with slight modification, it may be used with adolescents. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Attention is called to a group of patients who show a clinical symptomatology which is considered by many psychiatrists to be psychoneurotic. These patients do not deteriorate and have no delusions or hallucinations. Nevertheless, they show clinical symptomatology which is very similar to that seen in schizophrenic patients. It can be demonstrated in follow-up studies that a considerable number of these patients have short psychotic episodes or later become frankly schizophrenic. A few of these borderline cases are described and their symptomatology analyzed. It is suggested these patients be classified pseudoneurotic form of schizophrenia.
The frequency of mania has not changed during the last century even with the development of new diagnostic criteria sets. More specifically, from the mid-1970s to 2000, the rate of mania (variably labeled major affective disorder-bipolar disorder and bipolar I disorder) was consistently identified in US and international studies as ranging from 0.4% to 1.6%. By the late 1990s to the 2000s, the prevalence reported by some researchers for bipolar disorders (I and II and others) was in the 5% to 7% and higher ranges. The purpose of this paper was to review explanations for this change and the potentially negative impacts on the field.
The Social Security Administration is considering whether schizophrenia may warrant inclusion in their new "Compassionate Allowance" process, which aims to identify diseases and other medical conditions that almost always qualify for Social Security disability benefits simply on the basis of their confirmed presence. This paper examines the reliability and validity of schizophrenia diagnosis, how a valid diagnosis is established, and the stability of the diagnosis over time. A companion paper summarizes evidence on the empirical association between schizophrenia and disability, thus leading to this paper that evaluates how valid clinical diagnoses of schizophrenia are. Literature review and synthesis, based on a workplan developed in an expert meeting convened by the National Institute of Mental Health and the Social Security Administration. At least since the introduction of the 3rd edition of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-III) in 1980, diagnoses of schizophrenia made by mental health specialists are valid, reliable, and stable over time, across community as well as academic practice settings, and across different assessment methods. These analyses are particularly valid during the time-frame relevant to social security awards: at least 2 years after the initial stages of illness. We could not find studies that have evaluated the validity or reliability of schizophrenia diagnoses made exclusively by primary care providers (vs. mental health professionals). In the post-DSM-III era, schizophrenia diagnosis-using modern diagnostic criteria-is valid and reliable when performed by doctoral-level mental health specialists (i.e., psychiatrists and psychologists), in community as well as academic settings.
The authors review the literature on the clinical and economic impact of unrecognized and inadequately treated bipolar disorder, highlighting the need to improve identification and treatment of this disabling disorder. Epidemiologic data on prevalence, diagnosis, and treatment of bipolar disorder (including subthreshold conditions) are presented, including data from the recent National Comorbidity Survey Replication. Clinical factors that contribute to misdiagnosis and resulting inappropriate treatment of bipolar disorder are reviewed as well as negative clinical consequences of such misdiagnosis and inappropriate treatment. The economic impact of underrecognized and inadequately treated bipolar disorder is discussed. The data provide empirical support for screening all patients diagnosed with depression for evidence of bipolar disorder before initiating treatment, to ensure that bipolar illness is not misdiagnosed and treated as unipolar mood disorder. Readers are referred to performance measures and treatment resources assembled by the STAndards for BipoLar Excellence (STABLE) Project to help clinicians screen more accurately for bipolar disorder.
Schizoaffective disorder is a common diagnosis in mental health services. The present article aims to provide an overview of diagnostic reliability, symptomatology, outcome, neurobiology and treatment of schizoaffective disorder. Literature was identified by searches in "Medline" and "Cochrane Library". The diagnosis of schizoaffective disorder has a low reliability. There are marked differences between the current diagnostic systems. With respect to psychopathological symptoms, no clear boundaries were found between schizophrenia, schizoaffective disorder and affective disorders. Common neurobiological factors were found across the traditional diagnostic categories. Schizoaffective disorder according to ICD-10 criteria, but not to DSM-IV criteria, shows a more favorable outcome than schizophrenia. With regard to treatment, only a small and heterogeneous database exists. Due to the low reliability and questionable validity there is a substantial need for revision and unification of the current diagnostic concepts of schizoaffective disorder. If future diagnostic systems return to Kraepelin's dichotomous classification of non-organic psychosis or adopt a dimensional diagnostic approach, schizoaffective disorder will disappear from the psychiatric nomenclature. A nosological model with multiple diagnostic entities, however, would be compatible with retaining the diagnostic category of schizoaffective disorder.
Many research questions in psychiatry can be adequately studied by cross-sectional evaluations of psychopathology at one or more points in time, such as before and after evaluation of various treatment modalities. Other important questions relevant to issues such as diagnosis and prognosis can only be answered satisfactorily by including historical information. There are, however, practically no standardized procedures for obtaining and recording historical information. This paper describes a new instrument, the Current and Past Psychopathology Scales (CAPPS), which can be used for evaluating both current and past psychopathology and social functioning in patients and nonpatients. The coverage includes dimensions of importance in the evaluation of severity of illness, prognosis, and diagnosis. Individuals from a variety of disciplines and with various levels of education have been trained to use it with a degree of reliability and validity satisfactory for research purposes.
A structured "present state" interview has been developed and tested. As used by five trained interviewers the provisional categorizations made are reliable and so are most of the clinical scores. The advantage of the procedure is that it is based on clinical practice and experience, but introduces a degree of standardization and precision which suggests that more of the diagnostic process might be brought under control with obvious benefit to clinical practice and research.