Reliability of a procedure for measuring and classifying "present psychiatric state"

Diagnostic shift in adolescents with first episode psychosis: findings from the 2-year follow-up of the "Parma Early Psychosis" program

PURPOSE

Diagnostic stability for people with First Episode Psychosis (FEP) is essential for treatment, but it remains poorly investigated, especially in adolescents and within a prospective design. The aims of this research were: (a) to examine diagnostic change in Italian adolescents with FEP treated within an "Early Intervention in Psychosis" program during a 2-year follow-up period and (b) to investigate any sociodemographic and clinical predictors at baseline.

METHODS

At baseline, 66 adolescents with FEP was recruited. Their primary diagnosis was formulated both at baseline and at the end of follow-up. At presentation, FEP adolescents completed the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA). As for diagnostic stability, the Kappa statistic was calculated. The associations of diagnostic change with baseline clinical and sociodemographic features were analyzed using a logistic model with the diagnostic shift as dependent variable. A propensity score was finally calculated based on logistic analysis results.

RESULTS

38 (57.6%) FEP adolescents changed their opening diagnosis. The highest prospective diagnostic stability was for initial diagnosis of schizophrenia (95.4%) and affective spectrum psychoses (75%). Diagnostic instability was high for opening diagnosis of psychosis not otherwise specified, brief psychosis and schizophreniform disorder (100%). The best predictors of diagnostic change were fewer years of education, shorter duration of untreated psychosis and higher baseline levels of psychiatric symptoms.

CONCLUSION

Diagnostic stability is crucial for treatment and clinical decision making. Addressing instability in FEP diagnoses is an important challenge for future diagnostic development in early psychosis, especially in adolescence.

Fifty Years of Psychiatric Classification and Epidemiology Interactions: What is a Mental Disorder?

Psychiatric clinical diagnostic formulation has evolved over time. The changes alter our understanding and our ability to provide a public health perspective on the epidemiology of mental disorders in large populations. Epidemiology is an important perspective and set of tools to assess prevalence, treated prevalence, untreated prevalence, individual risks for mental disorders, and possible links to the etiology of disorders by following the trails of environmental exposures, biological measures, interpersonal dynamics, and genetic risk factors. As communities develop health-care services to treat individuals with mental disorders, knowledge about their prevalence and treatment requirements is also important. Since severe mental disorders may require institutional care, the diagnostic criteria used may either protect an individual's liability for dangerous behavior (i.e. the insanity defense) or be used to control political and social dissidents. The criteria may also be used to determine evidence-based treatment options and eligibility for disability benefits. In this paper, using my vantage points as a physician scientist and public health officer, with leadership positions in national federal and professional mental health organizations, I address the developments in these areas over the past 50 years that have influenced institutional positions in the U.S. National Institute of Mental Health, the World Health Organization, the American Psychiatric Association, and the Center for the Study of Traumatic Stress. These perspectives may aid the next generation of investigators to advance the epidemiological and mental disorder classification scientific fields.

Adult Attention Deficit-Hyperactivity Disorder is associated with Lewy Body Disease and Cognitive Impairment: A prospective cohort Study With 15-year Follow-Up

OBJECTIVES

Past reports have suggested that attention-deficit/hyperactivity disorder (ADHD) may be a risk factor for Lewy body disease (LBD). To confirm this relationship, we conducted the present study.

DESIGN

A prospective observational cohort study with a follow-up to 15 years.

SETTING

The subjects were recruited from cognitive neurology clinics, where they attended for a cognitive complaint or health check-up.

PARTICIPANTS

Two groups of subjects: ADHD adults and healthy subjects.

MEASUREMENTS

The risk of dementia and LBD was estimated with Kaplan-Meier analysis comparing for the presence or absence of ADHD with the log-rank test. Predictors of conversion were assessed through separate univariate and multivariate Cox regression analyses, adjusting for several variables.

RESULTS

The baseline sample consisted of 161 subjects with ADHD and 109 without ADHD. At the end of the follow-up, 31 subjects developed dementia, 27 cases in the ADHD group and 4 in comparison group. Dementia with Lewy bodies (DLB) was the most frequent type (N:20) of which 19 corresponded to the ADHD group. The incidence of non-amnestic-MCI in the ADHD group was higher representing 67.1 % of these subjects (N:108), and 17.4% (N:19) of healthy cases. The hazard ratios for dementia and LBD in the multivariate adjusted model were 3.33 (95% CI 1.0915 to 10.1699) and 54.54 (95% CI 7.4849 to 397.5028), respectively in the ADHD group.

CONCLUSIONS

This study showed that adult ADHD is independently associated with an increased risk of LBD, dementia, and na-MCI. Future studies should clarify this relationship to develop preventive measures for these patients.

Psychosocial stress, interpersonal sensitivity, and social withdrawal in clinical high risk for psychosis: a systematic review

Stress has repeatedly been implicated in the onset and exacerbation of positive symptoms of psychosis. Increasing interest is growing for the role of psychosocial stress in the development of psychosis symptoms in individuals at Clinical High Risk (CHR) for psychosis. A systematic review was therefore conducted to summarize the existing evidence base regarding psychosocial stress, interpersonal sensitivity, and social withdrawal in individuals at CHR for psychosis. An electronic search of Ovid (PsychINFO, EMBASE, MEDLINE, and GLOBAL HEALTH) was conducted until February 2022. Studies that examined psychosocial stress in CHR were included. Twenty-nine studies were eligible for inclusion. Psychosocial stress, interpersonal sensitivity, and social withdrawal were higher in CHR individuals compared to healthy controls and there was some evidence of their association with positive symptoms of psychosis. Two types of psychosocial stressors were found to occur more frequently with CHR status, namely daily stressors, and early and recent trauma, while significant life events did not appear to be significant. Greater exposure to psychosocial stress, emotional abuse, and perceived discrimination significantly increased risk of transition to psychosis in CHR. No studies examined the role of interpersonal sensitivity on transition to psychosis in CHR. This systematic review provides evidence for the association of trauma, daily stressors, social withdrawal, and interpersonal sensitivity with CHR status. Further studies investigating the impact of psychosocial stress on psychosis symptom expression in individuals at CHR and its effects on transition to psychosis are therefore warranted.

Inter-Rater Reliability between Structured and Non-Structured Interviews Is Fair in Schizophrenia and Bipolar Disorders-A Systematic Review and Meta-Analysis

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 (β = 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.

Symptom variability in depersonalization-derealization disorder: A latent profile analysis

OBJECTIVE

Depersonalization-derealization disorder (DDD) is characterized by diverse symptomatology overlapping with anxiety and dissociative disorders, but the sources of this variability are poorly understood. This study aims to determine whether symptom heterogeneity is attributable to the presence of latent subgroups.

METHOD

We applied latent profile analysis to psychometric measures of anxiety, depersonalization-derealization, and dissociation in 303 DDD patients.

RESULTS

The analysis yielded evidence for five discrete subgroups: three of varying severity levels and two moderate-to-severe classes characterized by differential dissociative symptoms. The five classes reliably differed on several nondissociative symptoms, comorbidities, and factors precipitating their diagnosis but did not significantly differ in other symptoms including anxiety.

CONCLUSION

These results suggest the presence of three distinct DDD subtypes in the upper severity range that are distinguished by differential expression of detachment and compartmentalization symptoms. Further elucidation of these subtypes has potential implications for the etiology, mechanisms, and treatment of DDD.

A major flaw in the diagnosis of schizophrenia: what happened to the Schneider's first rank symptoms

Kurt Schneider introduced in the definition of the first-rank symptoms (FRS) the criterion that, where unequivocally present, the FRS are always psychological primaries and irreducible. This criterion, grounded on 'phenomenology' (description of subjective experiences), cannot be applied, according to Schneider, to delusions, either two-stage FRS delusional perception, or second-rank delusional notions. The Schneider's key criterion was neglected since the initial adoption of the 'Schneider's FRS' in the subsequent international literature (e.g. PSE, RDC, DSM, and ICD). The 'Schneider's FRS' (e.g. thought insertion, thought withdrawal, passivity, and influence) were persistently equivocated as 'delusions', in spite of the Schneider's FRS exclusion criterion. The internationally equivocated 'Schneider's FRS' (only homonymous of the original 'Schneider's FRS'), were eliminated in the DSM-5 and de-emphasized in ICD-11. However, the diagnostic value of the original 'Schneider's FRS', assessed on the basis of the strict compliance with the Schneider's criterion for their definition, was never determined. The 'damnatio memoriae' of the original Schneider's FRS may be premature. The definition and assessment of the 'experienced' symptoms of schizophrenia, only directly observed and reported by the patients, represent a specific, crucial, irreplaceable domain of psychopathology, to be carefully distinguished from the domain of the 'behavioral' symptoms observed by the clinician. Contemporary psychopathology research is aware of the absolute need for psychiatry to enhance precision and exactness in the definition of the experienced symptoms of schizophrenia, through the formulation of unequivocal inclusion and exclusion criteria (descriptive micro-psychopathology), in order to determine their value in research and care.

Schizophrenia Infrastructures: Local and Global Dynamics of Transformation in Psychiatric Diagnosis-Making in the Twentieth and Twenty-First Centuries

This article uses the concept of "diagnosis infrastructures" to propose a framework for narrating the history of schizophrenia as a global category in the twentieth century. Diagnosis infrastructures include the material and architectural arrangements, legal requirements, and professional models that enable both the ways in which patients come to clinics and navigate the world of schizophrenia as well as the means through which clinicians organize their diagnostic work. These infrastructures constitute a framework for how schizophrenia has been identified as a disorder. This article explores three moments in the history of schizophrenia infrastructures in the twentieth century. The first is the German psychiatrist Kurt Schneider's discussion of first- and second-rank symptoms in the interwar period. The second is the research on criteria for defining schizophrenia within the framework of the WHO International Pilot Study of Schizophrenia at the turn of the 1970s. The third corresponds to the changing infrastructures of mental health care in the context of both global mental health and the changing landscape of schizophrenia research over the last decades.

Psychiatry's contribution to the public stereotype of schizophrenia: Historical considerations

The public stereotype of schizophrenia is characterized by craziness, a split personality, unpredictable and dangerous behaviour, and by the idea of a chronic brain disease. It is responsible for delays in help-seeking, encourages social distance and discrimination, and furthers self-stigmatization. This paper discusses the circumstances of the origins of the idea of a chronic brain disease (Emil Kraepelin, 1856-1926), of the split personality concept derived from the term "schizophrenia" (Eugen Bleuler, 1857-1939), and the craziness idea reflected in the "first rank symptoms", which are all hallucinations and delusions (Kurt Schneider, 1887-1967). It shows how Emil Kraepelin's scientific search for homogenous groups of patients with a common aetiology, symptom pattern, and prognosis materialized in the definition of "dementia praecox" as a progressing brain disease; how Eugen Bleuler's life and professional circumstances facilitated an "empathic" approach to his patients and prompted him to put in the foreground incoherence of cognitive and affective functioning, and not the course of the disease; finally, how Kurt Schneider in his didactic attempt to teach general practitioners how to reliably diagnose schizophrenia, neglected what Emil Kraepelin and Eugen Bleuler had emphasized decades earlier and devised his own criteria, consisting exclusively of hallucinations and delusions. In a strange conglomerate, the modern operational diagnostic criteria reflect all three approaches, by claiming to be Neo-Kraepelinean in terms of defining a categorical disease entity with a suggestion of chronicity, by keeping Bleuler's ambiguous term schizophrenia, and by relying heavily on Kurt Schneider's hallucinations and delusions. While interrater reliability may have improved with operational diagnostic criteria, the definition of schizophrenia is still arbitrary and has no empirical validity-but induces stigma.

The mental state examination

The mental state examination is unlike any other assessment in medicine. Karl Jaspers is largely attributed with describing the structure and method of its use. In the centenary year of Jaspers' seminal work General Psychopathology, psychiatry can celebrate the mental state examination as part of its rational and secular heritage.

Early-Onset Schizophrenia: Exploring the Contribution of the Thought Disorder Index to Clinical Assessment

Background:

Differentiating diagnostically between schizophrenia and emotional and personality disorders with psychotic or psychotic-like symptoms is a challenging task. It is especially difficult when working with adolescent patients, because their symptoms tend to manifest at lower levels as compared with adult patients. Thought disorder is a core symptom of schizophrenia, and the Rorschach Inkblot Method is widely used for the assessment of formal thought disorder.

Objective:

In this study, which is situated within ongoing clinical practice, we investigated whether the Rorschach test is helpful for assessing early-onset schizophrenia due to its ability to detect thought disorder. We also wanted to examine whether the Thought Disorder Index (TDI) is superior to the Comprehensive System (CS) for differentiating between patients with early-onset schizophrenia and non-psychotic patients experiencing auditory and visual hallucinations. An additional aim was to examine whether the TDI correlated with the Positive and Negative Syndrome Scale (PANSS).

Methods:

Twenty-three subjects between the ages of 12 and 18 years were examined with the use of the Rorschach test, and the protocols were scored according to both the TDI and the CS. All subjects were also assessed with the Positive and Negative Syndrome Scale. The sample included 14 subjects who fulfilled the criteria for schizophrenia and 9 subjects who were experiencing hallucinations that emanated from severe emotional and relational problems but who had different non-psychotic disorders.

Results:

Although the two groups could not be distinguished with regard to their total scores for thought disorder, the identification of specific thought disorder types proved useful for differential diagnosis. Verbalizations that were categorized by the TDI as “absurd responses,” “fluidity,” “contamination,” “autistic logic,” and “word-finding difficulty” were only given by patients who had been diagnosed with schizophrenia. When patients’ responses were scored with the use of the CS, the “contamination” score was the only one found to be specific to schizophrenia.

Conclusions:

Although the sample size limits the conclusions that can be drawn, the results indicate that the TDI may be superior to the CS for the identification of thought disorder specific to—but not always present in—adolescents with schizophrenia. In other words, the absence of severe thought disorder is not synonymous with the absence of severe psychopathology, but the presence of the most severe thought disorder types (i.e., “absurd responses,” “fluidity,” “incoherence,” “contamination,” and “autistic logic”) seems to be a strong indicator of schizophrenic psychopathology.

Screening tools for clinical high risk for psychosis

AIM

The purpose of this article was to review existing screening instruments that could be used to identify individuals who may be at increased risk for psychosis and to determine the suitability of these instruments.

METHODS

Medline (Ovid) and PubMed were searched for peer-reviewed articles published in English, which reported performance evaluation of screening instruments for symptoms of high risk for psychosis. The articles' titles, abstracts and, when necessary, full texts were read to filter them against the selection criteria. Citations within relevant articles were hand searched for other potentially eligible studies.

RESULTS

This selection strategy resulted in identifying 56 articles (including three articles available only in an abstract format) that reported performance evaluation of 17 screening instruments.

CONCLUSIONS

The sensitivity of these scales ranged from 67% to 100% and the specificity ranged from 39% to 100%. The positive predictive value was less precise with scores ranging from 24% to 100%, and the negative predictive value ranging from 58% to 100%. There were several scales that might be useful for screening for individuals who are at increased risk for developing psychosis; however, the majority of measures are underexplored with poor validation.

One hundred years of limited impact of Jaspers' General Psychopathology on US psychiatry

Jaspers, a German psychiatrist, published General Psychopathology in 1913. Jaspers, Schneider, and Mayer-Gross were members of the Heidelberg school. General Psychopathology, indirectly through Schneider's and Mayer-Gross' textbooks and directly by its English translation in 1963, led to a narrow set of schizophrenia criteria in the United Kingdom. General Psychopathology had very limited direct impact on US psychiatry, which adopted a broader schizophrenia definition. The difference between UK and US schizophrenia was a key element in the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, and the neo-Kraepelinian revolution. General Psychopathology contains two essential interrelated ideas: a) psychiatry is a hybrid scientific discipline that must combine natural and social science methods that provide an explanation of illness that follows the medical model and an understanding of psychiatric abnormalities that are variations of human living, respectively, and b) psychiatric disorders are heterogeneous. Berrios' ideas on the hybridity of psychiatry in the United Kingdom and McHugh's ideas on psychiatric diagnoses in the United States can be considered neo-Jasperian approaches because they further elaborate these two Jasperian concepts in the late 20th century.

Toward understanding ethnic and cultural factors in the interviewing process

The clinical interview is critical in the diagnostic assessment undertaking in clinical settings, and cultural/ethnic influences have been shown to influence the outcome of this process. Specifically, a number of studies have reported that proportionally far more ethnic minorities than Caucasians are likely to be misdiagnosed when assessed for psychiatric disorders. This particularly is the case when open clinical interviews are used. Semistructured interviews, on the other hand, result in an increase in diagnostic accuracy with ethnic minorities. Parameters associated with bias in the clinical interview of ethnic minorities and its impact on assessment, diagnosis, and treatment decisions are examined. Although the current discussion focuses primarily on African Americans, many examples are provided that pertain to other ethnic groups. Strategies for addressing these issues are explored and recommendations for increasing cultural competence are made. (PsycINFO Database Record (c) 2011 APA, all rights reserved).

Diagnosis of schizophrenia: consistency across information sources and stability of the condition

BACKGROUND

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.

METHODS

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.

FINDINGS

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).

DISCUSSION

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.

Challenges in validating quality of care data in a schizophrenia registry: experience from the Danish National Indicator Project

BACKGROUND

Improvement of quality of care for psychiatric patients is a key objective of health care systems worldwide. Consequently, there is an increasing interest in documenting quality of care; however, little is known about the validity of the available data on psychiatric care.

OBJECTIVE

To assess the validity of process of care data recorded in the Danish National Indicator Project (DNIP), a national population-based registry containing quality of care data of patients diagnosed with schizophrenia in Denmark.

METHODS

A random sample of 1% of patients with schizophrenia registered in the DNIP between 2004 and 2009 (111 inpatient and 85 outpatient) was identified for validation. Medical records for these patients, which were used as the gold standard, were retrieved and reviewed for information on the processes of care received. Agreement between the data in the DNIP and the medical records were assessed by computing sensitivity, specificity, and positive and negative predictive values.

RESULTS

The agreement between the recorded processes of care in the DNIP and in the medical records varied substantially across the individual process of care variables. However, a collection of the processes of care demonstrated a high agreement (80% or more) between data in the DNIP and the medical records, according to all examined aspects of data validity (sensitivity, specificity, and positive and negative predictive values). The medical records contained varying levels of missing information regarding the processes of care, from 1% for antipsychotic medication prescription to 54% for psychoeducation.

CONCLUSION

Current documentation practices in Danish psychiatric hospitals appear to be inconsistent and may preclude the use of psychiatric medical records as the gold standard when validating registry data.

Schizophrenia: from epidemiology to rehabilitation

Purpose/Objective:

We discuss recent evidences about schizophrenia (frequency, onset, course, risk factors and genetics) and their influences to some epidemiological myths about schizophrenia diffuse between psychiatric and psychopathology clinicians. The scope is to evaluate if the new acquisitions may change the rehabilitation approaches to schizophrenia modifying the balance about the neurodevelopmental hypothesis of schizophrenia accepting that the cognitive deficits are produced by errors during the normal development of the brain (neurodevelopmental hypothesis) that remains stable in the course of illness and the neurodegenerative hypothesis according of which they derived from a degenerative process that goes on inexorably.

Research Method/Design:

A review of the literature about epidemiology of schizophrenia has been performed and the contributions of some of these evidence to neurodevelopmental hypothesis and to rehabilitation has been described.

Results:

It cannot be definitively concluded for or against the neurodevelopmental or degenerative hypothesis, but efforts in understanding basis of schizophrenia must go on. Until now, rehabilitation programs are based on the vulnerability-stress model: supposing an early deficit that go on stable during the life under favorable circumstances. So, rehabilitation approaches (as neuro-cognitive approaches, social skill training, cognitive-emotional training) are focused on the individual and micro-group coping skills, aiming to help people with schizophrenia to cope with environmental stress factors.

Conclusions/Implications:

Coping of cognitive deficits in schizophrenia may represents the starting-point for further research on schizophrenia, cohort studies and randomized trials are necessary to defined the range of effectiveness and the outcome of the treatments.

A longitudinal study of maternal prenatal, postnatal and concurrent depressive symptoms and adolescent well-being

BACKGROUND

Maternal depression is known to be a risk for abnormal child development. Girls and boys have been found to respond differently to maternal depression. Although prenatal and postnatal depression has been widely studied, longitudinal studies of adolescent outcome are still rare.

METHODS

The original sample of 349 mothers in this longitudinal study was collected in 1989-1990 in Tampere, Finland. At the latest stage, of the 327 contacted in 2006, 191 mothers and 192 adolescents aged 16 to 17 years participated in the study. Maternal depressive symptoms were screened using the Edinburgh Postnatal Depression Scale (EPDS) prenatally, postnatally and at the latest stage. Adolescent outcome was examined using the Child Behavior Checklist (CBCL) and the Youth Self Report (YSR).

RESULTS

Maternal concurrent depressive symptoms were associated with adolescent behavioral and emotional problems in both genders. Maternal prenatal depressive symptoms were associated with Externalizing Problems in the YSR and boys' lower Social Competence in both the CBCL and YSR. Maternal postnatal depressive symptoms were associated with boys' lower Social Competence both in the CBCL and YSR and Externalizing Problems in the YSR.

LIMITATIONS

Being a longitudinal normal population sample, the number of symptomatic mothers and adolescents is relatively small and the number of drop-outs is relatively high. Clinical evaluation of mothers and adolescents is also lacking.

CONCLUSIONS

Maternal prenatal and postnatal depressive symptoms are a risk to adolescent boys' wellbeing and concurrent depressive symptoms a risk for both girls' and boys' well-being. This long-term influence should be noted when treating women with depressive symptoms throughout motherhood.

The evolution of Indian psychiatric research: An examination of the early decades of the Indian Journal of Psychiatry

Research in psychiatry has travelled far since the inception of the Indian Journal of Psychiatry (IJP) in 1949. We reviewed publications in the IJP during its initial three decades to identify path breaking articles and trends in research. We present the evolution of research design in the IJP from cases studies to randomized controlled trials. We identify the earliest studies in different fields, ranging from drug trials to social interventions, and from women's mental health to geriatric psychiatry. We consider special issues such as the measurement of psychopathology specific to the Indian context, studies of treatments specific to Indian traditions, epidemiology of psychiatric disorders in India, and innovations in service delivery. Students interested in the history of Indian psychiatric research will be rewarded by the richness and variety of thought evidenced in the publications in the early decades of the IJP.

An historical framework for psychiatric nosology

This essay, which seeks to provide an historical framework for our efforts to develop a scientific psychiatric nosology, begins by reviewing the classificatory approaches that arose in the early history of biological taxonomy. Initial attempts at species definition used top-down approaches advocated by experts and based on a few essential features of the organism chosen a priori. This approach was subsequently rejected on both conceptual and practical grounds and replaced by bottom-up approaches making use of a much wider array of features. Multiple parallels exist between the beginnings of biological taxonomy and psychiatric nosology. Like biological taxonomy, psychiatric nosology largely began with 'expert' classifications, typically influenced by a few essential features, articulated by one or more great 19th-century diagnosticians. Like biology, psychiatry is struggling toward more soundly based bottom-up approaches using diverse illness characteristics. The underemphasized historically contingent nature of our current psychiatric classification is illustrated by recounting the history of how 'Schneiderian' symptoms of schizophrenia entered into DSM-III. Given these historical contingencies, it is vital that our psychiatric nosologic enterprise be cumulative. This can be best achieved through a process of epistemic iteration. If we can develop a stable consensus in our theoretical orientation toward psychiatric illness, we can apply this approach, which has one crucial virtue. Regardless of the starting point, if each iteration (or revision) improves the performance of the nosology, the eventual success of the nosologic process, to optimally reflect the complex reality of psychiatric illness, is assured.

Development and psychometric evaluation of the Ostomy Adjustment Inventory-23

PURPOSE

This article describes the development of the Ostomy Adjustment Inventory-23 (OAI-23), a self-report, multidimensional scale designed to assess psychosocial adjustment in patients with ostomy.

SUBJECTS AND SETTING

Five hundred seventy persons with a colostomy, ileostomy, or urostomy, who were randomly selected from 3 national databases, provided assessable data.

RESULTS

The results indicate that the OAI-23 is reliable (the Cronbach alpha = .93, split-half = 0.91, and test-retest (r) = 0.83) and valid, correlating positively with Felton's Acceptance of Illness Scale (r = 0.72) and confirming expected improvements in adjustment consistent with increasing time since surgery (F 5,531 = 5.22, P < .001). Four factors (eigenvalue >or= 1) that accounted for 55.4% of the total variance emerged from factor analysis.

CONCLUSION

The OAI-23 is a valid and reliable measure of psychosocial adjustment that will be of interest to both researchers investigating life after stoma surgery and clinicians making objective assessments of their patients' progress.

The Upper Bavarian longitudinal community study on psychopathology 1975-2004: 1. Methods and first results

OBJECTIVE

This paper presents background information on the methods and first results of the 25-years follow-up of the prospective longitudinal Upper Bavarian Study in the community. Longitudinal epidemiological studies which cover very long time spans require special methods. Issues concerning these requirements are discussed using design and experiences from the Upper Bavarian Study.

METHOD

Assessments focused on three time points: baseline survey, five-year follow-up, and 25-year follow-up. Self-rating scales as well as expert-rating interviews yielded data on a wide range of social and psychopathological risk factors and outcome measures.

RESULTS

Of the 1,342 study participants in the original sample, 390 had died during the 25-year follow-up period. Participation rate was 88% of those alive. At all three time points, a total of 838 participants were interviewed. Data on this unselected sample over a quarter century will be presented in forthcoming papers. Because of their mobility young individuals from our original sample were more difficult to follow up. We analyzed in detail data of subjects interviewed at t3 (and earlier time points) as compared to data from subjects not traced or reached, and subjects who refused to participate at wave t3. We found no evidence that the long-term outcome was biased by drop-out due to gender or earlier mental illness.

CONCLUSION

Methodological possibilities and limitations concerning long-term epidemiological studies across decades are presented and discussed.

Reflexology and progressive muscle relaxation training for people with multiple sclerosis: a crossover trial

PURPOSE

To compare the effects of reflexology and progressive muscle relaxation training for people with multiple sclerosis, provided by nurse therapists, on psychological and physical outcomes.

METHODS

A crossover design was chosen with a 4-week break between treatment phases. The Short Form 36 and General Health Questionnaire 28 were completed by patients (n=50) pre and post each of the 6-week treatment phases. Salivary cortisol levels, State Anxiety Inventory, systolic and diastolic blood pressure and heart rate data were collected pre and post the weekly sessions.

RESULTS

All of the chosen measures except for three SF-36 scales recorded significant changes, however, despite the 4-week break (washout period), most outcome measures did not return to their pre-treatment baseline levels. This meant that the analysis of the data was complicated by significant effects involving ordering of treatment occurring for eight of the variables (one from SF-36, two from the GHQ, SAI, Salivary Cortisol, Systolic BP and HR). However, there was a difference in the State Anxiety Inventory values between the treatments of the order of 1.092 units (95%CI 0.211-1.976) (p=0.016, Wilks lambda=0.885, df=1, 48) in favour of reflexology. Changes in salivary cortisol comparing levels pre 1st to post 6th session favoured reflexology (95%CI 0.098-2.644) (p=0.037, Wilks lambda=0.912, df=1, 48). A significant difference was found in the way the treatments affected change in systolic blood pressure following sessions; this favoured progressive muscle relaxation training (p=0.002, Wilks lambda=0.812, df=1, 48).

CONCLUSION

Positive effects of both treatments following sessions and over the 6 weeks of treatment are reported, with limited evidence of difference between the two treatments, complicated by ordering effects.

Gene-based SNP mapping of a psychotic bipolar affective disorder linkage region on 22q12.3: association with HMG2L1 and TOM1

Genetic linkage studies in both bipolar affective disorder (BPAD) and schizophrenia have implicated overlapping regions of chromosome 22q. We previously reported that BPAD pedigrees containing multiple members with psychotic symptoms showed suggestive linkage to chromosome 22q12.3. Now we have tested 189 single nucleotide polymorphisms (SNPs) spanning a 3 Mb region around the linkage peak for association with BPAD in 305 families, unrelated cases, and controls. SNPs were selected in or near genes, resulting in coverage at a density of 1 SNP per 6.7 kb across the 22 annotated genes in the region. The strongest signal emerged from family-based association analysis of an 11-SNP, 54 kb haplotype straddling the gene HMG2L1 and part of TOM1. A 3-marker haplotype of SNPs within TOM1 was associated with BPAD (allele-wise P = 0.0011) and with psychotic BPAD (allele-wise P = 0.00049). As hypothesized, the mean odds ratio for the risk alleles across the region was 1.39 in the psychotic but only 0.96 in the non-psychotic subset. Genotype-wise analyses yielded similar results, but the psychotic/non-psychotic distinction was more pronounced with mean odds ratios of 1.91 versus 0.8. Permutation of genotype-wise results for rs2413338 in HMG2L1 showed an empirical P = 0.037 for the difference between subsets. HMG2L1 is a negative regulator of Wnt signaling, a pathway of interest in psychotic BPAD as it is activated by both mood stabilizer and anti-psychotic medications. Further work is needed to confirm these results and uncover the functional variation underlying the association signal.

Time to remission for eating disorder patients: a 2(1/2)-year follow-up study of outcome and predictors

The aim of the present study was to analyse outcome, time to remission, and predictors of time to remission in a cohort of Danish eating disorder patients. Seventy-eight patients (35 anorexic, 30 bulimic and 13 unspecified eating disorder patients) were interviewed 2(1/2) years after initial assessment. Method of assessment was Eating Disorder Examination (EDE), Longitudinal Interval Follow-up Evaluation of Eating Disorders (LIFE-EAT-II), Eating Disorder Inventory (EDI), Symptom Check List (SCL-90R), Present State Examination (PSE) and the Structured Clinical Interview for DSM-III-R Axis-II (SCID-II). Method of analysis was Kaplan-Meier estimate of survival, Log Rank test and Cox regression analysis. In total 48.7% reached remission with mean time to remission at 27 months. A trend difference between the diagnostic groups when measuring time to remission was found, i.e. patients with unspecified eating disorders remitted faster than bulimic (BN) patients who in turn remitted faster than anorexic (AN) patients. Body mass index (BMI) at baseline was the best predictor of time to remission for the total sample. Predictors differed when looking at diagnostic groups separately. Final outcome was comparable with earlier studies while relapse frequency was low. Patients with AN remitted faster than found in earlier survival analysis studies, while the remission rate for BN patients was comparable with earlier studies. Despite the prognostic value of BMI for the total sample, predictor analysis implied more disorder diversity than homogeneity.

Case identification in psychiatric epidemiology: a review

BACKGROUND

Psychiatric epidemiologic surveys since 1980 have relied heavily on a small number of survey diagnostic instruments for case ascertainment, which encode reports of respondents to highly structured interview questions delivered by interviewers without clinical training. Many validations of these survey diagnostic instruments have been carried out.

OBJECTIVE

This paper reviews the success of the survey diagnostic instruments, for eight diagnostic categories, in validations with a psychiatrist examination as the gold standard.

METHOD

Public databases were searched for potentially relevant publications, of which more than 1000 were located. Tables show sensitivity, specificity, Kappa, sample source and size, survey instrument and validation method.

RESULTS

The number of validation studies relevant to the eight disorders ranged from 8 for schizophrenia to 29 for major depressive disorder. Reported sensitivities ranged from zero to 100%, and specificities from 22% to 100%.

CONCLUSION

Results for common mental disorders such as major depressive disorder, alcohol disorder, drug disorder, and agoraphobic disorder are better than for panic disorder, obsessive compulsive disorder, bipolar disorder, and schizophrenia. The validity of case ascertainment in psychiatric epidemiology is still in question.

The psychological sequelae on mothers of thermally injured children and adolescents: future directions: Part 3

Part 3 of this study focused on maternal psychopathology and relationship with their children in three groups, assessed in Parts 1 and 2. Evidence of greater psychopathology in the mothers of burned children was supported by findings of both interview and self-report data, which indicated more symptoms of worry, depression, tension, anxiety, lack of energy, lower self confidence with other people and guilt, compared with mothers of Fracture Clinic and Normal Controls. Marital and social functioning and adverse life events did not differentiate groups, with the exception of a significantly higher divorce rate in the parents of burned children, following thermal injury.

Short-term stability of diagnoses of major and minor depression in older medical inpatients

The authors sought to determine the short-term stability of diagnoses of major and minor depression in older medical inpatients. The investigation was a test-retest design involving comparisons between different pairs of interviewers who assessed patients independently on medical wards of two acute-care, university-affiliated hospitals by use of the Diagnostic Interview Schedule (DIS) at intervals between 1 and 51 days. Patients were 380 cognitively-intact patients age > or =65, assessed twice with the DIS. Core depressive symptoms (depressed mood, loss of interest or pleasure) were more stable than the other depressive symptoms. The presence of moderate-to-severe depressive symptoms, moderate-to-severe disability, and depression symptoms of > or =6 months' duration were associated with a higher short-term stability of diagnosis. Age, gender, language, education, rater, interval between assessments, baseline number of medications, medical comorbidity, severity of medical illness, acute physiology score, and cognitive functioning were not associated with short-term depression stability. Stability of diagnosis may be improved by emphasis on core depressive symptoms or the presence of more severe depressive symptoms, moderate-to-severe disability, and duration of symptoms > or =6 months.

Toward specifying the nature of the relationship between expressed emotion and schizophrenic relapse: the utility of curvilinear models

Although expressed emotion (EE) has been demonstrated to be associated with the course of schizophrenia, the nature of this relationship is unclear. This study proposes that testing for curvilinear relationships can identify the specific nature of the relationships between EE indices and relapse. The utility of curvilinear models was explored through a reanalysis of data from a prior study of EE among Mexican-Americans (Karno et al., 1987). The results suggest that the relationship between the EE index of emotional overinvolvement (EOI) and relapse is curvilinear and that high levels of EOI may exert a toxic effect on course of illness whereas medium levels of EOI may be protective. The relationship between the EE index of warmth and relapse is also curvilinear and high levels of warmth appear to exert a protective effect on the course of illness. The role of culture is explored in explaining the specific manner in which EE relates to relapse among Mexican-Americans.

Ethnicity, Expressed Emotion, Attributions, and Course of Schizophrenia: Family Warmth Matters

The authors examined the role of family factors and the course of schizophrenia by carrying out additional assessments and analyses in 2 previously published studies of Mexican American and Anglo American patients and families. The authors found partial support for an attributional model of relapse for families who are low in emotional overinvolvement. Attributions of control, criticism, and warmth together marginally predicted relapse. The data also indicated that for Mexican Americans, family warmth is a significant protective factor, whereas for Anglo Americans, family criticism is a significant risk factor. These findings suggest that the sociocultural context shapes the pathways by which family processes are related to the course of illness. Moreover, the warmth findings suggest that families may contribute to preventing relapse.

Familial aggregation of psychotic symptoms in a replication set of 69 bipolar disorder pedigrees

We found evidence previously of familial aggregation of psychotic symptoms in 65 bipolar disorder pedigrees. This finding, together with prior evidence from clinical, family, neurobiological, and linkage studies, suggested that psychotic bipolar disorder may delineate a valid subtype. We sought to replicate this finding in 69 new bipolar disorder pedigrees. The presence of psychotic symptoms, defined as hallucinations or delusions, during an affective episode was compared in families of 46 psychotic and 23 non-psychotic bipolar I probands ascertained at Johns Hopkins for the NIMH Bipolar Disorder Genetics Initiative. There were 198 first-degree relatives with major affective disorder including 90 with bipolar I disorder. Significantly more psychotic proband families than non-psychotic proband families (76% vs. 48%) contained at least one affected relative with psychotic symptoms. Psychotic symptoms occurred in 35% of relatives of psychotic probands and in 22% of relatives of non-psychotic probands (P = 0.10). Both psychotic affective disorder generally and psychotic bipolar I disorder clustered significantly in families. These results are consistent with our prior report although the magnitude of the predictive effect of a psychotic proband is less in the replication families. Our findings provide modest support for the validity of psychotic bipolar disorder as a subtype of bipolar disorder. This clinically defined subtype may prove more homogeneous than the disorder as a whole at the level of genetic etiology and of neuropathology/pathophysiology. Families with this subtype should be used to search for susceptibility genes common to bipolar disorder and schizophrenia, and for biological markers that may be shared with schizophrenia.

The Geriatric Mental State Examination in the 21st century

The Geriatric Mental State Examination (GMS) is now established as one of the most commonly used mental health assessments for older people. Its strengths lie in extensive validity studies, high inter-rater reliability, accessibility to trained raters, irrespective of professional background and its continual evolution and adaptation. Its computerisation, association with supplementary instruments and support by a diagnostic algorithm provides a comprehensive diagnostic system and syndrome profile for each subject. The instrument has been validated against most major diagnostic systems and has been used as outcome measures in intervention studies. It has been translated into numerous languages and validated as a diagnostic instrument in various cultures. Such studies have exposed weaknesses, including the over diagnoses of organic states in populations with poorly developed education. On-going studies continue to address these issues, providing a culture sensitive instrument enabling unique trans-cultural research in a relatively under-researched field.

Fifty years of psychiatric nomenclature: reflections on the 1943 War Department Technical Bulletin, Medical 203

War Department Technical Bulletin, Medical 203 is presented in historical context as the first psychodynamic nomenclature. The history of Medical 203 is presented to show how Medical 203 was adapted to become DSM-I. Medical 203 then is compared and contrasted to DSM-IV to illustrate how changes in the modern DSMs have led to an 800% increase in the number of psychiatric diagnoses over the last half century. The role of critical history is emphasized in evaluating those changes and in speculating about the next 50 years of psychiatric nomenclature.

Core mental state in irritable bowel syndrome

OBJECTIVE

Psychiatric illness is higher among patients with irritable bowel syndrome (IBS) who seek medical care; however, a specific psychopathology that differentiates patients with IBS from patients with other organic gastrointestinal disorders has not been found. In the study described here, we investigated the predominant psychiatric symptoms in women with IBS.

METHODS

The criteria of Manning et al., as modified by Thompson et al., were used to make the diagnoses of IBS. Psychiatric assessment was performed by using a structured interview in 64 women, aged 20 to 70 years, 36 with IBS and 28 with chronic cholelithiasis. Diagnosis of chronic cholelithiasis was made by histopathological examination. The final diagnoses were confirmed by interview after 1 year. The diagnostic system based on the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) was used to make the current diagnoses. The Present State Examination (PSE)-Index of Definition (ID) computer program (CATEGO) was used to define total psychopathology (total PSE score), current clinical severity (ID), and clusters of psychiatric symptoms.

RESULTS

No difference in the specific DSM-IV diagnostic categories was found, but there were more total depressive disorders in the IBS group. The ID and total PSE score were high among patients with IBS. Multiple logistic regression analysis showed that duration of gastrointestinal pain, and the symptoms of general anxiety, and hypochondriasis significantly predicted a diagnosis of IBS.

CONCLUSIONS

Female patients with IBS are categorized into the general DSM-IV category of depressive disorder, their current psychiatric severity is high compared with that of women with chronic cholelithiasis, and patients with IBS are characterized by the psychiatric syndromes of general anxiety and hypochondriasis. The implications of these findings and areas for future research are discussed.

Rating antidepressant efficacy with naturalistic live versus structured videotaped interviews

Two different methods were compared in the assessment of depressive symptomatology improvement: live naturalistic (N) performed by the patient's therapist, and from videotape record of structured clinical interview (VSI) assessed by an independent rater out of five psychiatrists. Sixty-one newly admitted depressed inpatients, with a Montgomery and Asberg Depression Rating Scale (MADRS) total score above 20, were assessed before antidepressant treatment (DO), after 10 days (D10) and 4 weeks of treatment (D28). Assessments were based on the MADRS and the Depression Retardation Rating Scale (DRRS) for both N and VSI methods, and on the SCL-90-R for self-rating. With the MADRS, the N method was shown to be more sensitive to symptomatology change than the VSI method, but the VSI method was more correlated to self-assessment than the N method was. However, these results were not replicated on the DRRS, for which an underscoring with the VSI method was evidenced as compared to the N method. As shown in other studies, the poorest agreement between the two methods was evidenced at DO, suggesting a "novelty effect" particularly with the VSI method. This "novelty effect" may be all the more pronounced if a personality disorder is associated to depression. Consequently, information concerning each patient before rating videotapes is needed, as well as investigations in the field of depression and personality disorders. The greater change observed in MADRS with the N method as compared to the VSI method, may be due non-specific factors related mostly to therapist expectations by comparison to neutral raters. This hypothesis should be tested in the placebo group of a double-blind study, and, if confirmed, the use of VSI methods, by minimising non-specific factors of improvement due to therapist expectations, may decrease the placebo response in antidepressant drug trials.

Detecting psychiatric morbidity after stroke: comparison of the GHQ and the HAD Scale

BACKGROUND AND PURPOSE

Mood disorders are common after stroke and may impede physical, functional, and cognitive recovery, making early identification and treatment of potential importance. We aimed to compare the accuracy of the General Health Questionnaire (GHQ-30) and the Hospital Anxiety and Depression (HAD) Scale in detecting psychiatric morbidity after stroke and to determine the most suitable cutoff points for different purposes.

METHODS

One hundred five hospital-referred stroke patients completed both the GHQ-30 and HAD Scale 6 months after onset before a blinded psychiatric assessment in which the Schedule for Affective Disorders and Schizophrenia with some supplementary questions was used to determine a DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition) diagnosis. Measures were compared in terms of sensitivity, specificity, and receiver operating characteristic curves.

RESULTS

No significant differences were found between the GHQ-30 and the HAD Scale in identifying those patients with any DSM-IV diagnosis (P=0.95), grouped depression (P=0.56), or anxiety (P=0.25) disorders. The previously recommended cutoff points for identifying "cases" for the GHQ (4/5) and for the HAD Scale (8/9 and 11/12) were found to be suboptimal in this population.

CONCLUSIONS

The GHQ-30 and HAD scale exhibited similar levels of sensitivity and specificity. Data are presented, taking into account the "cost" of false-positives and negatives, to allow a choice of cutoff points suitable for differing situations.

Psychopathologic domains and insight in schizophrenia

The earlier conceptualization of positive and negative symptom topologies for schizophrenia has given way to more complex models that propose three-and-four dimensions of psychopathology. These constructs may relate to neurobiologic heterogeneity and discrete symptom clusters have been shown to have distinct anatomical and cognitive correlates. Insight is an excellent example and the understanding of insight at psychopathologic and cognitive levels has facilitated new approaches to treatment and enhanced medication compliance.

Prevalence of anxiety disorders in elderly adults: a critical analysis

The authors examined the prevalence of anxiety disorders in elderly adults as presented in a recent review of the topic (Flint, 1994) where it was concluded that these disorders are rare in this segment of the population. Considering that anxiety research with older adults often involves instruments and criteria that have not been validated with elders, it is suggested that results may lack validity and underestimate the occurrence of anxiety in this age group. Issues that should be considered in the assessment of anxiety in elderly adults are reviewed. In particular, elderly persons may tend to somatize anxiety symptoms and there is a large overlap between anxiety and other psychiatric symptoms among older persons. It is concluded that anxiety may present differently in elderly persons and estimates of prevalence should await more research in this area.

Vietnamese and Arabic women's responses to the Diagnostic Interview Schedule (depression) and self-report questionnaires: cause for concern

OBJECTIVE

The original study aimed to determine the best cut-off scores to screen for postnatal depression on translated versions of the Edinburgh Postnatal Depression Scale (EPDS) for Vietnamese and Arabic women. This research was conducted using the depression module of the Diagnostic interview Schedule (DIS) to determine caseness. This paper reports on the suitability of this diagnostic interview as a criterion measure of depression in these women with a non-English speaking background.

METHOD

Vietnamese and Arabic women in south-west Sydney completed the EPDS and a General Health Questionnaire (GHQ-30) antenatally. At 6-8 weeks postpartum they completed an EPDS, the GHQ-30 and a Faces Scale, and were interviewed using the depression module of the DIS. Members of a small convenience sample of women were asked about the cultural appropriateness of each of the instruments.

RESULTS

Vietnamese women admitted to few depressive symptoms on the DIS, whereas they appeared more open to reporting these on the EPDS and the GHQ-30. Arabic women responded more openly to the questionnaires and the interview, although they too were reluctant to report specific symptoms on the DIS.

CONCLUSION

The usefulness of the DIS in determining rates of major depression in the Vietnamese and Arabic community in Australia is questionable. Further studies designed specifically to investigate this are needed.

Development of a structured psychiatric interview for children: agreement between child and parent on individual symptoms

To test the reliability of children's reporting as compared with that of their mothers, a highly structured psychiatric diagnostic interview was used with 307 subjects, ages 6 through 16. Another interviewer gave each mother a similar interview about the child. Responses of each mother-child pair to 168 questions were compared using the kappa statistic. Highest agreement was found on questions concerning symptoms that are concrete, observable, severe, and unambiguous. Mothers tended to report significantly more behavioral symptoms, and children more subjective symptoms. Reasons for low kappas and asymmetrical reporting of symptoms are discussed.