The Spanish Diagnostic Interview Schedule. Reliability and comparison with clinical diagnoses

Obsessive-Compulsive Disorder: A Review of the Cross-Cultural Epidemiological Literature

Early clinical studies suggested that obsessive-compulsive disorder (OCD) was a rare disorder, but recent large-scale epidemiological research conducted in North America using standardized diagnostic criteria (DSM-III) report prevalence rates between 1 to 3%. A review of clinical and case reports of OCD among psychiatric population in non-Western countries reveals similar sociodemographic and clinical correlates for the disorder compared to Western findings. Epidemiological studies using translated versions of standardized diagnostic instruments and conducted in non-Western countries, report similar prevalence rates and clinical phenomenology for O CD as that found in Western settings. Methodological and measurement issues relevant to conducting valid cross- cultural psychiatric research are discussed in relationship to the diagnosis of OCD. The review concludes that OCD is generally similar in prevalence, sociodemographic characteristics and clinical features in both Western and non-Western countries for adult populations.

Spanish Versions of the MMPI-2 and PAI: An Investigation of Concurrent Validity With Hispanic Patients

Delivery of mental health services to Hispanic populations requires that assessment methods address the linguistic needs of their clientele. Toward this end, Spanish translations of two recent multiscale inventories (i.e., Minnesota Multiphasic Personality Inventory-2, MMPI, and Personality Assessment Inventory, PAI) were published in order to meet these needs. Unfortunately, the linguistic equivalence and criterion-based validation of these Spanish versions were not addressed prior to publication. We sought to take the first step in remedying this oversight by administering the MMPI-2 and PAI to 105 Hispanic patients for whom Spanish is the sole or preferred language. We employed a revised Spanish version of the Diagnostic Interview Schedule (DIS) as a criterion measure. By focusing on four common disorders (i.e., major depression, schizophrenia, anxiety disorders, and alcohol dependence), we examined the usefulness of codetypes and clinical elevations for establishing these disorders. Overall, we found moderate hit rates for the MMPI-2 ( N = .60, range from .46-.69) and moderate to high hit rates for the PAI ( M = .72, range from .57-.87). Correlations of selected scales with DIS symptoms varied widely and were generally in the low to moderate range. Finally, exploratory data suggested few within-minority differences on selected MMPI-2 and PAI scales when DIS symptoms were employed as covariates.

Hispanic Mental Health Research: A Case for Cultural Psychiatry

Contemporary research involving Hispanic mental health is critically e-xamined. Selected problem areas that span a spectrum covering folk/traditional conceptualizations of mental illness, standardized concepts and methods employed in epidemiology, approaches to psychiatric diagnosis in biomedical settings, and more basic epistemological assumptions involving psychiatric nosology and theory receive systematic attention. The idea is developed that a dominating and exclusive "establishment psychiatry " stipulates concepts and methods of mental health research, thereby setting priorities and legitimating distinctive modes ofpractice and reimbursement for treatment. The need to challenge and broaden establishment psychiatry's paradigms and biases with insights and knowledge drawn from culturally sensitive Hispanic facts in contemporary mental health paradigms pertaining to psychiatric theory and practice is seen to contribute to a truly representative cultural psychiatry. These and related issues are analyzed using a framework that centers on mental health research but includes ideas from social medicine, political economy, and social evolution.

Concurrent Validity of the DIS: Experience With Psychiatric Patients in Mexico City

The Diagnostic-Interview Schedule (DIS) is an instrument useful for cross-cultural studies and for research service delivery, therefore a study of the reliability and concurrent validity in Mexico was carried out. Interrater reliability showed intraclass correlation coefficient (ICC) values of .89 among lay interviewers. The DSM-III syndrome checklist was elicited as the clinical diagnostic measure for concurrent validity. hnzterrater reliability among clinicians showed ICC values ranging from .64 to .92. For the concurrent validity study a minimum quota of 10 patients for each diagnosis was sought. The final sample included 55 inpatients and 94 outpatients interviewed independently. Sensitivity as a whole was low, ranging from .08 to .53; specificity ranged from .80 to .99; kappa agreement ranged from -.02 to .60; Yules' Y ranged from -.05 to .81. Validity indices were higher on diagnostic categories on which the flow-chart is simpler, suggesting that the memorylcognition process is a factor that attenuates reliability and face validity assessments. Comparisons with three studies using the Spanish DIS are discussed as well as reasons for discrepancies.

The long-term psychological effect of fatal accidents at sea on survivors: a cross-sectional study of North-Atlantic seamen

OBJECTIVE

This study aimed to ascertain whether disasters at sea had an enduring traumatic effect on psychological functioning, accident proneness, and on their interest to continue working at sea.

METHOD

Crew members of selected sea-disasters were contacted. The chosen disasters were of differing severity and in some cases fatalities had occurred. The disasters had taken place on average 8 years previously. Those who agreed to participate were interviewed in a semi-structured interview. They also answered the CIDI; DIS; GHQ-30; IES, and PTSS-10. One hundred-and-twelve seamen who had been in disasters were compared with a comparison group consisting of 59 peers who had not been in a disaster.

RESULTS

Survivors of fatal disasters experienced more long-lasting negative effects than did others where lives were not lost. They had more frequently unpleasant intrusive thoughts on the IES (p < 0.01) compared with their peers. On the DIS, they also more frequently experienced heightened arousal (p < 0.001), sleep problems (p < 0.01), and nightmares (p < 0.01). The duration of PTSD symptoms from the time of the disaster was on average 18 months. Over 33% of the disaster group had experienced some PTSD symptoms within the past 12 months. Disaster survivors had not quit seamanship as frequently as non-disaster seamen.

CONCLUSION

The most severe and long-lasting symptoms were found among those who had been in disasters where one or more crew members had perished. Loss of life in disasters therefore seems significant in the process of creating or extending the endurance of symptoms of psychological vulnerability.

Depression and anxiety in labor migrants and refugees--a systematic review and meta-analysis

Prevalence rates of depression and anxiety among migrants (i.e. refugees, labor migrants) vary among studies and it's been found that prevalence rates of depression and anxiety may be linked to financial strain in the country of immigration. Our aim is to review studies on prevalence rates of depression and/or anxiety (acknowledging that Post-traumatic Stress Disorder (PTSD) is within that class of disorders), and to evaluate associations between the Gross National Product (GNP) of the immigration country as a moderating factor for depression, anxiety and PTSD among migrants. We carried out a systematic literature review in the databases MEDLINE and EMBASE for population based studies published from 1990 to 2007 reporting prevalence rates of depression and/or anxiety and or PTSD according to DSM- or ICD- criteria in adults, and a calculation of combined estimates for proportions using the DerSimonian-Laird estimation. A total of 348 records were retrieved with 37 publications on 35 populations meeting our inclusion criteria. 35 studies were included in the final evaluation. Our meta-analysis shows that the combined prevalence rates for depression were 20 percent among labor migrants vs. 44 percent among refugees; for anxiety the combined estimates were 21 percent among labor migrants vs. 40 percent among (n=24,051) refugees. Higher GNP in the country of immigration was related to lower symptom prevalence of depression and/or anxiety in labor migrants but not in refugees. We conclude that depression and/or anxiety in labor migrants and refugees require separate consideration, and that better economic conditions in the host country reflected by a higher GNP appear to be related to better mental health in labor migrants but not in refugees.

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.

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.

Inter-rater and test-retest reliability of the Spanish language version of the eating disorder examination interview: clinical and research implications

BACKGROUND

To examine the inter-rater and test-retest reliability of the Spanish Language version of the Eating Disorder Examination (S-EDE) in monolingual Latina women. Established measures are needed to study Latino groups, and short-term test-retest reliability findings are needed to provide context for clinical treatment and outcome studies.

METHODS

Inter-rater reliability (IRR) and short-term (5-14 days) test-retest reliability (TRR) of the S-EDE (using intraclass correlation coefficients [ICCs]) were examined in a non-clinical study group of 60 monolingual Latina women.

RESULTS

IRR was excellent for objective bulimic episodes (ICC = 0.99) but was modest for subjective bulimic episodes (ICC = 0.55). TRR was good for objective bulimic episodes (ICC = 0.79) but was unacceptable for subjective bulimic episodes (ICC = 0.22). IRR and TRR kappa coefficients (0.56 and 0.37, respectively) for identifying the presence or absence of objective bulimic episodes were modest. For the S-EDE subscales, both IRR (ICCs ranged from 0.80 to 0.98) and TRR (ICCs ranged from 0.67 to 0.90) were good to excellent.

CONCLUSIONS

These findings provide preliminary support for the reliability of the S-EDE for use with Latina women. The constructs of eating disorder psychopathology measured by the S-EDE subscales (restraint, eating concern, weight concern, and shape concern) and the core feature of binge eating (objective bulimic episodes) show high short-term consistency. The results for subjective bulimic episodes are consistent with previous studies that have questioned whether these eating behaviors are reliable indicators of eating disorders. Additional evaluation is needed with clinical groups.

Assessment of somatoform disorders: a review of strategies and instruments

We provide an overview of methods and instruments developed for the assessment of somatoform disorders. Four diagnostic purposes have been identified: (i) classification according to a diagnostic system; (ii) screening for probable cases; (iii) dimensional measurement of syndrome severity; and (iv) assessment of associated clinical features. Existing instruments designed for each of these strategies are described, including specifications of their psychometric properties, particular features, advantages and disadvantages. A conclusion of this review is that the currently existing 'family of assessment instruments' in the field of somatoform disorders should be used to improve the comparability of scientific findings in different cultures and settings.

The Spanish-Language Version of the Diagnostic Interview for DSM-IV personality disorders: development and initial psychometric evaluation of diagnoses and criteria

We describe the development of the Spanish-Language Version of the Diagnostic Interview for DSM-IV Personality Disorders (S-DIPD-IV). Initial descriptive (frequency and gender distribution of personality disorders [PDs]) and psychometric findings (inter-rater reliability of diagnoses, internal consistency, and criteria inter-relatedness) are reported based on administration of the S-DIPD-IV to 95 adult monolingual Hispanic patients. The S-DIPD-IV had adequate inter-rater reliability for most PD (mean kappa =.83). Except for the significantly greater proportion of males diagnosed with antisocial PD, no significant gender differences in the distribution of PD were observed. Within-category inter-relatedness of PD criteria was evaluated by coefficient alpha and mean intercriterion correlations (MIC). Between-category criteria overlap was evaluated by intercategory mean intercriterion correlations between all pairs of PD (ICMIC). For PD criteria, alpha ranged .36 to .99 (mean =.75, median =.81), MIC ranged .07 to .95 (mean = .36), and ICMIC ranged.09 to.45 (mean = .24). Six PD (borderline, antisocial, narcissistic, avoidant, obsessive-compulsive, and depressive) had no instances in which their criteria sets correlated higher with those of other PD than their own. Two PD (histrionic and dependent PD) had some instances of overlap, and four PD (paranoid, schizotypal, schizoid, and passive-aggressive) had pervasive overlap with other PD criteria sets. These findings suggest the utility of the S-DIPD-IV for assessing PD in Spanish-speaking Hispanic outpatients. Our initial findings for this patient group suggest that, except for antisocial PD in males, specific PD diagnoses are not differentially distributed by gender. Moreover, except for cluster A PD, the criteria for specific PD tend to be more highly correlated within than across PD. The S-DIPD-IV appears to have utility to facilitate PD research with Hispanic groups.

Are drunk-driving offenders referred for screening accurately reporting their drug use?

Several studies report that a substantial percentage of offenders arrested for impaired driving test positive for drugs of abuse besides alcohol. Current guidelines recommend screening offenders for both alcohol and other drug use, yet little is known about the accuracy of self-reports of drug use in this population. We compared drug abuse and dependence DSM-III-R diagnoses from an initial, court-ordered screening evaluation of 583 female and 495 male convicted drunk-driving offenders with diagnoses obtained via a voluntary, non-coerced interview 5 years later. At initial screening, fewer than 6% of offenders were diagnosed with drug abuse or dependence. Among offenders who did not receive an initial drug diagnosis, 28% subsequently reported having experienced drug use problems consistent with a retrospective diagnosis of drug abuse or dependence by the age at which they were screened. Half of those with a retrospective diagnosis of drug dependence reported their initial screening responses were "very accurate". We conclude that, although many drunk-driving offenders undergoing screening have diagnosable drug problems, a high proportion under-report their drug use. We suggest that certain modifications to screening procedures, such as urine drug screening, reducing barriers to treatment, and training counselors in motivational interviewing techniques, may increase accurate identification of drug use problems in this population.

Sociocultural change and health status among the Seri Indians of Sonora, Mexico

The influence of changes in sociocultural status on obesity, arterial blood pressure, and depression was examined in a cohort of 81 Seri Indians living in two communities in Sonora, Mexico. Residents of the less acculturated and modernized community, Desemboque, exhibited significantly higher waist circumference and prevalence of obesity than did residents of the more acculturated and modernized community of Punta Chueca. The prevalence of obesity was also significantly associated with low levels of acculturation and modernization, while the prevalence of clinically significant depressive symptoms was associated with low levels of modernization and household income. Lifestyle incongruity was a significant independent risk factor for body mass index and depressive symptom scores but not for arterial blood pressure. The results support the notion of a curvilinear relationship between health status and sociocultural change in which health status initially declines with increasing lifestyle incongruity but eventually improves with increasing acculturation, modernization, and income.

Case-finding for depression in primary care: a randomized trial

PURPOSE

Depression is a highly prevalent, morbid, and costly illness that is often unrecognized and inadequately treated. Because depression questionnaires have the potential to improve recognition, we evaluated the accuracy and effects on primary care of two case-finding instruments compared to usual care.

SUBJECTS AND METHODS

The study was conducted at three university-affiliated and one community-based medical clinics. Consecutive patients were randomly assigned to be asked a single question about mood, to fill out the 20-item Center for Epidemiologic Studies Depression Screen, or to usual care. Within 72 hours, patients were assessed for Diagnostic and Statistical Manual of Mental Disorders Third Revised Edition (DSM-III-R) disorders by an assessor blinded to the screening results. Process of care was assessed using chart audit and administrative databases; patient and physician satisfaction was assessed using Likert scales. At 3 months, depressed patients and a random sample of nondepressed patients were re-assessed for DSM-III-R disorders and symptom counts.

RESULTS

We approached 1,083 patients, of whom 969 consented to screening and were assigned to the single question (n = 330), 20-item questionnaire (n = 323), or usual care (n = 316). The interview for DSM-III-R diagnosis was completed in 863 (89%) patients; major depression, dysthymia, or minor depression was present in 13%. Both instruments were sensitive, but the 20-item questionnaire was more specific than the single question (75% vs 66%, P = 0.03). The 20-item questionnaire was less likely to be self-administered (54% vs 90%) and took significantly more time to complete (15 vs 248 seconds). Case-finding with the 20-item questionnaire or single question modestly increased depression recognition, 30/77 (39%) compared with 11/38 (29%) in usual care (P = 0.31) but did not affect treatment (45% vs 43%, P = 0.88). Effects on DSM-III-R symptoms were mixed. Recovery from depression was more likely in the case-finding than usual care groups, 32/67 (48%) versus 8/30 (27%, P = 0.03), but the mean improvement in depression symptoms did not differ significantly (1.6 vs 1.5 symptoms, P = 0.21).

CONCLUSIONS

A simple question about depression has similar performance characteristics as a longer 20-item questionnaire and is more feasible because of its brevity. Case-finding leads to a modest increase in recognition rates, but does not have consistently positive effects on patient outcomes.

Monash Interview for Liaison Psychiatry (MILP). Development, reliability, and procedural validity

The Monash Interview for Liaison Psychiatry (MILP) is a structured interview designed for use with patients who have physical and psychiatric comorbidity. Linked to a computerized diagnostic algorithm, the MILP is able to establish diagnoses according to DSM-III-R, International Classification of Diseases--10th Edition (ICD-10), and DSM-IV criteria, as well as a range of other criteria relevant to consultation-liaison psychiatry. Interrater reliability was assessed with 54 joint interviews, in which the mean kappa for agreement of items was 0.83 and of diagnoses was 0.68. Comparative procedural validity was tested against DSM-III-R decision-tree diagnoses, ICD-10 checklist diagnoses, and Structured Clinical Interview for DSM-III-R interview diagnoses on another sample of 54 patients. Mean kappas for these comparisons were 0.61, 0.56, and 0.31, respectively. As predicted, the MILP more fully covered the spectrum of somatizing disorders, compared with the other methods for establishing diagnoses.

Anxiety disorders: a result of long-term chronic fatigue--the psychiatric characteristics of the sufferers of Iceland disease

OBJECTIVE

In order to clarify the lifetime likelihood of developing psychiatric disorder following the Akureyri disease, we have investigated 55 well documented cases of the Akureyri disease.

MATERIALS AND METHODS

All participants were interviewed and diagnosed as to psychiatric disorders according to DSM-III.

RESULTS

Of the 55 subjects included in this analysis 53 were women. The mean age of the participants was 67.7 years. The most common problem was agoraphobia with panic attacks 12.7% (P < 0.0001); agoraphobia without panic attacks 21.8% (P < 0.0001); social phobia 14.5% (P < 0.001); simple phobia 18.1% (P < 0.05); schizophrenia 3.6% (P < 0.01); and alcohol dependence 5.4% (P < 0.05).

CONCLUSION

Prolonged chronic fatigue most commonly results in anxiety disorders. Following the infection, the more serious psychiatric disorders do not seem to play a major role in the long run.

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.

The Diagnostic Interview Schedule for Children (DISC-2.1) in Spanish: reliability in a Hispanic population

The reliability across time, informants and interviewers of the Spanish translation of the DISC-2.1 was tested on a Puerto Rican Hispanic sample using a test-retest design. Levels of reliability between clinic and community samples and between younger and older children were compared to explore the sources of low reliability for certain psychiatric disorders. Parents' reports tended to be more reliable than those of their children, although the difference was less obvious with older children. Reliability was generally higher for the externalizing disorders and when the second interviewer was a psychiatrist rather than a lay interviewer.

Experiences with a checklist for DSM-III-R in the Russian Federation and Belarus. A study about the interrater reliability and the concurrent validity of the Munich Diagnostic Checklist for DSM-III-R

The interrater reliability of the Munich Diagnostic Checklist (MDCL) was assessed in a small clinical sample and two population samples in the Russian Federation and Belarus. A team of Russian and Belarussian psychiatrists made DSM-III-R diagnoses, using the MDCL as the basis for a standardized interview. The interrater reliability was found to be satisfactory (kappa = 0.86 for case vs non-case distinction). In the population samples, the interviewing psychiatrist, in addition to making a DSM-III-R diagnosis, classified each respondent on a checklist of 11 clinical syndromes familiar to Russian psychiatry and made a severity rating. The overall concurrent validity indices based on the comparison of these diagnostic ratings were fairly high (kappa 0.48-0.82), suggesting considerable agreement between the DSM-III-R and traditional Russian diagnostic concepts.

The qualitative difference of visions and visual hallucinations: a comparison of a general-population and clinical sample

Our objective was to analyze the frequency and quality of visions in a general-population sample compared with those experienced among schizophrenics. A sample group from the general population (n = 862) was compared with a group of schizophrenic patients (n = 19). Significant and qualitative differences were found in visions experienced by schizophrenic patients compared with subjects in the population sample. Women were more likely to experience visions of relatives than were men. The general population most commonly experienced visions of people, whereas schizophrenics were more likely to experience other phenomena. A qualitative difference thus exists in the type of visions experienced by schizophrenics compared with visions experienced by subjects from the general public.

Reliability and validity studies of the WHO--Composite International Diagnostic Interview (CIDI): a critical review

This paper reviews reliability and validity studies of the WHO - Composite International Diagnostic Interview (CIDI). The CIDI is a comprehensive and fully standardized diagnostic interview designed for assessing mental disorders according to the definitions of the Diagnostic Criteria for Research of ICD-10 and DSM-III-R. The instrument contains 276 symptom questions many of which are coupled with probe questions to evaluate symptom severity, as well as questions for assessing help-seeking behavior, psychosocial impairments, and other episode-related questions. Although primarily intended for use in epidemiological studies of mental disorders, it is also being used extensively for clinical and other research purposes. The review documents the wide spread use of the instrument and discusses several test-retest and interrater reliability studies of the CIDI. Both types of studies have confirmed good to excellent Kappa coefficients for most diagnostic sections. In international multicenter studies as well as several smaller center studies the CIDI was judged to be acceptable for most subjects and was found to be appropriate for use in different kinds of settings and countries. There is however still a need for reliability studies in general population samples, the area the CIDI was primary intended for. Only a few selected aspects of validity have been examined so far, mostly in smaller selected clinical samples. The need for further procedural validity studies of the CIDI with clinical instruments such as the SCAN as well as cognitive validation studies is emphasized. The latter should focus on specific aspects, such as the use of standardized questions in the elderly, cognitive probes to improve recall of episodes and their timing, as well as the role of order effects in the presentation of diagnostic sections.

Concordance between two measures of depression in the Hispanic Health and Nutrition Examination Survey

A concordance analysis between the Center for Epidemiologic Studies Depression Scale (CES-D) and the National Institute of Mental Health (NIMH) Diagnostic Interview Schedule (DIS) for current major depression was conducted using data from Cuban Americans and Puerto Rican respondents to the Hispanic Health and Nutrition Examination Survey (HHANES). Overall agreement between the two depression measures was relatively high, which suggested that the CES-D might be appropriate as a first-stage screening instrument for community-based surveys of clinical depression. Female gender and indicators of social class (education, income, poverty index, and employment) were related to low specificity and low agreement. The estimated cutoff points of the CES-D that best predicted DIS current major depression were different between the two ethnic groups; 17 for Cuban Americans, and 20 for Puerto Ricans. A receiver operating characteristics (ROC) curve analysis revealed that the traditional method of defining CES-D cases by summing the scores for each item was superior to counting only the persistent symptoms, that is, those present nearly everyday.

An empirical comparison of diagnoses and reliabilities in ICD-10 and DSM-III-R

The psychiatric classification systems ICD-10 and DSM-III-R were compared by applying both sets of diagnostic criteria to the same sample of patients suffering from affective and psychotic disorders. Four independent raters assessed diagnoses according to both systems to 100 written case records which had been prepared in a traditional, standard format. The International Diagnostic Checklists (IDCL) were employed to rate relevant psychopathological signs and symptoms and to apply diagnostic decision rules. The results showed that ICD-10 yielded a generally higher reliability for all main disorders except for bipolar disorder. Overall reliability was kappa = 0.53 for diagnoses according to DSM-III-R and 0.59 for diagnoses according to ICD-10. Agreement was best for affective disorders, moderate for schizophrenia and inacceptable for schizoaffective disorder. Insufficient boundaries were found in both systems between schizoaffective disorder on one side and schizophrenia and bipolar disorder on the other side. The different duration criteria for schizophrenia of six months in DSM-III-R and one month in ICD-10 tend to have considerable consequences for frequency rates of schizophrenia in a typical clinical setting.

Routine psychiatric examinations guided by ICD-10 diagnostic checklists (International Diagnostic Checklists)

A systematic assessment of psychiatric diagnoses according to the new classification system ICD-10 can be guided and enhanced by the International Diagnostic Checklists (IDCL). This instrument was developed and evaluated primarily for use in routine clinical care. It consists of 30 separate lists in pocket form, each assigned to a specific disorder and allowing immediate and operationalized diagnostic decisions (without the need of computer assistance). Personality disorders are covered by a separate 12-page booklet (IDCL-P). Examples of the checklists are given together with possible areas of application. First studies have indicated good clinical practicability and satisfactory to excellent diagnostic reliability.

Pain and pain problems among subjects with systemic lupus erythematosus in Iceland

This population study includes the majority of all systemic lupus erythematosus (SLE) patients in Iceland (n = 65). The study lists various self-rated pain descriptions both from a 54-item pain questionnaire and from the somatisation section of the Diagnostic Interview Schedule (DIS). Results show SLE patients to have significantly more joint and chest pain than does another patient group; to use analgesics more frequently; to have been in hospital more often during the past 10 years and to believe they know the reason for their pain. Also listed are factors that patients have found to increase and decrease SLE pain.

Limitation of the Mini-Mental State Examination for the detection of amnesia

The present study demonstrates the limitation of the Mini-Mental State Examination (MMSE) for detecting the amnestic syndrome. Although neuropsychological testing yielded severe memory deficits in all of the 11 amnesic patients tested, six of the patients obtained total MMSE scores above the standard cutoff score of 24. Further, only six patients completely failed the MMSE recall item, and three patients performed errorlessly on this item. Results from one postencephalitic patient are presented in detail. She performed the serial sevens task very quickly and subsequently recalled all three of the to-be-remembered words. Her performance on other memory tests confirmed that a longer retention interval than that provided by the MMSE is necessary to elicit her memory disorder.

Why discrepancies exist between structured diagnostic interviews and clinicians' diagnoses

The authors employed empirical methods to study the causes of discrepancies between clinicians' and epidemiologists' diagnoses of "cases" from the general population within the homogeneous DSM-III/DIS system. Four interviewers conducted 139 interviews using the DIS, while psychiatrists completed a DSM-III checklist, after which they could then ask any questions they wanted. All kappas exceeded 0.58. Meetings were subsequently organized with all participating psychiatrists in order to point out reasons for discrepancies between DIS diagnoses and clinical judgement. The authors came to the following conclusions: (1) DSM-III ambiguities led to discrepancies, especially when reference periods were not specified. (2) Discrepancies arose when cases were difficult: symptoms pertaining to different diagnoses or multiple diagnoses and the fact that clinicians could use volunteered comments, while interviewers were obliged to keep strictly to the schedule, contributed to discrepancies. (3) Other approaches, such as CIDI for anxiety and DISSA for depression, could improve DIS performances.

A comparison of two computer-administered versions of the NIMH Diagnostic Interview Schedule

This study compared three versions of the NIMH Diagnostic Interview Schedule (DIS): "traditional" interviewer-administered DIS; computer-administered DIS (subject interacting alone with computer); computer-prompted DIS (interviewer using computer program as a guide). Kappas for 20 diagnoses ranged from .15 to .94, and averages for the three method pairs ranged from .57 to .64, which are comparable to other DIS reliability studies. Agreement between pairs of methods were comparable. Subjects' attitudes toward the computer interview were positive. While they felt they could better describe their feelings and ideas to a human, they found the computer contact less embarrassing. Overall, subjects had no preference for one method over another. Measures of social desirability and deviant response biases were correlated with diagnostic results. Reading ability did not affect subject's ability to respond to the DIS, although subjects with lower reading levels preferred the computer interview more.

A cross-cultural adaptation of a psychiatric epidemiologic instrument: the diagnostic interview schedule's adaptation in Puerto Rico

The advent of the use of structured interview schedules that generate psychiatric diagnoses in epidemiologic studies has promoted an intense interest in its cross-cultural use. However, the valid use of these instruments across cultures requires a careful adaptation process which goes beyond mere language translation. In this article the authors illustrate the application of a comprehensive cross-cultural adaptation model to both the translation into Spanish and the adaptation to the population of Puerto Rico of a widely used psychiatric epidemiologic research instrument: the Diagnostic Interview Schedule (DIS). The process aimed to ensure the development of a research instrument that is not only in correct Spanish and comprehensible for most Spanish-speaking people, but also culturally adapted to Puerto Rico's population. Various steps were taken (including bilingual committee, back-translation, instrument testing and diagnostic comparisons) to address cross-cultural validity in five important dimensions (i.e., semantic, technical, content, criterion and conceptual equivalence). The result is an interview schedule that is not only linguistically and culturally adequate for the targeted population but also includes elements which can contribute to the development of the instrument both in its original English language and in its translated versions.

Comparison of Diagnostic Interview Schedule to psychiatrist diagnoses of alcohol use disorder in psychiatric inpatients

This study provides data about the extent of alcohol use disorders among general adult psychiatric inpatients. The accuracy of alcohol use disorder diagnoses given by the lay-administered Diagnostic Interview Schedule (DIS) and by staff psychiatrists, as compared to each other, was investigated. From consecutive admissions to a private psychiatric hospital, 55 patients with alcohol use disorders were identified by trained research assistants using the DIS (n = 162). A comparison of DIS diagnoses to clinicians' diagnoses revealed that 66 patients (40.7% of all admissions) were given an alcohol diagnosis by the DIS or clinician, 35 patients (21.6%) by DIS and clinician, 20 (12.3%) by DIS only, and 11 (6.8%) by clinician only. The two diagnostic approaches were also compared using several accuracy measures (sensitivity and specificity ratios, percentage of agreement, and kappa). With psychiatrists' diagnoses as reference, the DIS sensitivity ratio was 76 and specificity ratio 83. There were 12.3% false positive and 6.8% false negative diagnoses assigned by the DIS. Kappa was .56 and percentage of agreement 80.9%. Recomputing accuracy measures for the psychiatrist, using the DIS as the reference, clinician assessment sensitivity was 64 and specificity 90. Compared to each other, the DIS "overdiagnosed" and the staff psychiatrists "underdiagnosed" by about 1 in 20 cases. Among those alcohol use diagnoses upon which both clinician and DIS agreed, alcohol abuse was the predominant diagnosis. Among all patients with an alcohol diagnosis, the main nonsubstance abuse diagnoses (as assigned by the clinician) were: major depressive, dysthymic, bipolar, schizophrenic, and personality disorders.

Responses to Depression Scale items among Mexican-Americans and non-Hispanic whites

This study examined two possible patterns of ethnic differences in responses to Center for Epidemiologic Studies Depression scale items: isolated differences in relatively disparate items and consistent differences in conceptually related items. Data were from randomly selected household residents (4,222 Mexican-Americans, 1,063 non-Hispanic Whites). The most common symptoms reflected lack of positive affect; least common were crying, feelings of failure, and feeling disliked. Mexican-Americans were more likely than non-Hispanic Whites to report symptoms that reflect lack of positive affect, which suggests possible limitations on this dimension's cross-cultural validity. U.S.-born Mexican-Americans reported more somatic and negative affect symptoms than did the Mexican-born, which suggests an overall immigration difference in depressed mood.

Reliability of checklist-guided diagnoses for DSM-IIIR affective and anxiety disorders

The test-retest reliability of DSM-IIIR diagnoses for affective and anxiety disorders was determined under clinical routine conditions in a psychiatric outpatient department. The sample consisted of 60 patients, and the Munich Diagnostic Checklists (MDCL) were administered for diagnostic evaluation and classification. Each subject was independently examined by two of four participating diagnosticians (two psychiatrists, two psychologists). Acceptably high levels of agreement were indicated by several statistics (including kappa) for most disorders. Reliability was analyzed for diagnoses, subclassifications, and symptoms. Reduced agreement was found only for dysthymia, agoraphobia, and social phobia. Major causes were information variance and weaknesses of operationalization. Overall results were satisfactory when compared with other reliability studies.

Phobia: prevalence and risk factors

This article is the presentation of the main phobia data from the Epidemiologic Catchment Area (ECA) program, with a sample size of n = 18.571. Work on this article was initiated in 1981 at the beginning of the ECA study, but publication has been delayed a decade. Phobias are determined from information from the Diagnostic Interview Schedule (DIS), classified according to DSM III. Phobias are found to be the most common psychiatric disorder in the community, more common than major depression or alcohol abuse or dependence in the month prior to interview. The one month prevalence is between 4.0 and 11.1%, with the estimated prevalence in the United States being 6.2%. There were nine community surveys of the prevalence of phobia that pre-dated the ECA studies, which found a wide range of prevalence rates from 1.2% to 26.1%. By far the strongest risk factor associated with phobias is the presence of another psychiatric disorder. Prevalence rates of simple phobia and agoraphobia are found in the ECA studies to be significantly higher in women; social phobia, which is less prevalent, has no significant sex difference. The prevalence rates are higher in younger age groups, and in those with low socioeconomic status (SES). The onset of phobias occurs primarily in the childhood or teenage years, and they tend to be chronic conditions. Less than a quarter of phobics receive treatment.

Spiritism in Puerto Rico. Results of an island-wide community study

Using data from the first community-based, epidemiological survey of Puerto Rico, this paper examines the current prevalence of use of spiritist healers by Puerto Ricans, the role of spiritism in the provision of mental health services, and the association between spiritism and psychiatric disorders and symptoms. Those who visit spiritists were found to be more likely to work outside the home, to have a low family income, to have sought help for emotional problems from mental health professionals, and to have mild symptoms of depression.

Using the CES-D scale to screen for depression and anxiety: effects of language and ethnic status

The purpose of this report is to present data on the effects of language (English/Spanish) and ethnic status (white/non-Hispanic or Mexican origin) on the ability of the Center for Epidemiologic Studies Depression (CES-D) scale to detect cases of clinical depression and generalized anxiety identified using the Diagnostic Interview Schedule (DIS) in psychiatric treatment settings. The agreement between the CES-D scale and the DIS diagnoses of major depressive disorder (MDD) and generalized anxiety disorder (GAD) was poor, especially among Mexican-origin patients interviewed in Spanish. Multiple regression analysis revealed that the CES-D scale was positively associated with MDD in all groups. In addition, GAD also was associated with the CES-D scale in Anglos and English-speaking Mexican-Americans but not in Spanish-speaking Mexican-Americans.

Socioeconomic status (SES) and psychiatric disorders. Are the issues still compelling?

One of the most consistent findings in psychiatric epidemiology prior to 1980 has been that socioeconomic status (SES) was inversely related to the recent prevalence of a variety of important types of disorder. The findings raised and re-raised major issues about the role of adversity in these disorders. In recent years, however, research interest in these issues has been declining. At the same time, marked changes have been taking place in the case identification and diagnostic procedures available for epidemiological research. In this paper, I inquire into whether these changes in diagnostic concepts and methods have led to a change in the "facts" that gave rise to the issues about the role of SES. I rely particularly on results from our on-going epidemiological research in Israel and from the National Institute of Mental Health (NIMH) Epidemiological. Catchment Area (ECA) studies in the United States, reevaluate the shift away from research on the role of SES, and offer suggestions for future research.

Affective, substance use, and anxiety disorders in persons with arthritis, diabetes, heart disease, high blood pressure, or chronic lung conditions

The authors estimated the sex- and age-adjusted prevalence of affective, substance use, and anxiety disorders in persons in a general population sample who identified themselves as having arthritis, diabetes, heart disease, high blood pressure, chronic lung disease, or no chronic medical conditions. Persons who reported ever having arthritis, heart disease, chronic lung disease, or high blood pressure had a significantly increased adjusted prevalence of each of the three groups of lifetime psychiatric disorders, relative to a no-chronic conditions comparison group (each p less than 0.05). Persons who ever had diabetes had an increased adjusted prevalence of lifetime affective and anxiety but not substance use disorder. Persons with current (i.e., active) arthritis, heart disease, or high blood pressure had a significantly increased adjusted prevalence of recent (6-month) anxiety disorder, whereas those with current chronic lung disease had an increased adjusted prevalence of recent affective and substance use but not anxiety disorder.

Major depression and the NIMH Diagnostic Interview Schedule: validation in medically ill hospitalized patients

The authors validate the usefulness of the Diagnostic Interview Schedule (DIS) in prevalence studies of major depression (MD) in medically ill male veterans. The affective disorders portion of the DIS was administered by a trained interviewer to a representative sample of 408 medically-ill hospitalized patients (75% over age 70). Using a standardized handscoring method for the DIS, the patients were categorized as having or not having MD. Using a two-stage design, sixty-nine patients scoring above a cutoff score on a self-rated depression scale were referred for blind evaluation by a psychiatrist. The psychiatrist made a clinical diagnosis of MD using a standard checklist of DSM-III criteria. The DIS correctly diagnosed MD in 78 percent (14/18) of older and 69 percent (9/13) of younger patients, and correctly ruled out the disorder in 65 percent (15/23) of older and 67 percent (10/15) of younger patients; the kappa statistic of agreement was .40 in older and .36 in younger patients.

Psychiatric epidemiology

In this paper, some of the basic concepts of epidemiology are presented. Their applicability to psychiatry is outlined, and the definitions of terms are given. Various methods of epidemiological investigation are discussed. The background for the development of recent prevalence studies, including advances in diagnostic methods and case ascertainment, are given in some detail, and some recent results are presented. Additional areas of investigation are discussed more briefly.

Male/female differences in alcohol-related problems: alcohol rehabilitation patients

Differences in male and female prevalence of drinking problems have been studied previously. However, few studies have focused on gender differences in a range of alcohol-related problems in individuals identified as dysfunctional drinkers. We analyzed such differences in 299 alcohol patients who met DSM-III criteria for alcohol abuse/dependence. Male and female patients differed significantly on heavy consumption patterns and negative social experiences resulting from drinking. However, no significant differences were found in loss of control, dependence, or health problems. The similarities were obtained even though females had been problem drinkers for a shorter number of years. Implications of these results are discussed.

Procedural validity of standardized symptom questions for the assessment of psychotic symptoms--a comparison of the DIS with two clinical methods

The study examines to what degree well-documented present and life-time psychotic symptoms in a group of former psychiatric inpatients are ascertained when using the Diagnostic Interview Schedule (DIS). The Inpatient Multidimensional Psychiatric Scale (IMPS) and the Manual for the Assessment and Documentation of Psychopathology/Diagnostische Sichtlochkartei (AMDP/DiaSika) Interview-Checklist approach were used for the "clinical" evaluations of symptoms. The results indicate fair concordance between the two clinical approaches and the DIS with regard to the presence of any delusional or hallucination symptoms. Low to poor agreement was found in the assessment of many of the rather specific hallucinations and delusions. Generally, the concordance found was higher when compared to the more clinical AMDP/DiaSiKa approach than to the IMPS. More detailed comparisons with diagnostic subgroups of schizophrenic and schizoaffective patients substantiated the findings in the overall sample. Overall it was reconfirmed that the DIS approach is limited to those patients who are cooperative and at least partly remitted.

Design and field methods of the Edmonton survey of psychiatric disorders

This paper describes aspects of the study design and field methods used in a survey of psychiatric disorders carried out in Edmonton, Alberta, Canada. Between January 1983 and May 1986, information was gathered on 3,258 community residents using the Diagnostic Interview Schedule and the General Health Questionnaire - 30 item version. The survey had a response rate of 71.6%. The nature of the sampling strategy used, features of the study instruments chosen, the selection and training of interviewers, and the approach to data analysis are briefly described.

Suicide ideation and attempts in Hispanics and non-Hispanic whites: demographic and psychiatric disorder issues

This study examined the lifetime prevalence of suicide ideation and attempts in a community sample of 1,425 Hispanics and 1,309 non-Hispanic whites. The relationship between psychiatric disorder (as assessed by the Diagnostic Interview Schedule, or DIS) and suicide ideation and attempts was also examined. Fewer Hispanics reported suicide ideation (8.8% vs. 18.9%; p less than .001) and suicide attempts (3.2% vs. 5.1%; p less than .001) than non-Hispanic whites. More women of both ethnic groups reported suicide attempts than men of either ethnic group (p less than .001). Disrupted marital bonds were typically associated with higher rates of ideation and attempts. Individuals with any DIS diagnosis were more than four times as likely to think about killing themselves (p less than .01) and more than seven times as likely to attempt suicide (p less than .01) as those without a psychiatric disorder.

Prevalence of suicide attempts in a Mexican-American population: prevention implications of immigration and cultural issues

Self-reported suicide ideation and suicide attempts were examined among 2,393 Mexican-Americans (706 born in Mexico, 538 born in the United States) and non-Hispanic whites (1,149 born in the United States). Mexican-Americans born in Mexico reported significantly lower age- and gender-adjusted lifetime rates of suicide thoughts (4.5%, 2.7-6.3%) than Mexican-Americans born in the United States (13.0%, 10.0-15.9%), who reported significantly lower rates than non-Hispanic whites born in the United States (19.2%, 17.4-21.0%). Adjusted rates of suicide attempt were lowest among Mexican-Americans born in Mexico (1.6%, 0.6-2.6%) and higher among both Mexican-Americans (4.8%, 2.4-7.2%) and non-Hispanic whites (4.4%, 3.4-5.4%) born in the United States. Rates were not affected by degree of acculturation when immigration status was controlled. High schools and the Catholic church are suggested as sites for programs designed to prevent suicide and suicide attempts among Mexican-Americans.