The ICD-10 clinical field trial for mental and behavioral disorders: results in Canada and the United States

Discrepancies in ICD-9/ICD-10-based codes used to identify three common diseases in cancer patients in real-world settings and their implications for disease classification in breast cancer patients and patients without cancer: a literature review and descriptive study

Background

International Classification of Diseases, Ninth/Tenth revisions, clinical modification (ICD-9-CM, ICD-10-CM) are frequently used in the U.S. by health insurers and disease registries, and are often recorded in electronic medical records. Due to their widespread use, ICD-based codes are a valuable source of data for epidemiology studies, but there are challenges related to their accuracy and reliability. This study aims to 1) identify ICD-9/ICD-10-based codes reported in literature/web sources to identify three common diseases in elderly patients with cancer (anemia, hypertension, arthritis), 2) compare codes identified in the literature/web search to SEER-Medicare's 27 CCW Chronic Conditions Algorithm ("gold-standard") to determine their discordance, and 3) determine sensitivity of the literature/web search codes compared to the gold standard.

Methods

A literature search was performed (Embase, Medline) to find sources reporting ICD codes for at least one disease of interest. Articles were screened in two levels (title/abstract; full text). Analysis was performed in SAS Version 9.4.

Results

Of 106 references identified, 29 were included that reported 884 codes (155 anemia, 80 hypertension, 649 arthritis). Overall discordance between the gold standard and literature/web search code list was 32.9% (22.2% for ICD-9; 35.7% for ICD-10). The gold standard contained codes not found in literature/web sources, including codes for hypertensive retinopathy/encephalopathy, Page Kidney, spondylosis/spondylitis, juvenile arthritis, thalassemia, sickle cell disorder, autoimmune anemias, and erythroblastopenia. Among a cohort of non-cancer patients (N=684,376), the gold standard identified an additional 129 patients with anemia, 33,683 with arthritis, and 510 with hypertension compared to the literature/web search. Among a cohort of breast cancer patients (N=303,103), the gold standard identified an additional 59 patients with anemia, 10,993 with arthritis, and 163 with hypertension. Sensitivity of the literature/web search code list was 91.38-99.96% for non-cancer patients, and 93.01-99.96% for breast cancer patients.

Conclusion

Discrepancies in codes used to identify three common diseases resulted in variable differences in disease classification. In all cases, the gold standard captured patients missed using the literature/web search codes. Researchers should use standardized, validated coding algorithms when available to increase consistency in research and reduce risk of misclassification, which can significantly alter the findings of a study.

The efficacy and safety of acupuncture combined with language training for motor aphasia after stroke: study protocol for a multicenter randomized sham-controlled trial

BACKGROUND

Motor aphasia after stroke is a common and intractable complication of stroke. Acupuncture and language training may be an alternative and effective approach. However, the efficacy of acupuncture and language training for motor aphasia after stroke has not been confirmed. The main objectives of this trial are to evaluate the effectiveness and safety of acupuncture and low-intensity, low-dose language training in treating ischemic motor aphasia after stroke from 15 to 90 days.

METHODS

This is a multicenter randomized sham-controlled clinical trial. We will allocate 252 subjects aged between 45 and 75 years diagnosed with motor aphasia after stroke with an onset time ranging from 15 to 90 days into two groups randomly in a 1:1 ratio. Patients in the experimental group will be treated with "Xing-Nao Kai-Qiao" acupuncture therapy plus language training, and those in the control group will be treated with sham-acupoint (1 cun next to the acupoints) acupuncture therapy plus language training. All the patients will be given acupuncture and language training for 6 weeks, with a follow-up evaluation 6 weeks after the end of the treatment and 6 months after the onset time. The patients will mainly be evaluated using the Western Aphasia Battery and Chinese Functional Communication Profile, and the incidence of treatment-related adverse events at the 2nd, 4th, and 6th weeks of treatment will be recorded. The baseline characteristics of the patients will be summarized by group, the chi-squared test will be used to compare categorical variables, and repeated measures of analysis of variance or a linear mixed model will be applied to analyze the changes measured at different time points.

DISCUSSION

The present study is designed to investigate the effectiveness and safety of traditional acupuncture therapy and language training in ischemic motor aphasia after stroke and explore the correlation between the treatment time and clinical effect of acupuncture. We hope our results will help doctors understand and utilize acupuncture combined with language training.

TRIAL REGISTRATION

ChiCTR ChiCTR1900026740 . Registered on 20 October 2019.

Reliability and clinical utility of the chronic pain classification in the 11th Revision of the International Classification of Diseases from a global perspective: results from India, Cuba, and New Zealand

ABSTRACT

Chronic pain affects 1 in 5 persons and contributes substantially to the global burden of disease. The 11th Revision of the International Classification of Diseases (ICD-11) includes a comprehensive classification of chronic pain. The aim of this ecological implementation field study was to evaluate the classification's interrater reliability and clinical utility in countries with different income levels. The study was conducted in 4 pain clinics in Cuba, India, and New Zealand. Twenty-one clinicians used the ICD-11 to diagnose and code n = 353 patients with chronic pain. Of these, 111 were assessed by 2 clinicians, and Fleiss' kappa was calculated to establish interrater reliability for any diagnosis assigned to ≥15 patients. The clinicians rated the clinical utility of all diagnoses. The interrater reliability could be calculated for 11 diagnoses. It was substantial for 10 diagnoses and moderate for 1 (kappa: 0.596-0.783). The mean clinical utility of the ICD-11 chronic pain diagnoses was rated as 8.45 ± 1.69/10. Clinical utility was rated higher for ICD-11 than for the commonly used classification systems (P < 0.001, η2 = 0.25) and differed between all centers (P < 0.001, η2 = 0.60). The utility of the ICD-11 diagnoses was rated higher than the commonly used diagnoses in Dunedin and Havana, and no difference was found in Kolkata and Hyderabad. The study showed the high interrater reliability of the new chronic pain diagnoses. The perceived clinical utility of the diagnoses indicates their superiority or equality compared with the classification systems currently used in pain clinics. These results suggest the global applicability of the classification in specialized pain treatment settings.

Evaluation of the International Classification of Diseases-11 chronic pain classification: study protocol for an ecological implementation field study in low-, middle-, and high-income countries

Introduction

The purpose of the present ecological implementation field study is to evaluate the new classification of chronic pain as implemented in the 11th revision of the International Classification of Diseases (ICD-11) with regard to clinical utility and interrater reliability. To evaluate the classification in a variety of settings, the study will be implemented in different low-, middle-, and high-income countries.

Methods

The study will be conducted in 2 phases. Participating pain clinics of the first phase are located in India, Cuba, and New Zealand. Two or more clinicians per study center will use the ICD-11 classification of chronic pain to diagnose 75 to 100 consecutive new chronic pain patients per center. A structured classification algorithm will guide the diagnostic process. Interrater reliability will be analyzed for the first 20 consecutive new patients per center. Before the coding, a training workshop will introduce the clinicians to the new classification. The main outcome parameter of the ecological implementation field study is clinical utility. More specifically, this entails clinical utility ratings, interrater reliability, as well as the exhaustiveness of the classification and the mutual exclusiveness of the new chronic pain categories. Differences between countries with different cultural backgrounds and income levels will be analyzed.

Perspective

The ecological implementation field study presented here will be implemented in several countries with different income levels. This increases the generalizability of the results and allows initial insight into the global applicability of the new chronic pain classification. A positive evaluation can facilitate the implementation of the classification.

Use and validity of child neurodevelopment outcome measures in studies on prenatal exposure to psychotropic and analgesic medications - A systematic review

In recent years there has been increased attention to child neurodevelopment in studies on medication safety in pregnancy. Neurodevelopment is a multifactorial outcome that can be assessed by various assessors, using different measures. This has given rise to a debate on the validity of various measures of neurodevelopment. The aim of this review was twofold. Firstly we aimed to give an overview of studies on child neurodevelopment after prenatal exposure to central nervous system acting medications using psychotropics and analgesics as examples, giving special focus on the use and validity of outcome measures. Secondly, we aimed to give guidance on how to conduct and interpret medication safety studies with neurodevelopment outcomes. We conducted a systematic review in the MEDLINE, Embase, PsycINFO, Web of Science, Scopus, and Cochrane databases from inception to April 2019, including controlled studies on prenatal exposure to psychotropics or analgesics and child neurodevelopment, measured with standardised psychometric instruments or by diagnosis of neurodevelopmental disorder. The review management tool Covidence was used for data-extraction. Outcomes were grouped as motor skills, cognition, behaviour, emotionality, or "other". We identified 110 eligible papers (psychotropics, 82 papers, analgesics, 29 papers). A variety of neurodevelopmental outcome measures were used, including 27 different psychometric instruments administered by health care professionals, 15 different instruments completed by parents, and 13 different diagnostic categories. In 23 papers, no comments were made on the validity of the outcome measure. In conclusion, establishing neurodevelopmental safety includes assessing a wide variety of outcomes important for the child's daily functioning including motor skills, cognition, behaviour, and emotionality, with valid and reliable measures from infancy through to adolescence. Consensus is needed in the scientific community on how neurodevelopment should be assessed in medication safety in pregnancy studies. Review registration number: CRD42018086101 in the PROSPERO database.

Interictal psychiatric comorbidities of drug-resistant focal epilepsy: Prevalence and influence of the localization of the epilepsy

Psychiatric comorbidities are 2 to 3 times more frequent in patients with epilepsy than in the general population. This study aimed to prospectively assess the following: (i) the prevalence of specific and nonspecific interictal psychiatric comorbidities in a population of patients with drug-resistant focal epilepsy and (ii) the influence of epilepsy lateralization and localization on these psychiatric comorbidities. In this prospective monocentric study, we collected demographic data, characteristics of the epilepsy, interictal psychiatric comorbidities, mood, anxiety, and alexithymia dimensions. We used criteria from Diagnostic and Statistical Manual of Mental Disorders IV ( DSM IV) (Mini International Mental Interview (MINI)), diagnosis criteria for specific comorbidities, and validated mood and anxiety scales (general and specific for epilepsy). Among the 87 enrolled patients (39 males, 48 females), 52.9% had at least one psychiatric comorbidity. The most common comorbidity was anxiety disorder (28.7% according to the MINI, and 38.4% screening by the Generalized Anxiety Disorder 7 (GAD 7)). Mood disorders were the second most frequent psychiatric comorbidity: 21.8% of our patients had interictal dysphoric disorders (IDDs), 16.1% presented major depressive disorders according to the MINI, and 17.2% screening by the Neurological Disorders Depression Inventory for Epilepsy (NDDIE). Patients with temporal lobe epilepsy had a higher prevalence of psychiatric comorbidities than patients with extratemporal lobe epilepsy (p = 0.002), which is probably related to a higher rate of anxiety disorders in this subgroup (p = 0.012). Prevalence of psychiatric disorders prior to epilepsy in patients was higher in right- than in left-sided epilepsy (p = 0.042). No difference was found according to limbic involvement at seizure onset. Overall, this article highlighted a very high proportion of anxiety disorders in these patients with drug-resistant focal epilepsy and the necessity to systematically detect them and thus lead to a specific treatment.

Clinical utility of ICD-11 diagnostic guidelines for high-burden mental disorders: results from mental health settings in 13 countries

In this paper we report the clinical utility of the diagnostic guidelines for ICD-11 mental, behavioural and neurodevelopmental disorders as assessed by 339 clinicians in 1,806 patients in 28 mental health settings in 13 countries. Clinician raters applied the guidelines for schizophrenia and other primary psychotic disorders, mood disorders (depressive and bipolar disorders), anxiety and fear-related disorders, and disorders specifically associated with stress. Clinician ratings of the clinical utility of the proposed ICD-11 diagnostic guidelines were very positive overall. The guidelines were perceived as easy to use, corresponding accurately to patients' presentations (i.e., goodness of fit), clear and understandable, providing an appropriate level of detail, taking about the same or less time than clinicians' usual practice, and providing useful guidance about distinguishing disorder from normality and from other disorders. Clinicians evaluated the guidelines as less useful for treatment selection and assessing prognosis than for communicating with other health professionals, though the former ratings were still positive overall. Field studies that assess perceived clinical utility of the proposed ICD-11 diagnostic guidelines among their intended users have very important implications. Classification is the interface between health encounters and health information; if clinicians do not find that a new diagnostic system provides clinically useful information, they are unlikely to apply it consistently and faithfully. This would have a major impact on the validity of aggregated health encounter data used for health policy and decision making. Overall, the results of this study provide considerable reason to be optimistic about the perceived clinical utility of the ICD-11 among global clinicians.

Impulsivity and Cluster B Personality Disorders

PURPOSE OF REVIEW

Impulsivity is a multifaceted construct and an important personality trait in various mental health conditions. Among personality disorders (PDs), especially cluster B PDs are affected. The aims of this review are to summarize the relevant findings of the past 3 years concerning impulsivity in cluster B PDs and to identify those subcomponents of self-reported impulsivity and experimentally measured impulse control that are most affected in these disorders.

RECENT FINDINGS

All studies referred to antisocial (ASPD) or borderline PD (BPD), and none were found for narcissistic or histrionic PD. In ASPD as well as BPD, self-report scales primarily revealed heightened impulsivity compared to healthy controls. In experimental tasks, ASPD patients showed impairments in response inhibition, while fewer deficits were found in delay discounting. BPD patients showed specific impairments in delay discounting and proactive interference, while response inhibition was less affected. However, after inducing high levels of stress, deficits in response inhibition could also be observed in BPD patients. Furthermore, negative affect led to altered brain activation patterns in BPD patients during impulse control tasks, but no behavioral impairments were found. As proposed by the DSM-5 alternative model for personality disorders, heightened impulsivity is a core personality trait in BPD and ASPD, which is in line with current research findings. However, different components of experimentally measured impulse control are affected in BPD and ASPD, and impulsivity occurring in negative emotional states or increased distress seems to be specific for BPD. Future research could be focused on measures that assess impulsive behaviors on a momentary basis as this is a promising approach especially for further ecological validation and transfer into clinical practice.

Interrater reliability of schizoaffective disorder compared with schizophrenia, bipolar disorder, and unipolar depression - A systematic review and meta-analysis

Schizoaffective disorder is a common diagnosis in clinical practice but its nosological status has been subject to debate ever since it was conceptualized. Although it is key that diagnostic reliability is sufficient, schizoaffective disorder has been reported to have low interrater reliability. Evidence based on systematic review and meta-analysis methods, however, is lacking. Using a highly sensitive literature search in Medline, Embase, and PsycInfo we identified studies measuring the interrater reliability of schizoaffective disorder in comparison to schizophrenia, bipolar disorder, and unipolar disorder. Out of 4126 records screened we included 25 studies reporting on 7912 patients diagnosed by different raters. The interrater reliability of schizoaffective disorder was moderate (meta-analytic estimate of Cohen's kappa 0.57 [95% CI: 0.41-0.73]), and substantially lower than that of its main differential diagnoses (difference in kappa between 0.22 and 0.19). Although there was considerable heterogeneity, analyses revealed that the interrater reliability of schizoaffective disorder was consistently lower in the overwhelming majority of studies. The results remained robust in subgroup and sensitivity analyses (e.g., diagnostic manual used) as well as in meta-regressions (e.g., publication year) and analyses of publication bias. Clinically, the results highlight the particular importance of diagnostic re-evaluation in patients diagnosed with schizoaffective disorder. They also quantify a widely held clinical impression of lower interrater reliability and agree with earlier meta-analysis reporting low test-retest reliability.

Variability in clinical diagnoses during the ICD-8 and ICD-10 era

AIMS

To explore whether the diagnostic homogeneity in a daily, routine clinical activity changed visibly over two historical periods (the ICD-8 and the ICD-10 era) across and within five psychiatric in-patient clinics.

METHODS

In this register study, we analyzed the discharge diagnoses from five university-affiliated departments of psychiatry in Denmark in two time periods: 1980-1985 (ICD-8) and 2001-2010 (ICD-10).

RESULTS

The synchronic inter-departmental diagnostic differences did not decrease in the ICD-10 era compared with ICD-8 era. Nor did the diachronic stability within each department become more homogeneous.

CONCLUSION

The diagnostic variability reflected by the diagnostic differences between the departments and by the diagnostic homogeneity within each department remained similar in the two historical periods with no evidence of an increased homogeneity of diagnostic habits after the introduction of the ICD-10.

LIMITATIONS

There is a myriad of variables that affects the diagnostic variability over time that we were not able to control.

Variant GADL1 and response to lithium therapy in bipolar I disorder

BACKGROUND

Lithium has been a first-line choice for maintenance treatment of bipolar disorders to prevent relapse of mania and depression, but many patients do not have a response to lithium treatment.

METHODS

We selected subgroups from a sample of 1761 patients of Han Chinese descent with bipolar I disorder who were recruited by the Taiwan Bipolar Consortium. We assessed their response to lithium treatment using the Alda scale and performed a genomewide association study on samples from one subgroup of 294 patients with bipolar I disorder who were receiving lithium treatment. We then tested the single-nucleotide polymorphisms (SNPs) that showed the strongest association with a response to lithium for association in a replication sample of 100 patients and tested them further in a follow-up sample of 24 patients. We sequenced the exons, exon-intron boundaries, and part of the promoter of the gene encoding glutamate decarboxylase-like protein 1 (GADL1) in 94 patients who had a response to lithium and in 94 patients who did not have a response in the genomewide association sample.

RESULTS

Two SNPs in high linkage disequilibrium, rs17026688 and rs17026651, that are located in the introns of GADL1 showed the strongest associations in the genomewide association study (P=5.50×10(-37) and P=2.52×10(-37), respectively) and in the replication sample of 100 patients (P=9.19×10(-15) for each SNP). These two SNPs had a sensitivity of 93% for predicting a response to lithium and differentiated between patients with a good response and those with a poor response in the follow-up cohort. Resequencing of GADL1 revealed a novel variant, IVS8+48delG, which lies in intron 8 of the gene, is in complete linkage disequilibrium with rs17026688 and is predicted to affect splicing.

CONCLUSIONS

Genetic variations in GADL1 are associated with the response to lithium maintenance treatment for bipolar I disorder in patients of Han Chinese descent. (Funded by Academia Sinica and others.).

Genome-wide association study of atypical psychosis

Atypical psychosis with a periodic course of exacerbation and features of major psychiatric disorders [schizophrenia (SZ) and bipolar disorder (BD)] has a long history in clinical psychiatry in Japan. Based upon the new criteria of atypical psychosis, a Genome-Wide Association Study (GWAS) was conducted to identify the risk gene or variants. The relationships between atypical psychosis, SZ and BD were then assessed using independent GWAS data. Forty-seven patients with solid criteria of atypical psychosis and 882 normal controls (NCs) were scanned using an Affymetrics 6.0 chip. GWAS SZ data (560 SZ cases and 548 NCs) and GWAS BD (107 cases with BD type 1 and 107 NCs) were compared using gene-based analysis. The most significant SNPs were detected around the CHN2/CPVL genes (rs245914, P = 1.6 × 10(-7)) , COL21A1 gene (rs12196860, P = 2.45 × 10(-7) ), and PYGL/TRIM9 genes (rs1959536, P = 7.73 × 10(-7) ), although none of the single-nucleotide polymorphisms exhibited genome-wide significance (P = 5 × 10(-8) ). One of the highest peaks was detected on the major histocompatibility complex region, where large SZ GWASs have previously disclosed an association. The gene-based analysis suggested significant enrichment between SZ and atypical psychosis (P = 0.01), but not BD. This study provides clues about the types of patient whose diagnosis lies between SZ and BD. Studies with larger samples are required to determine the causal variant.

Is depression simply a nonspecific response to brain injury?

Depressive disorders are among the most common ailments affecting humankind and some of the world's leading causes of medical disability. Despite being common, disabling and a major public health problem, the etiology of depression is unknown. Indeed, investigators have suggested that the causes of depression are multiple and multi-factorial. With these considerations in mind, in this article we examine the hypothesis that our inability to identify the causes of depressive disorders is because depression is a nonspecific epiphenomenon of brain injury or insult arising through multiple pathways.

Genome-wide association study of bipolar I disorder in the Han Chinese population

We report the first genome-wide association study in 1000 bipolar I patients and 1000 controls, with a replication of the top hits in another 409 cases and 1000 controls in the Han Chinese population. Four regions with most strongly associated single-nucleotide polymorphisms (SNPs) were detected, of which three were not found in previous GWA studies in the Caucasian populations. Among them, SNPs close to specificity protein 8 (SP8) and ST8 α-N-acetyl- neuraminide α-2,8-sialyltransferase (ST8SIA2) are associated with Bipolar I, with P-values of 4.87 × 10(-7) (rs2709736) and 6.05 × 10(-6) (rs8040009), respectively. We have also identified SNPs in potassium channel tetramerization domain containing 12 gene (KCTD12) (rs2073831, P=9.74 × 10(-6)) and in CACNB2 (Calcium channel, voltage-dependent, β-2 subunit) gene (rs11013860, P=5.15 × 10(-5)), One SNP nearby the rs1938526 SNP of ANK3 gene and another SNP nearby the SNP rs11720452 in chromosome 3 reported in previous GWA studies also showed suggestive association in this study (P=6.55 × 10(-5) and P=1.48 × 10(-5), respectively). This may suggest that there are common and population-specific susceptibility genes for bipolar I disorder.

Study of the correlation between psychiatric and psychological diagnoses in sample offenders

This study deals with the frequency with which expert psychiatrists and psychologists make structural or nosographic diagnoses within the context of expert assessment. Thus, the rates of concordance between psychiatrists and psychologists in both types of diagnoses will be assessed. To do so, the level of inter-observer agreement on diagnoses between 1990 and 2003 was studied retrospectively in France through psychiatric and psychological assessments of 505 male offenders. The assessment of the correlation rates was carried out using the Kappa coefficient. The results show a range of 0.55 to 0.71 in inter-observer (psychiatrists vs psychologists) agreement for structural diagnoses, and 0.51 to 0.89 for nosographic diagnoses. In addition, a marked correlation between psychiatrists and psychologists may be noted regarding abstention in both structural (k=66) and nosographic (k=73) diagnoses. In fact, recommendations are made for improvement in the consistency of offender assessment in the psycho-legal French context.

Schizophrenia, "just the facts" 4. Clinical features and conceptualization

Although dementia praecox or schizophrenia has been considered a unique disease entity for the past century, its definitions and boundaries have continued to vary over this period. At any given time, the changing concept of schizophrenia has been influenced by available diagnostic tools and treatments, related conditions from which it most needs to be distinguished, extant knowledge and scientific paradigms. There is significant heterogeneity in the etiopathology, symptomatology, and course of schizophrenia. It is characterized by an admixture of positive, negative, cognitive, mood, and motor symptoms whose severity varies across patients and through the course of the illness. Positive symptoms usually first begin in adolescence or early adulthood, but are often preceded by varying degrees of negative and cognitive symptomatology. Schizophrenia tends to be a chronic and relapsing disorder with generally incomplete remissions, variable degrees of functional impairment and social disability, frequent comorbid substance abuse, and decreased longevity. Although schizophrenia may not represent a single disease with a unitary etiology or pathogenetic process, alternative approaches have thus far been unsuccessful in better defining this syndrome or its component entities. The symptomatologic, course, and etio-pathological heterogeneity can usefully be addressed by a dimensional approach to psychopathology, a clinical staging approach to illness course, and by elucidating endophenotypes and markers of illness progression, respectively. This will allow an approach to the deconstruction of schizophrenia into its multiple component parts and strategies to reconfigure these components in a more meaningful manner. Possible implications for DSM-V and ICD-11 definitions of schizophrenia are discussed.

Relationships Among the Level of Response to Alcohol and the Number of Alcoholic Relatives in Predicting Alcohol-Related Outcomes

BACKGROUND

The low level of response (LR) to alcohol is related to a family history (FH) of alcohol use disorders (AUDs), and each predicts alcohol-related outcomes. Few studies have evaluated the interrelationships between the number of alcoholic relatives, LR, and a range of alcohol-related outcomes. This study tests the hypotheses that there will be an inverse relationship between LR and FH and that LR will be a better predictor of the maximum quantity of alcohol consumed.

METHODS

Data were extracted from personal interviews with 376 males from 20 years of follow-up in the San Diego Prospective Study. Level of response had been established at about age 20 through alcohol challenges in this population, about half of whom had at least one alcoholic relative. Face-to-face follow-ups with both the subjects and additional informants were carried out 10, 15, and 20 years later. These analyses used correlations and regressions to evaluate the relationship between the 2 major predictors (FH and LR) and 5 alcohol-related outcomes over 20 years of follow-up.

RESULTS

As predicted, the alcohol challenge-based LR correlated significantly with the number of alcoholic relatives (up to -0.17 for subjects with clearly high and low LR scores). Each of the 2 predictors correlated with the 5 outcomes, including the maximum quantity of alcohol consumed since original testing, maximum frequency, nondiagnostic alcohol-related problems, the number of 11 DSM-IV (Fourth Diagnostic and Statistical Manual of Mental Disorders) abuse and dependence items, and having developed alcohol abuse or dependence. In hierarchical regression analyses, LR contributed significantly to the prediction of all 5 outcomes, even when considered in the context of FH, with only LR predicting drinking quantity and frequency, but both items adding to the prediction of alcohol-related problems and diagnoses. These results were not affected by the intensity of usual drinking when LR had been measured at age 20.

CONCLUSIONS

Both FH and LR contributed to a range of alcohol-related outcomes, with LR alone significantly predicting maximum quantity and frequency in regression analyses.

Compulsive aspects of impulse-control disorders

Impulsivity and compulsivity have been considered opposite poles of a continuous spectrum, but their relationship seems to be more complex. Disorders characterized by impulsivity often have features of compulsivity and vice-versa. Impulse-control disorders (ICDs) are characterized by repetitive behaviors and impaired inhibition of these behaviors, suggesting a similarity to the frequently excessive, unnecessary, and unwanted rituals of obsessive-compulsive disorder (OCD). There are, however, important differences be-tween ICDs and OCD. The construct of compulsivity as related to ICDs and OCD warrants additional investigation to identify the similarities and differences and to examine the implications for prevention and treatment strategies.

Interrater Reliability, Prevalence, and Relation to ICD-10 Diagnoses of the Diagnostic Criteria for Psychosomatic Research in Consultation-Liaison Psychiatry Patients

The Diagnostic Criteria for Psychosomatic Research (DCPR) have been proposed by an international group of psychosomatic investigators as an operationalized tool for the assessment of psychological distress in medical patients. The aims of the present study were to evaluate interrater reliability, the distribution of DCPR syndromes, and their relationship with ICD-10 diagnostic categories. One hundred consecutive patients who were referred for psychiatric consultation in a university general hospital consented to assessment for DCPR syndromes as elicited in a joint interview conducted by two researchers. The results showed excellent interrater agreement, with kappa values for the 11 DCPR syndromes ranging from 0.69 to 0.97. More patients met criteria for one or more of the DCPR (87%) than for an ICD-10 diagnosis (75%). Four DCPR syndromes were particularly prevalent: demoralization, alexithymia, illness denial, and type A behavior. DCPR criteria appear to be a useful, reliable, and promising approach in the assessment and description of psychological distress in medical patients. They may serve as a focus of intervention studies in this population.

Reliability of Multidimensional Substance Abuse Treatment Matching

For meaningful adoption, the Patient Placement Criteria (PPC) of the American Society of Addiction Medicine (ASAM) will need adequate interrater reliability. In a decision analysis of the original PPC, we reduced potential sources of unreliability, mapped question items from clinical research instruments to each decision point, and programmed the item map as a computerized structured interview. Then, target videotapes from eight substance dependent adults who had been distributed by the algorithm into three levels of care (LOC) were independently scored by four raters who were blind as to ASAM LOC. The intraclass correlation coefficient for ASAM LOC assignment was .77. For all but two subscales of component instruments, values were above .70 and significant, indicating high interrater reliability. With these methods, excellent reliability is possible for complex decision trees, making it possible to improve the validity of the ASAM Criteria and similar complex hierarchical clinical protocols.

DSM-IV Major Depressive Episode criteria: An evaluation of reliability and validity across three different rating methods

This study examined the reliability and validity of the DSM-IV Major Depressive Episode (MDE) symptoms in a sample of outpatients based on clinician ratings of assessment interviews, videotape of these interviews, and chart information. A group of 44 patients admitted to a university based outpatient community clinic were rated by trained clinicians on the nine MDE symptom criteria (A1-A9). Patients also completed a self-report measure of depressive symptomatology. Interrater reliability was found to be highest between the interview and videotape ratings. Conversely, when comparing chart ratings with those made from either interview or videotape, reliability for many of the individual criteria were found to be in the poor range of reliability. Good internal consistency was found for both the interview and videotape ratings, while internal consistency was less adequate for chart-based ratings. However, the three MDE ratings converge on a single dimension in a similar manner regardless of which source (i.e. interview, videotape, or chart) provided the rating. Additional analyses revealed a consistent relationship between the three MDE ratings (interview, videotape, and chart) with measures of patient reported depressive symptoms that exceeded the relationship between these scores with global levels/severity of psychopathology. The effects of longer interviews as well as examining depressive symptoms within the context of interpersonal functioning is discussed regarding the reliable assessment of depressive symptomatology in the mild to moderate range of severity. (Int J Psych Can Pract 2004; 8: 3-10).

Placement matching: challenges and technical progress

Although it is highly desirable, standardized placement matching for substance use disorders poses challenges due to variability in settings, services, and syndromes; multidimensionality of clinical problems; multiplicity of outcome constructs; and temporal phenomena in the course of recovery. Despite these obstacles, progress is being made in developing patient placement criteria that are comprehensive with adequate reliability, feasibility, and resolution. With these methodological advances, it has been possible to initiate controlled research with placement criteria. The first such studies provide early evidence supporting such criteria and indicate areas for refinement.

Dentist reliability in classifying disease risk and reason for treatment

OBJECTIVES

The reliability of practicing dentists' classifications of patients' caries risk and periodontal disease risk and reason for treatment for individual teeth were determined. The risk classification protocols had been in use in a group practice for more than a year, and the reason-for-treatment protocol had been introduced six months previously.

METHODS

Eight dentists' classifications for caries (n = 66) and periodontal disease risk (n = 66), and six dentists' classifications for reason for treatment (n = 73) were compared to those of a nominal standard examiner. Reliability was expressed as percent agreement and kappa values.

RESULTS

Percent agreement was 76 percent, 83 percent, and 74 percent for caries, periodontal disease, and reason for treatment, respectively, with kappa values of 0.56, 0.70, and 0.69.

CONCLUSIONS

Dentists can attain reasonable levels of reliability using simple classification protocols with little formal training, although misclassification may be problematic for specific administrative or research-related purposes.

The nature of psychiatric classification: issues beyond ICD-10 and DSM-IV

OBJECTIVE

The aim of this paper is to provide an overview of the methodological underpinnings of current classification systems in psychiatry, their impact on clinical and social practices, and likely scenarios for future development, as an introduction to a series of related articles in this issue.

METHOD

The method involved a selective literature review.

RESULTS

The role and significance of psychiatric classifications is placed in a broader social and cultural context; the 'goodness of fit' between ICD-10 and DSM-IV on one hand, and clinical reality on the other hand, is examined; the nature of psychiatric classification, compared to biological classifications, is discussed; and questions related to the impact of advances in neuroscience and genetics on psychiatric classification are raised for further discussion.

CONCLUSIONS

The introduction of explicit diagnostic criteria and rule-based classification, a major step for psychiatry, took place concurrently with the ascent to dominance of a biomedical paradigm and the synergistic effects of social and economic forces. This creates certain risks of conceptual closure of clinical psychiatry if phenomenology, intersubjectivity and the inherent historicism of key concepts about mental illness are ignored in practice, education and research.

Psychopathology: description and classification

DSM-IV's strong empirical base has yielded an instrument with good to excellent reliability and improved validity. Diagnostic reliability depends on both the clarity and validity of diagnostic criteria and the changeability of disorders over time: The reliability of schizophrenic spectrum disorders, personality disorders, and some childhood and adolescent disorders remains problematic. Findings on diagnostic validity appear paradoxical: Attempts to validate schizophrenic spectrum disorders with neurobiological and genetic-familial validators have been only modestly successful, whereas the tripartite personality trait model has differentiated a range of depressive and anxiety disorders. Research on comorbidity has identified several highly comorbid disorders (substance-related disorders, personality disorders, depression, and anxiety) as well as some adverse consequences of comorbidity. The advantages of dimensional approaches to diagnosis have largely been demonstrated conceptually; ultimate conclusions about the strengths and weaknesses of dimensional and syndromal methods await substantial additional empirical research.

How specific are "specific developmental disorders"? The relevance of the concept of specific developmental disorders for the classification of childhood developmental disorders

The concept of "specific developmental disorder" (SDD) refers to delays in developmental domains such as language and speech development, motor coordination or the development of scholastic skills, in the absence of sensory deficits, subnormal intelligence or poor educational conditions. The key element in this concept is the notion of a discrepancy between observed and expected level of development. In DSM-III-R and ICD-10, SDD serves as a conceptual umbrella, suggesting that the subsumed disorders are of the same type. In DSM-IV, the SDD umbrella is not used explicitly, but the notion of a discrepancy is present in the categories of Learning Disorders, Motor Skill Disorder and Communication Disorders, suggesting a close relationship between these disorders. One of the advantages of the use of SDD as a unifying concept is that it contributes to the standardisation of the description of the various disorders. However, based on reviews of research regarding the reliability and validity of the SDD categories, we argue that the application of a unifying SDD concept has been premature. For each of the categories for disorders in scholastic skills, language, speech and motor coordination, the notion of a discrepancy between observed and expected level of development should be elaborated and tested more thoroughly, before SDD can be used as a unifying concept in classification.

Inter-rater reliability of ICD-10 in Chinese patients

In an attempt to assess the universal applicability of the International Classification of Disease (ICD-10), two psychiatrists from different socio-cultural backgrounds and training independently performed a chart review of 238 Chinese patients. Inter-rater reliability figures were comparable to those found in the WHO-coordinated ICD-10 field trials. The results suggest that ICD-10 has good ‘universality’ in routine clinical practice.