8. standardized psychiatric interviews

Standardized Psychiatric Interviews 39

7. Stoloff M, Couch J: Computer Use in Psychology: A Directory of Software, 3rd ed. Washington, DC,

8. Streiner D, Norman GR: Health Measurement Scales: A Practical Guide to Their Development and Use.

9. Thelen M, Farmer J, Wonderlich S, Smith M: A revision of the bulimia test-the BULIT-R. Psychological

American Psychological Association, 1992.

Oxford, Oxford University Press, 1989.

Assessment 3:119-124, 1987. 10. Thompson C: The Instruments of Psychiatric Research. Chichester, 1989. 11. Welch GW, Thompson L, Hall A: The BULIT-R: Its reliability and clinical validity as a screening tool for

DSM-I11 R bulimia nervosa in a female tertiary education population. Int J Eating Dis 14:95-105, 1993.

12. McCrae RR, Costa PT, Pedroso de Lima M: Age differences in personality across the adult life span: Parallels in five cultures. Develop Psycho1 35(2):466477, 1999.

8. STANDARDIZED PSYCHIATRIC INTERVIEWS Jacqueline A. S a ~ s o n , Ph.D

1. When should I use a standardized interview? Standardized interviews are necessary when collecting data for research and for comparing your

own patients with those reported in the psychiatric literature. They also are valuable as a systematic means of evaluating patients that is less subject to bias or incomplete assessment.

In clinical practice, its easy to spend a lot of time discussing the problems volunteered by the patient, but fail to ask about other problems that are less apparent but no less important. Patients are particularly reticent when they feel symptoms are embarrassing or socially unacceptable. Alcohol or drug abuse, sexual compulsions, or symptoms related to trauma often are missed because clinicians dont probe. Standardized interviews enhance understanding of specific syndromes and pin- point the questions most useful in eliciting psychiatric information. In this way, they are valuable training devices.

2. How is a standardized interview different from a clinical interview? In a standardized interview, there are specific guidelines that define the areas of questioning to

be covered and the kind of information to be elicited from a patient. The interviewer is expected to cover all the areas included in the guidelines and to ask for a sufficient amount of detail to complete ratings in each area. The format of the interview is also specified to insure that the interview is con- ducted in a comparable fashion by all clinicians both within and across institutions.

3. What is the difference between a fully structured and a semi-structured interview format? A fully structured interview specifies the wording of questions and the order in which questions

are asked. The format is defined and must not be altered by the interviewer in any way. In a semi- structured interview, the wording of questions and ordering are specified but may be modified by the interviewer to suit the needs of a particular patient, as long as all areas are covered in the interview. Fully structured interviews provide a high degree of consistency from one interview to another, and have been used extensively in epidemiologic studies that involve many raters. Semi-structured interviews are less standardized but allow for clarifications and probes that can improve the validity of re- sponses from atypical or severely impaired patients.

4. What kinds of standardized interviews are available? The two most common types are interviews to assess the psychiatric diagnosis (diagnostic in-

terviews) and interviews to assess the severity of certain types of symptoms at a specific point in time (cross-sectional symptom severity rating scales).

40 Standardized Psychiatric Interviews

Summary of Diagnostic Interviews INTERVIEW DIAGNOSTIC SYSTEM FORMAT INTERVIEWER

~~~

Schedule of Affective Disorders Research Diagnostic Semi-structured Clinician

Diagnostic Interview Schedule (DIS) DSM-I11 Fully structured Lay person Structured Clinical Interview DSM-111-R, DSM IV Semi-structured Clinician

Composite International Diagnostic DSM-111-R, ICD- 10 Fully structured Lay person

and Schizophrenia (SADS) Criteria (RDC)

for DSM Diagnosis (SCID)

Interview (CIDI)

5. Which fully structured diagnostic interview is used most commonly? The Diagnostic Interview Schedule (DIS). The DIS was developed for use in large-scale epidemi-

ologic surveys and for administration by specially trained nonclinicians.Is It is structured to obtain both lifetime and current diagnoses (within the last year). Questions are organized by symptoms, and patients are asked first whether the symptom has ever occurred in their lifetime, and second whether the symptoms occurred within the last 1-month, 6-month, or 12-month period. Probes are included for each symptom to determine whether alcohol or drugs were involved, the patient sought treatment, and occupational or social functioning was impaired. Symptoms are coded as present if they are indepen- dent of alcohol or drug use and resulted in either treatment or impairment of functioning. Diagnoses are assigned by computer on the basis of algorithms applied to coded interview data.

A modified version of the DIS called the Composite International Diagnostic Interview has been created to allow for assignment of diagnoses according to the International Classification of Diseases (ICD- 10) system?

6. Which semi-structured diagnostic interviews are used most commonly? The Schedule for Affective Disorders and Schizophrenia (SADS) interview contains 82

scales to assess symptoms of depression, mania, psychosis, and anxiety.' Multiple questions are pro- vided for each rating scale, and the interviewer may select those that work best with a particular patient. Supplementary information based on observation, clinical report, or chart review may be incorporated into interview ratings. At the completion of the interview, specific inclusion and exclu- sion criteria are applied to the symptom ratings, and diagnoses are assigned by the rater. The SADS comes in two parts: part I documents symptoms associated with the current episode; part I1 documents symptoms during previous episodes. A diagnostic system called Research Diagnostic Criteria (RDC) was developed for use with the SADS questions. The RDC system and SADS interview were created before the DSM-I11 systems (in fact, the DSM-I11 systems were modeled to a degree on the RDC), but are easily modified to obtain DSM-I11 or DSM-IV diagnoses.

The Structured Clinical Interview for DSM-111-R Diagnosis (SCID) obtains an accurate psychiatric diagnosis relatively quickly (unlike the SADS, which is for more comprehensive research use).*' Thus, certain questions can be skipped as soon as it is apparent that the patient does not meet the necessary diagnostic criteria. Symptoms are scored as absent, present, or subthreshold. Unlike the SADS, current and past diagnoses are assessed in the same interview. This strategy may be modified for patients who have difficulty shifting mental set from present to past and back to present. The questions in each section follow the diagnostic criteria outlined in DSM-111-R, and the interviewer notes at the conclusion of each module whether or not the patient meets full diagnostic criteria.

Versions of the SCID are available with questions worded so as to assume that the patient is cur- rently symptomatic (patient version) and also with questions worded with no assumption of present or past patient status (nonpatient version).

7. How do the various interviews accommodate the diagnoses found in the DSM-IV? At this point in time, the SCID has been revised and field tested for DSM-IV. While changes in the standard system of diagnoses allow updating of clinical methods to reflect

state-of-the-art knowledge about psychopathology, they also create difficulties for researchers in


long-term studies due to problems comparing results based on different diagnostic systems. Thus, many researchers continue to use the interviews in the original form to maintain consistency of data collection over time and across studies.

8. How much time is required to complete the diagnostic interview? The duration of the interview depends on the amount of psychopathology presented by the pa-

tient and the ability of the patient to give a concise history. A completed interview with a good infor- mant who shows a moderate amount of psychopathology (for example, a current episode of major depression, dysthymic disorder, and a past episode of panic disorder) requires about 1.5 hours.

9. When should I use a symptom severity rating scale instead of a diagnostic interview? Symptom severity rating scales are designed to measure the severity of specific symptoms at a

particular point in time. They are used to measure symptom severity once a diagnosis has already been made. Typically, symptom assessments are repeated to monitor response to treatment. For example, a psychiatrist might administer a Hamilton Depression Rating Scale, which measures the severity of depressive symptoms, before starting a drug, and then repeat the assessment each time the patient comes in. The initial score is compared with the followup scores to determine whether there is a significant improvement in symptoms over time.

Cross-Sectional Symptom Severity Rating Scales SYMPTOMS

RATING FUNCTIONING METHOD Depression Anxiety General

Interview: Hamilton Depression Hamilton Anxiety Brief Psychiatric Global Assessment Rating Scale Rating Scale Rating Scale of Functioning

Inventory for Depressive- (BPRS) (GAF) Symptomatology (IDS) Clinical Global

Montgomery-Asberg Scale Impression Scale Raskin Scale (CGI)

Self Report: Beck Depression Beck Anxiety Symptom Check- Social Adjustment Inventory Inventory list-90 (SCL-90) Scale (SAS)

Symptomatology (IDS-SR) Inventory States (POMS) Inventory for Depressive State-Trait Anxiety Profile of Mood

Zune Inventory

10. What if I dont have time to administer the assessment? Are there any questionnaires that the patient can fill out that will provide the same information?

Presently, there are no widely used self-report questionnaires for assessing psychiatric diagnosis. Valid diagnostic assessment requires a clinician who can interpret signs and symptoms against a standard and consider them in assigning a differential diagnosis. Some success has been reported by researchers who created an interactive computer program to assign a diagnosis based on the fully structured method used in the DIS.

Many self-report questionnaires are available to assess symptom severity. Some of these questionnaires are general and cover a wide variety of symptoms, while others focus on one symptom di- mension, such as depression (see table above).

11. Symptom assessment does not tell me whether or not a person is functioning in the com- munity. Are there any measures that monitor improvement in actual functioning?

Yes. Several simple scoring systems are widely used by clinicians to document functioning. The Global Assessment of Functioning Scale (see Chapter 4) provides descriptions of possible levels of functioning along a continuum ranging from functioning in all areas to persistent inability to maintain personal hygiene. The Clinical Global Impression Scale (see chart on next page) asks the clinician to rate the overall severity of the illness compared with all other psychiatric patients. The

42 Standardized Psychiatric Interviews

1. Severity of Illness

Considering your total clinical experience with this particular population, how mentally ill is the patient at this time?

0 = Not Assessed 4 = Moderately ill 1 = Normal, not at all ill 5 = Markedly ill 2 = Borderline mentally ill 6 = Severely ill 3 = Mildly ill 7 = Among the most extremely

ill patients

Global Improvement - Rate total improvement whether or not, in your judgment, it is due entirely to drug treatment.

Compared to his condition at admission to the project, how much has he changed?

0 = Not Assessed 4 = No change 1 = Very much improved 5 = Minimally worse 2 = Much improved 6 = Much worse 3 = Minimally improved I = Very much worse

Efficacy Index - Rate this item on the basis of DRUG EFFECT ONLY. Select the terms which best describe the degrees of therapeutic effect and side effects and record the number in the box where the two items intersect.

2 .

3.

I I

ratings range from normal, not at all ill (a score of 1) to among the most extremely ill patients. In addition, there are self-reported questionnaires that ask patients to assess their own functioning across a number of social roles. The Social Adjustment Scalezz has been widely used for this pur- pose, and published norms for scoring are available.

One drawback with self-reported instruments is that questions usually are based on the patients experience of satisfaction with their role performance. Thus, ratings do not directly assess actual functioning against an external standard.

MARKED : Vast improvement. Complete or nearly complete remission of all symptoms

MODERATE: Decided improvement. Partial remission of symptoms.

which doesnt alter status of care of patient.

MINIMAL: Slight improvement

UNCHANGED OR WORSE

Not Assessed = 00

CLINICAL GLOBAL IMPRESSIONS

01

0 5

09

13

THERAPEUTIC EFFECT I SIDE EFFECTS 02

06

10

14

03

07

11

15

04

08

12

16


BIBLIOGRAPHY

1. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders-111. Washington,

2. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders-111-R. Washing-

3. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders-IV. Washington,

4. Beck AT, Brown G, Epstein N, Steer RA: An inventory for measuring clinical anxiety: Psychometric proper-

5. Beck AT, Ward CH, Mendelson M, et al: An inventory for measuring depression. Arch Gen Psychiatry

6. Derogatis LR: SCL-90-R Administration, Scoring and Procedures Manual-11. for the Revised Version.

7. Endicott J, Spitzer RL: A diagnostic review. The Schedule for Affective Disorders and Schizophrenia. Arch

8. Guy W ECDEU Assessment Manual for Psychopharmacology, Revised, 1976. Rockville, MD, DHEW

9. Hamilton M: The assessment of anxiety states by rating. Br J Med Psychol 32:5&55, 1959.

DC, American Psychiatric Association, 1980.

ton, DC, American Psychiatric Association, 1987.

DC, American Psychiatric Association, 1994.

ties. J Consult Clin Psychol 55:893-987,1988.

4:561- 571, 1961.

Towson, MD, Clinical Psychometric Research, 1983.

Gen Psychiatry 35:837-844, 1978.

Publication No. (ADM) 76-338, 1976, pp 217-222.

10. Hamilton M: The development of a rating scale for primary depressive illness. Br J SOC Clin Psychol

11. Lipman RS: Differentiating anxiety and depression in anxiety disorders: use of rating scales. [description of

12. McNair DM, Lorr M, Droppleman LF: Manual for the Profile of Mood States. San Diego, Educational and

13. Montgomery SA, Asberg ML: A new depression scale designed to be sensitive to change. Br J Psychiatry

14. Overall JE, Gorham DR: The Brief Psychiatric Rating Scale. Psychol Rep 10:799-812, 1962. 15. Robins LN, Helzer JE, Croughan JL, Ratcliff KS: National Institute of Mental Health Diagnostic Interview

Schedule: Its history, characteristics and validity. Arch Gen Psychiatry 38:381-389, 1981. 16. Robins LN, Wing J, Wittchen H-U, Helzer JE: The Composite International Diagnostic Interview: An epi-

demiologic instrument suitable for use in conjunction with different diagnostic systems and in different cultures. Arch Gen Psychiatry 45:1069-1077, 1988.

17. Rush AJ, Giles DE, Schlesser MA, et al: The Inventory for Depressive Symptomatology (IDS): Preliminary findings. Psychiatry Res 18:65-87, 1986.

18. Skodol AE, Bender DS: Diagnostic interviews. In APA Taskforce for Handbook of Psychiatric Measures (eds): Handbook of Psychiatric Measures. Washington, DC, American Psychiatric Association, Inc., In Press.

19. Spielberger CD: Manual for the State-Trait Anxiety Inventory. Palo Alto, CA, Consulting Psychologists Press, 1983.

20. Spitzer RL, Endicott J, Robins E: Research diagnostic criteria. Rationale and reliability. Arch Gen Psychiatry 35:773-782, 1978.

21. Spitzer RL, Williams JBW, Gibbon M, First MB: The structured clinical interview for DSM-111-R (SCID). I: History, rationale and description. Arch Gen Psychiatry 49:624-629, 1992.

22. Weissman MM, Bothwell S: Assessment of social adjustment by patient self-report. Arch Gen Psychiatry 33:1111-1115, 1976,

23. Williams JBW, Gibbon M, First MB, et al: The structured clinical interview for DSM-11-R (SCID). 11: Multisite test-retest reliability. Arch Gen Psychiatry 49:630-636, 1992.

24. Wittchen H-U, Robins LN, Cottler LB, et al, and Participants in the Multicentre WHO/ADAMHA Field Trials: Cross-cultural feasibility, reliability and sources of variance in the Composite International Diagnostic Interview (CIDI). Br J Psychiatry 159:645453, 1991.

25. World Health Organization: Composite International Diagnostic Interview (CIDI), Version 1.0. Geneva, World Health Organization, 1990.

26. Yonkers KA, Samson JA: Mood disorders. In APA Taskforce for Handbook of Psychiatric Measures (eds): Handbook of Psychiatric Measures. Washington, DC, American Psychiatric Association, Inc., In Press.

6:278-296, 1967.

Raskin and Covi scales]. Psychopham Bull 18:69-105, 1982.

Industrial Testing Service, 197 1.

1341382-389, 1979.

8. standardized psychiatric interviews

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