OBJECTIVE: While considerable attention has focused on improving the detection of depression, assessment of severity is also important in guiding treatment decisions. Therefore, we examined the validity of a brief, new measure of depression severity.

https://onlinelibrary.wiley.com/doi/pdf/10.1046/j.1525-1497.2001.016009606.x

The PHQ-9: validity of a brief depression severity measure.

Objectives: To develop a 10-minute cognitive screening tool (Montreal Cognitive Assessment, MoCA) to assist first-line physicians in detection of mild cognitive impairment (MCI), a clinical state that often progresses to dementia.

Design: Validation study.

Setting: A community clinic and an academic center.

Participants: Ninety-four patients meeting MCI clinical criteria supported by psychometric measures, 93 patients with mild Alzheimer's disease (AD) (Mini-Mental State Examination (MMSE) score≥17), and 90 healthy elderly controls (NC).

Measurements: The MoCA and MMSE were administered to all participants, and sensitivity and specificity of both measures were assessed for detection of MCI and mild AD.

Results: Using a cutoff score 26, the MMSE had a sensitivity of 18% to detect MCI, whereas the MoCA detected 90% of MCI subjects. In the mild AD group, the MMSE had a sensitivity of 78%, whereas the MoCA detected 100%. Specificity was excellent for both MMSE and MoCA (100% and 87%, respectively).

Conclusion: MCI as an entity is evolving and somewhat controversial. The MoCA is a brief cognitive screening tool with high sensitivity and specificity for detecting MCI as currently conceptualized in patients performing in the normal range on the MMSE.

/pdf/the-montreal-cognitive-assessment-moca-a-brief-screening-4w06t9e7qy.pdf

The Montreal Cognitive Assessment, MoCA: A Brief Screening Tool For Mild Cognitive Impairment

Background Generalized anxiety disorder (GAD) is one of the most common mental disorders; however, there is no brief clinical measure for assessing GAD. The objective of this study was to develop a brief self-report scale to identify probable cases of GAD and evaluate its reliability and validity. Methods A criterion-standard study was performed in 15 primary care clinics in the United States from November 2004 through June 2005. Of a total of 2740 adult patients completing a study questionnaire, 965 patients had a telephone interview with a mental health professional within 1 week. For criterion and construct validity, GAD self-report scale diagnoses were compared with independent diagnoses made by mental health professionals; functional status measures; disability days; and health care use. Results A 7-item anxiety scale (GAD-7) had good reliability, as well as criterion, construct, factorial, and procedural validity. A cut point was identified that optimized sensitivity (89%) and specificity (82%). Increasing scores on the scale were strongly associated with multiple domains of functional impairment (all 6 Medical Outcomes Study Short-Form General Health Survey scales and disability days). Although GAD and depression symptoms frequently co-occurred, factor analysis confirmed them as distinct dimensions. Moreover, GAD and depression symptoms had differing but independent effects on functional impairment and disability. There was good agreement between self-report and interviewer-administered versions of the scale. Conclusion The GAD-7 is a valid and efficient tool for screening for GAD and assessing its severity in clinical practice and research.

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/410326/ioi60000.pdf

A Brief Measure for Assessing Generalized Anxiety Disorder: The GAD-7

Background: This study presents estimates of lifetime and 12-month prevalence of 14 DSM-III-R psychiatric disorders from the National Comorbidity Survey, the first survey to administer a structured psychiatric interview to a national probability sample in the United States. Methods: The DSM-III-R psychiatric disorders among persons aged 15 to 54 years in the noninstitutionalized civilian population of the United States were assessed with data collected by lay interviewers using a revised version of the Composite International Diagnostic Interview. Results: Nearly 50% of respondents reported at least one lifetime disorder, and close to 30% reported at least one 12-month disorder. The most common disorders were major depressive episode, alcohol dependence, social phobia, and simple phobia. More than half of all lifetime disorders occurred in the 14% of the population who had a history of three or more comorbid disorders. These highly comorbid people also included the vast majority of people with severe disorders. Less than 40% of those with a lifetime disorder had ever received professional treatment, and less than 20% of those with a recent disorder had been in treatment during the past 12 months. Consistent with previous risk factor research, it was found that women had elevated rates of affective disorders and anxiety disorders, that men had elevated rates of substance use disorders and antisocial personality disorder, and that most disorders declined with age and with higher socioeconomic status. Conclusions: The prevalence of psychiatric disorders is greater than previously thought to be the case. Furthermore, this morbidity is more highly concentrated than previously recognized in roughly one sixth of the population who have a history of three or more comorbid disorders. This suggests that the causes and consequences of high comorbidity should be the focus of research attention. The majority of people with psychiatric disorders fail to obtain professional treatment. Even among people with a lifetime history of three or more comorbid disorders, the proportion who ever obtain specialty sector mental health treatment is less than 50%. These results argue for the importance of more outreach and more research on barriers to professional help-seeking.

/pdf/lifetime-and-12-month-prevalence-of-dsm-iii-r-psychiatric-1o9w1oagsp.pdf

Lifetime and 12-Month Prevalence of DSM-III-R Psychiatric Disorders in the United States: Results From the National Comorbidity Survey

BACKGROUND: Somatoform disorders are characterised by chronic, medically unexplained physical symptoms (MUPS). Although different medications are part of treatment routines for people with somatoform disorders in clinics and private practices, there exists no systematic review or meta-analysis on the efficacy and tolerability of these medications. We aimed to synthesise to improve optimal treatment decisions.OBJECTIVES: To assess the effects of pharmacological interventions for somatoform disorders (specifically somatisation disorder, undifferentiated somatoform disorder, somatoform autonomic dysfunction, and pain disorder) in adults.SEARCH METHODS: We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) (to 17 January 2014). This register includes relevant randomised controlled trials (RCTs) from The Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). To identify ongoing trials, we searched ClinicalTrials.gov, Current Controlled Trials metaRegister, the World Health Organization International Clinical Trials Registry Platform, and the Chinese Clinical Trials Registry. For grey literature, we searched ProQuest Dissertation {\&} Theses Database, OpenGrey, and BIOSIS Previews. We handsearched conference proceedings and reference lists of potentially relevant papers and systematic reviews and contacted experts in the field.SELECTION CRITERIA: We selected RCTs or cluster RCTs of pharmacological interventions versus placebo, treatment as usual, another medication, or a combination of different medications for somatoform disorders in adults. We included people fulfilling standardised diagnostic criteria for somatisation disorder, undifferentiated somatoform disorder, somatoform autonomic dysfunction, or somatoform pain disorder.DATA COLLECTION AND ANALYSIS: One review author and one research assistant independently extracted data and assessed risk of bias. Primary outcomes included the severity of MUPS on a continuous measure, and acceptability of treatment.MAIN RESULTS: We included 26 RCTs (33 reports), with 2159 participants, in the review. They examined the efficacy of different types of antidepressants, the combination of an antidepressant and an antipsychotic, antipsychotics alone, or natural products (NPs). The duration of the studies ranged between two and 12 weeks.One meta-analysis of placebo-controlled studies showed no clear evidence of a significant difference between tricyclic antidepressants (TCAs) and placebo for the outcome severity of MUPS (SMD -0.13; 95{\%} CI -0.39 to 0.13; 2 studies, 239 participants; I(2) = 2{\%}; low-quality evidence). For new-generation antidepressants (NGAs), there was very low-quality evidence showing they were effective in reducing the severity of MUPS (SMD -0.91; 95{\%} CI -1.36 to -0.46; 3 studies, 243 participants; I(2) = 63{\%}). For NPs there was low-quality evidence that they were effective in reducing the severity of MUPS (SMD -0.74; 95{\%} CI -0.97 to -0.51; 2 studies, 322 participants; I(2) = 0{\%}).One meta-analysis showed no clear evidence of a difference between TCAs and NGAs for severity of MUPS (SMD -0.16; 95{\%} CI -0.55 to 0.23; 3 studies, 177 participants; I(2) = 42{\%}; low-quality evidence). There was also no difference between NGAs and other NGAs for severity of MUPS (SMD -0.16; 95{\%} CI -0.45 to 0.14; 4 studies, 182 participants; I(2) = 0{\%}).Finally, one meta-analysis comparing selective serotonin reuptake inhibitors (SSRIs) with a combination of SSRIs and antipsychotics showed low-quality evidence in favour of combined treatment for severity of MUPS (SMD 0.77; 95{\%} CI 0.32 to 1.22; 2 studies, 107 participants; I(2) = 23{\%}).Differences regarding the acceptability of the treatment (rate of all-cause drop-outs) were neither found between NGAs and placebo (RR 1.01, 95{\%} CI 0.64 to 1.61; 2 studies, 163 participants; I(2) = 0{\%}; low-quality evidence) or NPs and placebo (RR 0.85, 95{\%} CI 0.40 to 1.78; 3 studies, 506 participants; I(2) = 0{\%}; low-quality evidence); nor between TCAs and other medication (RR 1.48, 95{\%} CI 0.59 to 3.72; 8 studies, 556 participants; I(2) =14{\%}; low-quality evidence); nor between antidepressants and the combination of an antidepressant and an antipsychotic (RR 0.80, 95{\%} CI 0.25 to 2.52; 2 studies, 118 participants; I(2) = 0{\%}; low-quality evidence). Percental attrition rates due to adverse effects were high in all antidepressant treatments (0{\%} to 32{\%}), but low for NPs (0{\%} to 1.7{\%}).The risk of bias was high in many domains across studies. Seventeen trials (65.4{\%}) gave no information about random sequence generation and only two (7.7{\%}) provided information about allocation concealment. Eighteen studies (69.2{\%}) revealed a high or unclear risk in blinding participants and study personnel; 23 studies had high risk of bias relating to blinding assessors. For the comparison NGA versus placebo, there was relatively high imprecision and heterogeneity due to one outlier study. Although we identified 26 studies, each comparison only contained a few studies and small numbers of participants so the results were imprecise.AUTHORS' CONCLUSIONS: The current review found very low-quality evidence for NGAs and low-quality evidence for NPs being effective in treating somatoform symptoms in adults when compared with placebo. There was some evidence that different classes of antidepressants did not differ in efficacy; however, this was limited and of low to very low quality. These results had serious shortcomings such as the high risk of bias, strong heterogeneity in the data, and small sample sizes. Furthermore, the significant effects of antidepressant treatment have to be balanced against the relatively high rates of adverse effects. Adverse effects produced by medication can have amplifying effects on symptom perceptions, particularly in people focusing on somatic symptoms without medical causes. We can only draw conclusions about short-term efficacy of the pharmacological interventions because no trial included follow-up assessments. For each of the comparisons where there were available data on acceptability rates (NGAs versus placebo, NPs versus placebo, TCAs versus other medication, and antidepressants versus a combination of an antidepressant and an antipsychotic), no clear differences between the intervention and comparator were found.Future high-quality research should be carried out to determine the effectiveness of medications other than antidepressants, to compare antidepressants more thoroughly, and to follow-up participants over longer periods (the longest follow up was just 12 weeks). Another idea for future research would be to include other outcomes such as functional impairment or dysfunctional behaviours and cognitions as well as the classical outcomes such as symptom severity, depression, or anxiety.

Pharmacological interventions for somatoform disorders in adults.

The growing rate of failed clinical trials in neuroscience has led to increased attention being paid to methodologic factors that may contribute to this failure. An issue that has been largely overlooked is that of rater training and rater competency. Given that scores on clinician-administered symptom rating scales form the foundation on which the success of a study is built, it is surprising that so little attention has been paid to this issue. There are several issues related to rater training and rater competency, which warrant examination. These include who is qualified to rate, what components should be included, how and when training should be provided, and, perhaps most important, whether rater training is effective. 1. Who is qualified to administer outcome measures in clinical trials? There is great variety in the backgrounds and experience of persons administering rating scales in clinical trials conducted in the United States, ranging from psychiatrists to study coordinators with bachelor’s degrees (often in fields unrelated to psychiatry) with little, if any, clinical experience. Academic credentials alone fail to insure competence in this area, because few formal academic programs include training on the use of the clinician-administered rating scales that are typically used in clinical trials. Most training that does occur takes place at the investigative site. Despite the lack of empirical data supporting acquisition of a specific set of rater skills, we believe that the following general skills are essential to conduct a competent clinical interview using clinician-administered symptom rating scales: Conceptual understanding. Raters should have didactic training in psychopathology (particularly in the disorder of interest), so they have a good conceptual understanding of the constructs being evaluated. An example of such training would be a course in psychopathology that covers current theories of depression, including diagnostic constructs and criteria. Clinical experience. Raters should have enough clinical experience with patients who have the disorder being evaluated at all levels of severity to recognize and judge the severity of each of the symptoms rated in the scale (eg, ‘‘if he does not know what retardation is, he will be unable to recognize it when it is present and unable to rate it’’). Unfortunately, some raters get little training before seeing patients in clinical trials and often learn on clinical trial patients, with clinical trial data. Often, it is their first exposure to patients with the disorder being studied. Guest Editorial

Rater training in multicenter clinical trials: issues and recommendations.

The authors field-tested proposed criteria for diagnoses of psychoactive substance use disorders in the revision of DSM-III (DSM-III-R) and compared them with DSM-III criteria in a treated group of 83 patients They found a high level of agreement between the diagnostic systems in rates of diagnosis and in the individuals receiving the diagnosis The greatest cross-system agreement occurred when the minimum number of symptoms required to make the DSM-III-R diagnosis was set at three Discrepant diagnoses between systems related to removal of social consequences as a requirement for the DSM-III-R diagnoses, less emphasis on physiological tolerance in DSM-III-R, and disagreement in subjects with mild symptoms

A field trial of DSM-III-R psychoactive substance dependence disorders.

The authors review the important changes in the three sections of DSM-III-R that include only psychotic disorders (schizophrenia, delusional disorder, and psychotic disorders not elsewhere classified), outline the rationale for these changes, and, where available, review their empirical basis. In addition, they review two proposed changes that were not incorporated into DSM-III-R. They conclude by calling for an increasingly rigorous and data-based process of nosologic revision.

Psychotic disorders in DSM-III-R.

The organic/nonorganic distinction in contemporary classifications of mental disorders such as DSM-III and DSM-III-R has important prognostic and treatment implications, because it directs the clinician to pay special attention to the possibility of an underlying "physical" disorder as the cause of the mental disturbance However, the term "organic" raises serious and intractable problems, since the connotative meaning of the term always returns to its historical roots, which imply an outmoded functional/structural, psychological/biological, and mind/body dualism The authors present a proposal being considered for DSM-IV that would eliminate the term "organic" and reorganize the classification of organic mental disorders Disorders previously referred to as "organic mental disorders" would be renamed as either "secondary disorders" (if they are due to "physical" disorders) or "substance-induced disorders" The entire classification of mental disorders would be reorganized to distribute the secondary and substance-induced disorders into the major groups with which they share phenomenology The traditional organic mental disorders--delirium, dementia, and amnestic disorder--would be grouped together under the rubric of "cognitive impairment disorders" While acknowledging problems with the suggested new terminology and reorganization of the classification, the authors argue that the potential benefits of the proposal for clarity and for facilitating differential diagnosis justify putting to rest the familiar but now anachronistic term "organic mental disorders"

Now is the time to retire the term "organic mental disorders".

Although the use of telemedicine in psychiatry has a long history in providing clinical care to patients, its use in clinical trials research has not yet been commonly employed. Telemedicine allows for the remote assessment of study patients, which could be done by a centralized, highly calibrated, and impartial cohort of raters independent of the study site. This study examined the comparability of remote administration of the Montgomery-Asberg Depression Rating Scale (MADRS) by videoconference and by telephone to traditional face-to-face administration. Two parallel studies were conducted: one compared face-to-face with videoconference administration (N=35), and the other compared face-to-face with telephone administration (N=35). In each study, depressed patients were interviewed independently twice: once in the traditional face-to-face manner, and the second time by either videoconference or teleconference. A counterbalanced order was used. The mean MADRS score for interviews conducted remotely by videoconference was not significantly different from the mean MADRS scores conducted by face-to-face administration (mean difference=0.51 points), P=.388, intraclass correlation (ICC)=.94, P<0001. Similarly, the mean MADRS score for interviews conducted by telephone was not significantly different from the mean MADRS score conducted by face-to-face administration (mean difference=0.74 points), P=.270, ICC=.93, P<0001. Results of the study support the comparability of remote administration of the MADRS, by both telephone and videoconference, to face-to-face administration. Comparability of the administration mode allows for remote assessment of patients in both research and clinical applications.

Janet B. W. Williams

Papers

Rater training in multicenter clinical trials: issues and recommendations.

A field trial of DSM-III-R psychoactive substance dependence disorders.

Psychotic disorders in DSM-III-R.

Now is the time to retire the term "organic mental disorders".

Face-to-face versus remote administration of the Montgomery-Asberg Depression Rating Scale using videoconference and telephone.