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CompositeInternationalDiagnosticInterviewscreeningscalesforDSMIV
anxietyandmooddisorders
R.C.Kessler
,J.R.Calabrese,P
.A.Farley,M.J.Gruber,M.A.Jewell,W.Katon,P.E.Keck,Jr.,A.A.Nierenberg,N.A.
Sampson,M.K.Shear,A.C.Shillington,M.B.Stein,M.E.ThaseandH.U.Wittchen
PsychologicalMedicine/FirstViewArticle/October2012,pp113
DOI:10.1017/S0033291712002334,Publishedonline:
Linktothisarticle:http://journals.cambridge.org/abstract_S0033291712002334
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R.C.Kessler,J.R.Calabrese,P.A.Farley,M.J.Gruber,M.A.Jewell,W.Katon,P.E.Keck,Jr.,A.A.Nierenberg,N.A.
Sampson,M.K.Shear,A.C.Shillington,M.B.Stein,M.E.ThaseandH.U.WittchenCompositeInternationalDiagnostic
InterviewscreeningscalesforDSMIVanxietyandmooddisorders.PsychologicalMedicine,AvailableonCJOdoi:10.1017/
S0033291712002334
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Composite International Diagnostic Interview
screening scales for DSM-IV anxiety and
mood disorders
R. C. Kessler
1
*, J. R. Calabrese
2
, P. A. Farley
3
, M. J. Gruber
1
, M. A. Jewell
3
, W. Katon
4
, P. E. Keck Jr.
5
,
A. A. Nierenberg
6
, N. A. Sampson
1
, M. K. Shear
7
, A. C. Shillington
3
, M. B. Stein
8
, M. E. Thase
9
and H.-U. Wittchen
10
1
Department of Health Care Policy, Harvard Medical School, Boston, MA, USA ;
2
Department of Psychiatry, University Hospitals Case Medical
Center, Case Western Reserve University, Cleveland, OH, USA ;
3
Clinical Services, EPI-Q, Inc., Oakbrook Terrace, IL, USA ;
4
School of
Medicine, University of Washington, Seattle, WA, USA ;
5
Lindner Center of HOPE and Department of Psychiatry, University of Cincinnati
College of Medicine, Cincinnati, OH, USA ;
6
Depression Clinical and Research Program and the Bipolar Clinic and Research Program,
Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA ;
7
Columbia University School of Social Work, New York, NY,
USA ;
8
Department of Psychiatry, University of California San Diego, San Diego, CA, USA ;
9
Departments of Psychiatry, University of
Pennsylvania School of Medicine, Philadelphia Veterans Affairs Medical Center, and the University of Pittsburgh Medical Center, Philadelphia
and Pittsburgh, PA, USA ;
10
Institute of Clinical Psychology and Psychotherapy, Technische Universita
¨
t Dresden, Dresden, Germany
Background. Lack of coordination between screening studies for common mental disorders in primary care and
community epidemiological samples impedes progress in clinical epidemiology. Short screening scales based on the
World Health Organization (WHO) Composite International Diagnostic Interview (CIDI), the diagnostic interview
used in community epidemiological surveys throughout the world, were developed to address this problem.
Method. Expert reviews and cognitive interviews generated CIDI screening scale (CIDI-SC) item pools for 30-day
DSM-IV-TR major depressive episode (MDE), generalized anxiety disorder (GAD), panic disorder (PD) and bipolar
disorder (BPD). These items were administered to 3058 unselected patients in 29 US primary care offices. Blinded
SCID clinical reinterviews were administered to 206 of these patients, oversampling screened positives.
Results. Stepwise regression selected optimal screening items to predict clinical diagnoses. Excellent concordance
[area under the receiver operating characteristic curve (AUC)] was found between continuous CIDI-SC and DSM-IV/
SCID diagnoses of 30-day MDE (0.93), GAD (0.88), PD (0.90) and BPD (0.97), with only 9–38 questions needed to
administer all scales. CIDI-SC versus SCID prevalence differences are insignificant at the optimal CIDI-SC diagnostic
thresholds (x
2
1
=0.0–2.9, p=0.09–0.94). Individual-level diagnostic concordance at these thresholds is substantial (AUC
0.81–0.86, sensitivity 68.0–80.2%, specificity 90.1–98.8%). Likelihood ratio positive (LR+) exceeds 10 and LRx is 0.1
or less at informative thresholds for all diagnoses.
Conclusions. CIDI-SC operating characteristics are equivalent (MDE, GAD) or superior (PD, BPD) to those of the
best alternative screening scales. CIDI-SC results can be compared directly to general population CIDI survey results
or used to target and streamline second-stage CIDIs.
Received 21 June 2012 ; Accepted 5 September 2012
Key words : Bipolar disorder, Composite International Diagnostic Interview (CIDI), generalized anxiety disorder,
major depression, panic disorder, screening scales, validity.
Introduction
Although research on the community epidemiology of
mental disorders (i.e. general population incidence,
prevalence, risk factors, consequences) is an active
area of investigation (Susser et al. 2006; Kessler &
U
¨
stu
¨
n, 2008b; Tsuang et al. 2011), research on clinical
epidemiology (i.e. prevalence, severity, long-term
course in treatment samples) is underdeveloped,
especially in primary care settings. Indeed, the most
important clinical epidemiological study of mental
disorders in primary care remains the World Health
Organization (WHO) Collaborative Study on Psycho-
logical Problems in General Health Care (U
¨
stu
¨
n
& Sartorius, 1995), a study carried out nearly two
decades ago that led to few extensions (e.g. Wittchen
et al. 2002 ; Barkow et al. 2003; Kisely & Simon, 2005 ;
* Address for correspondence : R. C. Kessler, Ph.D., Department of
Health Care Policy, Harvard Medical School, 180 Longwood Avenue,
Boston, MA 02115, USA.
(Email : Kessler@hcp.med.harvard.edu)
Psychological Medicine, Page 1 of 13. f Cambridge University Press 2012
doi:10.1017/S0033291712002334
ORIGINAL ARTICLE
Kisely et al. 2006). More sustained long-term clinical
epidemiological studies exist in specialty treatment
samples (Katz et al. 1979; Bruce et al. 2005), but those
studies are now outdated because of changes in the
composition of patient populations since the studies
were initiated (Kessler et al. 2005).
We know from primary care screening studies that
untreated mental disorders are common in primary
care (Lowe et al. 2008; Gili et al. 2011). However,
screening studies tell us little about the natural history
of these disorders, as screening studies typically focus
on current prevalence or treatment response. Yet
information is needed on episode recurrence and
onset of secondary disorders to understand the public
health significance and long-term cost-effectiveness of
primary care screening, outreach and treatment qual-
ity improvement (Barrett et al. 2005; Konnopka et al.
2009). This integration of primary care with public
health is now an area of considerable policy interest
(Committee on Integration to Improve Population
Health, 2012).
One way to build a critical mass of such data would
be to blend longitudinal clinical epidemiological
studies with community epidemiological surveys. For
example, several new community epidemiological
surveys in the WHO World Mental Health (WMH)
Survey Initiative (Kessler & U
¨
stu
¨
n, 2008a) are using a
dual-frame sampling approach with parallel samples
of (i) patients in primary care (both with and without
detected and undetected mental disorders) and
(ii) other household residents in the same communi-
ties. This design facilitates comparisons of illness
prevalence course among treated and untreated cases
by collecting successive snapshots of current preva-
lence of disorders over multiple points in time.
Screening scales will be used in the primary care
segment of these surveys as the first stage in a two-
stage approach to oversample patients with current
mental disorders for second-stage interviews.
Screening scale responses are being ‘preloaded’ in the
computerized scripts of the second-stage interviews to
control question skip logic (e.g. skipping sections
based on negative screening responses; expanding
questions based on positive screening responses). The
screening scales used for this purposes are based on
the WHO Composite International Diagnostic
Interview (CIDI; Kessler & U
¨
stu
¨
n, 2004), the diagnos-
tic interview used in the WMH surveys and most
other psychiatric epidemiological surveys throughout
the world. Psychometric analyses of these disorder-
specific CIDI screening scales (CIDI-SC) have been
reported previously for adult attention deficit/hyper-
activity disorder (ADHD ; Kessler et al. 2007), insom-
nia, (Kessler et al. 2010a) and overall serious mental
illness (SMI; Kessler et al. 2010b). The current report
presents comparable results for the CIDI-SC scales of
major depressive episode (MDE), bipolar disorder
(BPD), generalized anxiety disorder (GAD) and panic
disorder (PD). Although the results presented are for
cross-sectional rather than longitudinal analyses, they
are relevant for the longitudinal design described
above because the latter is made up of a series of cross-
sectional snapshots.
Method
Screening scale development
The CIDI
The CIDI is a fully structured research diagnostic
interview developed for use by trained lay inter-
viewers to generate diagnoses of lifetime and recent
DSM-IV-TR/ICD-10 disorders (Robins et al. 1988).
Clinical reappraisal studies document generally good
concordance of CIDI diagnoses with blinded clinical
diagnoses (Wittchen, 1994 ; Kessler et al. 1998). The
CIDI uses extensive skip logic to reduce interview
length. This skip logic is also used in the CIDI-SC
based on the assumption that tablet computers will be
used to administer, score and print out summary
screening scale results.
Expanding the CIDI item pool
All CIDI symptom questions operationalize DSM/ICD
criteria using simple descriptive language (Robins
et al. 1988). However, validation studies find some
CIDI questions less concordant than others with in-
dependent clinical assessments (Wittchen et al. 1995;
Kessler et al. 2006 ; Green et al. 2011). We consequently
expanded the CIDI item pool in developing the
CIDI-SC scales by reviewing a wide range of other
diagnostic instruments to generate alternative symp-
tom questions. The expanded question set was re-
viewed iteratively, with diagnostic experts using their
judgment to pinpoint alternative questions they con-
sidered potentially useful and to help revise and
prioritize indicators. Previous methodological re-
search has shown that such iterative expert review is
often the most useful form of pretesting (Converse &
Presser, 1986; Presser & Blair, 1994 ; Groves et al. 2009).
Pilot testing
Once preliminary symptom questions were generated,
a convenience sample of 15 psychiatric out-patients
with each diagnosis was administered the disorder-
specific symptom questions. Cognitive debriefing
interviews (Willis, 2005) assessed problems in con-
ceptual understanding and question wording. These
interviews were conducted by professional cognitive
2 R. C. Kessler et al.
interviewers using the ‘ think aloud’ method (Presser
et al. 2004) to elicit initial respondent reactions and
collect alternative terminologies for confusing phrases.
The results were presented to the diagnostic experts
for review and final question revision.
The clinical reappraisal study
The sample
The revised questions were then administered to 3058
patients sampled from 29 primary care offices selected
to include practices in both urban and rural areas in all
four US Census Regions (Northeast, South, Midwest
and West). No other stratification criteria were used in
selecting practices. Practices were recruited through
the Primary Care Network (www.primarycarenet.
org). The original sample design called for a quota
sample of 100 completed interviews in each of 30
offices with an unselected consecutive sample of
patients. This sample size was selected to allow for the
second-stage assessment of at least 30 screened
positives for even the least common disorder (BPD)
assuming plausible prevalence estimates and second-
stage response rates. However, because one selected
office dropped out after office recruitment ended,
other offices in the same sample stratum were asked to
continue data collection for 2 days beyond the time
they met their quota, yielding a sample slightly larger
than the originally targeted 3000 and based on 29,
not 30, offices.
Respondent recruitment began by giving a ‘study
fact brochure’ to patients as they checked in that
explained the study as a test of a new screening ques-
tionnaire for common anxiety and mood disorders.
The brochure explained that the study needed people
aged o18 years both with and without the disorders
to complete a 15-min laptop computer questionnaire
in the waiting room; that participants would be re-
munerated US$25; that some participants would be
asked to participate in a telephone follow-up inter-
view that could take up to 1 h to complete; and that
telephone respondents would receive an additional
US$50. The brochure emphasized that responses were
confidential and decisions about participation would
not affect health-care treatment or benefits. Patients
who informed the office receptionist that they were
interested in the study then provided written in-
formed consent and received a laptop computer to
complete the questionnaire in the waiting room.
Telephone numbers provided in the questionnaire
were used to contact respondents and administer
clinical reappraisal interviews within 3 days of the
visit. The Human Subjects Committee of the New
England Institutional Review Board (www.neirb.com)
approved these recruitment, consent and field pro-
cedures.
The clinical reappraisal interview
Each CIDI-SC respondent was classified as ‘very like-
ly’, ‘likely’, ‘ possible ’ or ‘ no ’ on each screening scale.
A probability subsample of 30 respondents classified
‘very likely’ and 20 classified ‘likely-possible’ was
selected for each scale with replacement and admin-
istered the clinical reappraisal interview. The sampling
fraction varied across disorders due to prevalence
differences to make the sample well-distributed
across practices. Fifty patients who screened ‘ no ’
on all screening scales were also interviewed. The
total clinical reappraisal sample of 206 is less than
50r5=250 because some respondents were inde-
pendently selected for multiple disorders.
The clinical interview was an abridged Research
Version, Non-Patient Edition of the Structured Clinical
Interview for DSM-IV (SCID-I; First et al. 2002)
focused on the four syndromes under study : 30-day
MDE and GAD and lifetime and 30-day PD and
mania/hypomania. Experienced SCID interviewers
administered the interviews under the supervision of
a study collaborator (P.E.K.) blinded to CIDI-SC re-
sponses. 30-day PD was defined as lifetime PD with
30-day panic attacks and/or persistent concern
about additional attacks, worry about implications/
consequences of attacks, or significant change in be-
havior due to attacks. 30-day BPD was defined as
lifetime mania/hypomania with either 30-day MDE or
30-day mania/hypomania. SCID diagnoses were
made without diagnostic hierarchy rules but with
organic exclusions. Organic exclusions were not made
in the screening scales. Each SCID disorder was
classified as severe or non-severe to determine whe-
ther CIDI-SC could differentially detect more severe
cases. BP-I versus BP-II defined BPD severity whereas
the distinction between severe and non-severe cases of
the other disorders was based on SCID interviewer
assessments of whether there were (i) many symptoms
more than needed for diagnosis, (ii) several symptoms
that were particularly severe and/or (iii) marked
impairment in social or occupational functioning
associated with the disorder.
Analysis methods
The clinical reappraisal sample was weighted to adjust
for oversampling of patients screened as ‘very likely’,
‘likely’ or ‘possible’. Iterative stepwise logistic re-
gression was then used (0.05-level entry criterion) to
predict SCID diagnoses from CIDI-SC symptoms to
determine the minimum CIDI-SC question set needed
to approximate SCID diagnoses. An unweighted
CIDI screening scales for DSM-IV anxiety and mood disorders 3
summary CIDI-SC score was created for each
diagnosis from this minimum symptom set and re-
ceiver operating characteristic curve (ROC) analysis
(Margolis et al. 2002) was used to estimate the area
under the ROC curve (AUC) for each scale. The AUC
is the probability of correctly identifying SCID cases
from CIDI-SC scores in paired comparisons of ran-
domly selected pairs of SCID cases and non-cases,
where CIDI-SC tied scores are assigned a 50 % chance
of correct classification (Kraemer, 1992). The AUC has
a predicted value of 0.5 when the screening scale is
completely unrelated to the true score and 1.0 when
perfectly related. CIDI-SC scores were not weighted to
avoid overfitting in the absence of a large enough
sample for cross-validation.
Each CIDI-SC score was then collapsed so that SCID
prevalence estimates increased monotonically across
screening scale strata but did not differ significantly
within strata using the logic of stratum-specific likeli-
hood ratio (LR) analysis (Pepe, 2003). McNemar
x
2
tests then tested the significance of differences be-
tween CIDI-SC and SCID prevalence estimates.
Significance tests were based on Taylor series design-
based standard errors to adjust for data weighting
(Wolter, 1985).
Individual-level concordance was evaluated using
the AUC and Cohen’s k (Cohen, 1960). Although k is
the traditional measure used in psychiatric research,
it is not emphasized here because is varies across
populations that differ in prevalence even when sen-
sitivity (SN; the percentage of true cases correctly
classified) and specificity (SP ; the percentage of true
non-cases correctly classified) are constant (Cook,
1998). The AUC, in comparison, is a function of SN
and SP, which are considered the fundamental par-
ameters of agreement. The AUC equals (SN+SP)/2
when the screen is dichotomous. AUC scores between
0.5 and 1.0 are often interpreted in parallel with k as
slight (AUC=0.5–0.6, k=0.0–0.2), fair (AUC=0.6–0.7,
k=0.2–0.4), moderate (AUC=0.7–0.8, k=0.4–0.6),
substantial (AUC=0.8–0.9, k=0.6–0.8) and almost
perfect (AUC o0.9, k o0.8) (Landis & Koch, 1977). We
also report total classification accuracy (TCA), the
proportion of all respondents whose CIDI-SC and
SCID classifications are consistent.
In addition, we report disaggregated measures
of operating characteristics, including SN and SP,
positive predictive value (PPV; proportion of screened
positives confirmed by the SCID), negative predictive
value (NPV; proportion of screened negatives con-
firmed as non-cases by the SCID), LR positive [(LR+);
SN/(1 – SP)] and LR negative [LR–; (1 – SN)/SP)].
LR+ and LRx assess the relative proportions of
screened positives versus screened negatives con-
firmed as cases (LR+) or non-cases (LR–). LR+ values
o5 and LRx values f0.2 are generally considered
useful, whereas LR+ values o10 and LRx values
f0.1 are considered sufficient to rule in/out diag-
noses (Haynes et al. 2006).
Comparison with other widely used screening scales
To compare CIDI-SC operating characteristics with
other screening scales, a 1990–2012 Medline search of
screening scale validity studies was carried out using
search terms ‘screening’, ‘ validity ’, ‘sensitivity’,
‘specificity’, ‘ case finding’ and ‘AUC’ crossed with
‘depression’, ‘bipolar disorder ’, ‘manic depression ’,
‘generalized anxiety disorder’ and ‘panic disorder’.
We focused on studies where screening scales were
compared to blinded clinical reappraisal interviews in
samples of patients, community residents or internet
users. Only key studies were considered.
Results
Stepwise logistic regression
Separate stepwise logistic regression analyses were
used to predict each SCID disorder from the corre-
sponding CIDI screening items.
MDE
Three CIDI questions were entered stepwise to pre-
dict 30-day dysphoria (sad–depressed, down–
discouraged) and anhedonia (little–no interest in
day-to-day activities) in the total sample. Among re-
spondents with dysphoria and/or anhedonia, five
additional questions were entered to screen for other
DSM-IV Criterion A symptoms of MDE or the
Criterion C requirement of clinically significant dis-
tress or impairment. The AUC for the continuous
CIDI-SC scale with these eight questions was 0.93.
GAD
Two CIDI questions were entered to screen for 30-day
DSM-IV GAD Criterion A (excessive anxiety–worry
about multiple events–activities) in the total sample.
Among Criterion A screened positives, five additional
questions were entered to screen for Criteria B
(difficulty controlling worry), C (restless, difficulty re-
laxing) and E (clinically significant distress or im-
pairment). The AUC for the continuous CIDI-SC scale
with these seven questions was 0.88.
PD
Two CIDI questions were entered to screen for having
lifetime attacks of intense fear or discomfort that
came on very suddenly in the total sample. Among
4 R. C. Kessler et al.
