Standardized Psychiatric Interviews

39

7. Stoloff M, Couch J: Computer Use in Psychology: A Directory of Software, 3rd ed. Washington, DC, American Psychological Association, 1992. 8. Streiner D, Norman GR: Health Measurement Scales: A Practical Guide to Their Development and Use. Oxford, Oxford University Press, 1989. 9. Thelen M, Farmer J, Wonderlich S, Smith M: A revision of the bulimia test-the BULIT-R. Psychological 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 nPh.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 pinpoint 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 conducted in a comparable fashion by all clinicians both within and across institutions.
3. What is the difference between a fully structured and a semi-structuredinterview 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 semistructured 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 responses 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 interviews) and interviews to assess the severity of certain types of symptoms at a specific point in time (cross-sectionalsymptom severity rating scales).

40

Standardized Psychiatric Interviews Summary of Diagnostic Interviews

INTERVIEW
~~~

DIAGNOSTIC SYSTEM

FORMAT

INTERVIEWER

Schedule of Affective Disorders and Schizophrenia (SADS) Diagnostic Interview Schedule (DIS) Structured Clinical Interview for DSM Diagnosis (SCID) Composite International Diagnostic Interview (CIDI)

Research Diagnostic Criteria (RDC) DSM-I11 DSM-111-R, DSM IV DSM-111-R, ICD- 10

Semi-structured Fully structured Semi-structured Fully structured

Clinician Lay person Clinician Lay person

5. Which fully structured diagnostic interview is used most commonly? The Diagnostic Interview Schedule (DIS). The DIS was developed for use in large-scale epidemiologic 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 independent 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-structureddiagnostic 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 provided 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 exclusion 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 currently 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

Standardized Psychiatric Interviews

41

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 patient and the ability of the patient to give a concise history. A completed interview with a good informant 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 METHOD

Depression

Anxiety

General
Brief Psychiatric Rating Scale (BPRS)

FUNCTIONING

Interview:

Self Report:

Hamilton Depression Hamilton Anxiety Rating Scale Rating Scale Inventory for DepressiveSymptomatology (IDS) Montgomery-Asberg Scale Raskin Scale Beck Depression Beck Anxiety Inventory Inventory Inventory for Depressive State-Trait Anxiety Symptomatology (IDS-SR) Inventory Zune Inventory

Symptom Checklist-90 (SCL-90) Profile of Mood States (POMS)

Global Assessment of Functioning (GAF) Clinical Global Impression Scale (CGI) Social Adjustment Scale (SAS)

10. What if I dont have time to administer the assessment? Are there any questionnairesthat 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 dimension, such as depression (see table above). 11. Symptom assessment does not tell me whether or not a person is functioning in the community. 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

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 Scalezzhas been widely used for this purpose, 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.

CLINICAL GLOBAL IMPRESSIONS

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 1 = Normal, not at all ill 2 = Borderline mentally ill 3 = Mildly ill

4 = Moderately ill 5 = Markedly ill 6 = Severely ill 7 = Among the most extremely ill patients

2.

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 1 2 3 = Not Assessed

Very much improved = Much improved = Minimally improved

=

4 = No change 5 = Minimally worse 6 = Much worse I = Very much worse

3.

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. THERAPEUTIC EFFECT

I
01
02
05

SIDE EFFECTS

MARKED :

Vast improvement. Complete or nearly complete remission of all symptoms Decided improvement. Partial remission of symptoms. Slight improvement which doesnt alter status of care of patient.

03

04

MODERATE:

06

07

08

MINIMAL:

09

10

11

12

UNCHANGED OR WORSE Not Assessed = 00

13

14

15

16

Standardized Psychiatric Interviews

BIBLIOGRAPHY

43

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

DC, American Psychiatric Association, 1980. 2. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders-111-R. Washington, DC, American Psychiatric Association, 1987. 3. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders-IV. Washington, DC, American Psychiatric Association, 1994. 4. Beck AT, Brown G, Epstein N, Steer RA: An inventory for measuring clinical anxiety: Psychometric properties. J Consult Clin Psychol 55:893-987,1988. 5. Beck AT, Ward CH, Mendelson M, et al: An inventory for measuring depression. Arch Gen Psychiatry 4:561- 571, 1961. 6. Derogatis LR: SCL-90-R Administration, Scoring and Procedures Manual-11. for the Revised Version. Towson, MD, Clinical Psychometric Research, 1983. 7. Endicott J, Spitzer RL: A diagnostic review. The Schedule for Affective Disorders and Schizophrenia. Arch Gen Psychiatry 35:837-844, 1978. 8. Guy W ECDEU Assessment Manual for Psychopharmacology, Revised, 1976. Rockville, MD, DHEW Publication No. (ADM) 76-338, 1976, pp 217-222. 9. Hamilton M: The assessment of anxiety states by rating. Br J Med Psychol 32:5&55, 1959. 10. Hamilton M: The development of a rating scale for primary depressive illness. Br J SOCClin Psychol 6:278-296, 1967. 11. Lipman RS: Differentiating anxiety and depression in anxiety disorders: use of rating scales. [description of Raskin and Covi scales]. Psychopham Bull 18:69-105, 1982. 12. McNair DM, Lorr M, Droppleman LF: Manual for the Profile of Mood States. San Diego, Educational and Industrial Testing Service, 1971. 13. Montgomery SA, Asberg ML: A new depression scale designed to be sensitive to change. Br J Psychiatry 1341382-389, 1979. 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 epidemiologic 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 American Psychiatric Association, Inc., In (eds): Handbook of Psychiatric Measures. Washington, DC, 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.