Health problems, impairment and illnesses associated with bulimia nervosa and binge eating disorder among primary care and obstetric gynaecology patients.

BACKGROUND: Although psychiatric patients with eating disorders are known to be at risk for a variety of health problems, relatively little is known about eating disorders and associated health problems in other populations. An epidemiological study was conducted to investigate health problems and impairment associated with bulimia nervosa (BN) and binge eating disorder (BED) among female primary care and obstetric gynaecology patients. METHODS: Psychiatric disorders, physical illnesses, disabilities, functional status and stress were assessed among 4651 female patients (age range:18 to 99 years) at 8 primary care and 7 obstetric gynaecology clinics throughout the United States. RESULTS: Two hundred eighty-nine women (62%) were diagnosed with BN or BED. The prevalence of BN was approximately 1% among young and middle-aged women. The prevalence of BED increased steadily from early (3.3%) through middle (8.5%) adulthood. Anxiety disorders, mood disorders and diabetes were much more common among women with BN or BED than among women without these eating disorders. Women with BN or BED reported markedly poorer functioning and much higher levels of disability, health problems, insomnia, psychosocial stress and suicidal thoughts than did women without BN or BED, after co-occurring psychiatric disorders were controlled statistically. Yet, fewer than one of ten cases of BN or BED was recognized by the patients' physicians. CONCLUSIONS: Patients with BN or BED often experience considerable disability, impairment, distress and co-occurring illnesses. Increased recognition of eating disorders may be a crucial step towards encouraging more patients to seek treatment for these disabling conditions.

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

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. MEASUREMENTS: The Patient Health Questionnaire (PHQ) is a self-administered version of the PRIME-MD diagnostic instrument for common mental disorders. The PHQ-9 is the depression module, which scores each of the 9 DSM-IV criteria as "0" (not at all) to "3" (nearly every day). The PHQ-9 was completed by 6,000 patients in 8 primary care clinics and 7 obstetrics-gynecology clinics. Construct validity was assessed using the 20-item Short-Form General Health Survey, self-reported sick days and clinic visits, and symptom-related difficulty. Criterion validity was assessed against an independent structured mental health professional (MHP) interview in a sample of 580 patients. RESULTS: As PHQ-9 depression severity increased, there was a substantial decrease in functional status on all 6 SF-20 subscales. Also, symptom-related difficulty, sick days, and health care utilization increased. Using the MHP reinterview as the criterion standard, a PHQ-9 score > or =10 had a sensitivity of 88% and a specificity of 88% for major depression. PHQ-9 scores of 5, 10, 15, and 20 represented mild, moderate, moderately severe, and severe depression, respectively. Results were similar in the primary care and obstetrics-gynecology samples. CONCLUSION: In addition to making criteria-based diagnoses of depressive disorders, the PHQ-9 is also a reliable and valid measure of depression severity. These characteristics plus its brevity make the PHQ-9 a useful clinical and research tool.

Validation and utility of the patient health questionnaire in diagnosing mental disorders in 1003 general hospital Spanish inpatients.

OBJECTIVE: To determine whether the Spanish version of the patient health questionnaire (PHQ) has validity and utility for diagnosing mental disorders in general hospital inpatients. METHODS: Participants in the study were 1003 general hospital inpatients, randomly selected from all admissions over an 18-month period. All of them completed the PHQ, the Beck Depression Inventory (BDI), and measures of functional status, disability days, and health care use, including length of hospital stay. They also had a structured interview with a mental health professional. RESULTS: A total of 416 (42%) of the 1003 general hospital inpatients had a PHQ diagnosis. There was good agreement between PHQ diagnoses and those of an independent mental health professional (for the diagnosis of any PHQ disorder, kappa = 0.74; overall accuracy, 88%; sensitivity, 87%; specificity, 88%), similar to the original English version of the PHQ in primary care patients. Patients with PHQ diagnoses had more functional impairment, disability days, and health care use than did patients without PHQ diagnoses (group main effects for functional status measures and disability days, p < .001; group main effects for health care use, p < .01). The group main effect for hospital length of stay was not significant. An index of depression symptom severity calculated from the PHQ correlated significantly both with the number of depressive symptoms detected at interview and the total BDI score. PHQ administration was well accepted by patients. CONCLUSIONS: The Spanish version of the PHQ has diagnostic validity in general hospital inpatients comparable to the original English version in primary care.

Values and assumptions in the development of DSM-III and DSM-III-R: an insider's perspective and a belated response to Sadler, Hulgus, and Agich's "On values in recent American psychiatric classification".

It is widely acknowledged that the approach taken in the development of a classification of mental disorders is guided by various values and assumptions. The author, who played a central role in the development of DSM-III (American Psychiatric Association [1980] Diagnostic and statistical manual of mental disorders, 3rd ed. Washington, DC:Author) and DSM-III-R (American Psychiatric Association [1987] Diagnostic and statistical manual of mental disorders, 3rd ed, rev. Washington, DC:Author) will explicate the basic values and assumptions that guided the development of these two diagnostic manuals. In so doing, the author will respond to the critique of DSM-III and DSM-III-R made by Sadler et al. in their 1994 paper (Sadler JZ, Hulgus YF, Agich GJ [1994] On values in recent American psychiatric classification. JMed Phil 19:261-277). The author will attempt to demonstrate that the stated goals of DSM-III and DSM-III-R are not inherently in conflict and are easily explicated by appealing to widely held values and assumptions, most of which appeared in the literature during the development of the manuals. Furthermore, we will demonstrate that it is not true that DSM-III places greater emphasis on reliability over validity and is covertly committed to a biological approach to explaining psychiatric disturbance.

Development and validation of a screening instrument for bipolar spectrum disorder: the Mood Disorder Questionnaire.

OBJECTIVE: Bipolar spectrum disorders, which include bipolar I, bipolar II, and bipolar disorder not otherwise specified, frequently go unrecognized, undiagnosed, and untreated. This report describes the validation of a new brief self-report screening instrument for bipolar spectrum disorders called the Mood Disorder Questionnaire. METHOD: A total of 198 patients attending five outpatient clinics that primarily treat patients with mood disorders completed the Mood Disorder Questionnaire. A research professional, blind to the Mood Disorder Questionnaire results, conducted a telephone research diagnostic interview by means of the bipolar module of the Structured Clinical Interview for DSM-IV. RESULTS: A Mood Disorder Questionnaire screening score of 7 or more items yielded good sensitivity (0.73) and very good specificity (0.90). CONCLUSIONS: The Mood Disorder Questionnaire is a useful screening instrument for bipolar spectrum disorder in a psychiatric outpatient population.

Validity and utility of the PRIME-MD patient health questionnaire in assessment of 3000 obstetric-gynecologic patients: the PRIME-MD Patient Health Questionnaire Obstetrics-Gynecology Study.

OBJECTIVE: This study was undertaken to determine the prevalence of mental disorders among obstetric-gynecologic patients and to assess the validity and utility of the PRIME-MD Patient Health Questionnaire (PHQ) in this population. STUDY DESIGN: A total of 3000 patients were assessed by 63 clinicians at seven obstetrics-gynecology outpatient care sites. The main outcome measures were PRIME-MD PHQ diagnoses, psychosocial stressors, independent diagnoses made by mental health professionals, functional status measures, disability days, health care use, and treatment or referral decisions. RESULTS: Current mental disorders were fairly prevalent, present in 1 in 5 obstetric-gynecologic patients. Patients with PRIME-MD PHQ diagnoses had more functional impairment, disability days, health care use, and psychosocial stressors than did patients without PRIME-MD PHQ diagnoses (P <.005 for all measures). Although most clinicians judged the PRIME-MD PHQ to be useful in management decisions, the questionnaire diagnosis of mental disorder rarely led to therapeutic intervention. CONCLUSION: The PRIME-MD PHQ is a useful instrument for the assessment of mental disorders, functional impairment, and recent psychosocial stressors in the busy obstetrics-gynecology setting.

Self-defeating personality disorder reconsidered.

The objective of this study was to assess the distinctiveness, incremental validity, and gender bias of self-defeating personality disorder (SDPD) symptoms. A total of 441 nonclinical subjects completed personality disorder questionnaires. Structural equation modeling and regression analyses indicated that SDPD symptoms were distinctive, predicted impairment/distress beyond other personality disorder symptoms, and showed no gender bias. SDPD warrants reconsideration as a valid nosological category.

DSM-IV diagnostic criterion for clinical significance: does it help solve the false positives problem?

OBJECTIVE: A major change in DSM-IV is the inclusion in almost one-half of the diagnostic criteria sets of a clinical significance criterion, which requires that symptoms cause "clinically significant distress or impairment in social, occupational, or other important areas of functioning." In response to concerns that the DSM criteria are overly inclusive, the clinical significance criterion attempts to minimize false positive diagnoses in situations in which the symptom criteria do not necessarily indicate pathology. This article examines whether the clinical significance criterion achieves its purpose and considers its broader impact on diagnostic validity. METHOD: The effect of the clinical significance criterion on the diagnostic validity of DSM-IV criteria for a wide range of disorders was examined. RESULTS: For many diagnoses to which the clinical significance criterion was added, the symptom criteria are inherently associated with significant impairment, so the clinical significance criterion is redundant and therefore does not affect caseness. For some diagnoses, the clinical significance criterion is potentially helpful in eliminating false positives by elevating the level of required distress. However, there may be advantages to obtaining the same results by modifying some of the symptom criteria. Often the clinical significance criterion has led to the possibility of false negative diagnoses. CONCLUSIONS: In the process of revising DSM-IV, the generic use of the clinical significance criterion should be reconsidered. For each DSM diagnosis, it should be determined whether there is a need to raise the threshold of any of the existing symptom criteria or to add a criterion that excludes normal reactions to psychosocial stress.

Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire.

CONTEXT: The Primary Care Evaluation of Mental Disorders (PRIME-MD) was developed as a screening instrument but its administration time has limited its clinical usefulness. OBJECTIVE: To determine if the self-administered PRIME-MD Patient Health Questionnaire (PHQ) has validity and utility for diagnosing mental disorders in primary care comparable to the original clinician-administered PRIME-MD. DESIGN: Criterion standard study undertaken between May 1997 and November 1998. SETTING: Eight primary care clinics in the United States. PARTICIPANTS: Of a total of 3000 adult patients (selected by site-specific methods to avoid sampling bias) assessed by 62 primary care physicians (21 general internal medicine, 41 family practice), 585 patients had an interview with a mental health professional within 48 hours of completing the PHQ. MAIN OUTCOME MEASURES: Patient Health Questionnaire diagnoses compared with independent diagnoses made by mental health professionals; functional status measures; disability days; health care use; and treatment/referral decisions. RESULTS: A total of 825 (28%) of the 3000 individuals and 170 (29%) of the 585 had a PHQ diagnosis. There was good agreement between PHQ diagnoses and those of independent mental health professionals (for the diagnosis of any 1 or more PHQ disorder, kappa = 0.65; overall accuracy, 85%; sensitivity, 75%; specificity, 90%), similar to the original PRIME-MD. Patients with PHQ diagnoses had more functional impairment, disability days, and health care use than did patients without PHQ diagnoses (for all group main effects, P<.001). The average time required of the physician to review the PHQ was far less than to administer the original PRIME-MD (<3 minutes for 85% vs 16% of the cases). Although 80% of the physicians reported that routine use of the PHQ would be useful, new management actions were initiated or planned for only 117 (32%) of the 363 patients with 1 or more PHQ diagnoses not previously recognized. CONCLUSION: Our study suggests that the PHQ has diagnostic validity comparable to the original clinician-administered PRIME-MD, and is more efficient to use.

Jet lag: clinical features, validation of a new syndrome-specific scale, and lack of response to melatonin in a randomized, double-blind trial.

OBJECTIVE: The goals of this study were to validate a new rating scale for measuring severity of jet lag and to compare the efficacy of contrasting melatonin regimens to alleviate jet lag. METHOD: This was a randomized, double-blind trial of placebo and three alternative regimens of melatonin (5.0 mg at bedtime, 0.5 mg at bedtime, and 0.5 mg taken on a shifting schedule) for jet lag. The subjects were 257 Norwegian physicians who had visited New York for 5 days. Jet lag ratings were made on the day of travel from New York back to Oslo (6 hours eastward) and for the next 6 days in Norway. The main outcome measures were scale and item scores from a new, syndrome-specific instrument, the Columbia Jet Lag Scale, that identifies prominent daytime symptoms of jet lag distress. RESULTS: There was a marked increase in total jet lag score in all four treatment groups on the first day at home, followed by progressive improvement over the next 5 days. However, there were no significant group differences or group-by-time interactions. In addition, there was no group effect for sleep onset, time of awakening, hours slept, or hours napping. Ratings on a summary jet lag item were highly correlated with total jet lag scores (from a low of r = 0.54 on the day of travel to a high of r = 0.80 on day 3). The internal consistency of the total jet lag score was high on each day of the study. CONCLUSIONS: The use of melatonin for preventing jet lag needs further study.

Harmful dysfunction and the DSM definition of mental disorder.

Physicians, including psychiatrists, give a lot of thought in their everyday work to answer the question of whether or not a particular patient has a disorder; they rarely give much thought to the broader issue of what constitutes a disorder. Remarkably, and consistent with the harmful dysfunction (HD) analysis, there is a broad consensus in both the general public and the medical and health professions as to what conditions are disorders--even though there is no consensus definition of disorder. The HD analysis is a substantial advance over previous attempts to define disorder in specifying the nature of what is not working in the individual (the dysfunction). The adoption of the HD analysis in DSM-V (Diagnostic and Statistical Manual of Mental Disorders, 5th ed.) would probably have little if any effect on the list of categories of mental disorders. Its main value would be in helping make revisions in the diagnostic criteria more valid as true indicators of disorder.

Identifying patients with depression in the primary care setting: a more efficient method.

OBJECTIVE: To determine if there is a core subset of depressive symptoms that could be used to efficiently diagnose depression after administering the 2-item PRIME-MD a screening questionnaire for depression. METHODS: One thousand patients selected randomly and by convenience from 4 primary care clinics were assessed by PRIME-MD and completed a questionnaire measuring the following validation variables: functional status and well-being, disability days, somatic symptoms, depression severity, suicidal thoughts, health care utilization, and the physician-patient relationship. RESULTS: Four symptoms (sleep disturbance, anhedonia, low self-esteem, and decreased appetite) accounted for virtually all the depression symptom-related variance in functional status and well-being, with 8.3% of patients having 2 of these symptoms and 8.2% having 3 or 4 of these symptoms. There was excellent agreement between diagnosis based on core symptoms and major depression (K= 0.77; overall accuracy rate, 94%). There were significant differences (P<.001) among patients with negative depression screen, 0 to 1, 2, and 3 to 4 core symptoms with scores on each of the validation variables getting progressively worse in these 4 groups. A cutoff point of 2 core symptoms identified all but 3 patients with major depression and an additional 5% of the entire sample without major depression who were significantly (P<.05) worse than patients without depression on each of the validation variables. CONCLUSION: A strategy that includes the use of a 2-item depression screener followed by the evaluation of 4 core depressive symptoms is an efficient and effective way of identifying and classifying primary care patients with depression in need of clinical attention.

A symptom checklist to screen for somatoform disorders in primary care.

Current DSM-IV somatoform diagnoses may inadequately capture many somatizing patients in primary care. By using data from two studies (1,000 and 258 patients, respectively), the authors determined 1) the optimal threshold on a checklist of 15 physical symptoms to screen for a recently proposed somatoform diagnosis, multisomatoform disorder (MSD), and 2) the concordance between MSD and somatization disorder. The optimal threshold for pursuing a diagnosis of MSD was seven or more physical symptoms. The majority (88%) of the patients who met criteria for MSD had either full or abridged somatization disorder. MSD was intermediate between abridged and full somatization disorder in terms of its association with functional impairment, psychiatric comorbidity, family dysfunction, and health care utilization and charges.

Gender differences in the reporting of physical and somatoform symptoms.

OBJECTIVE: Women have consistently been shown to report greater numbers of physical symptoms. Our aim in this study was to assess gender differences for specific symptoms and to assess how much of these differences were attributable to psychiatric comorbidity. METHOD: Data from the PRIME-MD 1000 study (1000 patients from four primary case sites evaluated with the Primary Care Evaluation of Mental Disorders interview) were analyzed to determine gender differences in the reporting of 13 common physical symptoms. The effect of gender on symptom reporting was assessed by multivariate analysis, adjusting for depressive and anxiety disorders as well as age, race, education, and medical comorbidity. RESULTS: All symptoms except one were reported more commonly by women, with the adjusted odds ratios (typically in the 1.5-2.5 range) showing statistically significant differences for 10 of 13 symptoms. Somatoform (ie, physically unexplained) symptoms were also more frequent in women. Although depressive and anxiety disorders were the strongest correlate of symptom reporting, gender had an independent effect that persisted even after adjusting for psychiatric comorbidity. Gender was the most important demographic factor associated with symptom reporting, followed by education. CONCLUSIONS: Most physical symptoms are typically reported at least 50% more often by women than by men. Although mental disorders are also more prevalent in women, gender influences symptom reporting in patients whether or not there is psychiatric comorbidity.

Multisomatoform disorder. An alternative to undifferentiated somatoform disorder for the somatizing patient in primary care.

BACKGROUND: For clinical or research use in primary care, the DSM-IV diagnostic criteria for somatization disorder are too restrictive, while the criteria for undifferentiated somatoform disorder are overly inclusive. In this article, we examine the validity of multisomatoform disorder, defined as 3 or more medically unexplained, currently bothersome physical symptoms plus a long (> or = 2 years) history of somatization. METHODS: Data from the Primary Care Evaluation of Mental Disorders Study of 1000 patients from 4 primary care sites were analyzed. The outcomes assessed were 6 domains of health-related quality of life, using the 20-item Short-Form General Health Survey; self-reported disability days and health care use; satisfaction with care; and physician-rated difficulty of the encounter. RESULTS: Multisomatoform disorder was diagnosed in 82 (8.2%) of the 1000 patients who were enrolled in the Primary Care Evaluation of Mental Disorders Study. Compared with mood and anxiety disorders, multisomatoform disorder was associated with comparable impairment in health-related quality of life, more self-reported disability days and clinic visits, and greater clinician-perceived patient difficulty. CONCLUSIONS: Multisomatoform disorder may be a valid diagnosis and potentially more useful than the DSM-IV diagnosis of undifferentiated somatoform disorder. Also, because multisomatoform disorder has a large and independent effect on impairment, its diagnosis should not be precluded simply because of a coexisting mood or anxiety disorder.