The intimate connection between antisocial personality and substance abuse.

There is a powerful association between antisocial behavior and substance abuse. What is still uncertain is whether the association between the two is causal, so that one disorder leads to the other, or is explained by shared symptoms or shared risk factors, or suggests that the two disorders are not distinct, but are actually variants of the same underlying disorder. Each of these hypotheses is shown to be plausible. The paper considers four criteria for causality: precedence, coherence with existing knowledge, dose-related liability, and understandability of mechanisms. Problems are noted with each of these criteria. Conduct disorder as a cause of substance abuse fulfills these criteria more obviously than does substance abuse as a cause of antisocial behavior, but both have plausibility. A similarity is noted between the tasks of deciding whether one disorder causes another and deciding whether early symptom patterns predict the later course of a single disorder. The dearth of information about effect of the early symptom profile on the later course can be overcome with careful study design. Such studies promise important gains in patient management. The necessary data are outlined and instruments to collect such data are noted to be newly published or in development.

Detecting errors in a scoring program: a method of double diagnosis using a computer-generated sample.

This paper discusses a new method for locating errors in diagnostic computer scoring programs for structured clinical interviews. It was proposed as a test of the accuracy of the scoring program for the Composite International Diagnostic Interview, version 1.1. The proposal was to create an independent scoring program in a different computer language but serving the same criteria. Both programs were then applied to the same large set of valid (i.e., logically consistent) computer-generated test cases, and differences in diagnostic assignments reviewed. The method described can identify the program steps that account for the sources of the errors. Corrections can be made and the programs run again on new sets of test cases until discrepancy-free results are achieved. While this method cannot discover errors that are repeated in the two programs, it does discover more of the errors in a scoring program than we have previously been able to identify. This technique provides a systematic and rigorous approach to assuring the accuracy of scoring programs based on established algorithms.

Increasing brain tumor rates: is there a link to aspartame?

In the past two decades brain tumor rates have risen in several industrialized countries, including the United States. During this time, brain tumor data have been gathered by the National Cancer Institute from catchment areas representing 10% of the United States population. In the present study, we analyzed these data from 1975 to 1992 and found that the brain tumor increases in the United States occurred in two distinct phases, an early modest increase that may primarily reflect improved diagnostic technology, and a more recent sustained increase in the incidence and shift toward greater malignancy that must be explained by some other factor(s). Compared to other environmental factors putatively linked to brain tumors, the artificial sweetener aspartame is a promising candidate to explain the recent increase in incidence and degree of malignancy of brain tumors. Evidence potentially implicating aspartame includes an early animal study revealing an exceedingly high incidence of brain tumors in aspartame-fed rats compared to no brain tumors in concurrent controls, the recent finding that the aspartame molecule has mutagenic potential, and the close temporal association (aspartame was introduced into US food and beverage markets several years prior to the sharp increase in brain tumor incidence and malignancy). We conclude that there is need for reassessing the carcinogenic potential of aspartame.

Comorbidity and boundaries of affective disorders with anxiety disorders and substance misuse: results of an international task force.

Associations between affective disorders, anxiety disorders, and substance use disorders were examined in epidemiological studies conducted in Germany, Switzerland, Puerto Rico, and the mainland US. There was a remarkable degree of similarity across studies in the magnitude and type of specific disorders associated with the affective disorders. Comorbidity with affective disorders was greater for the anxiety disorders than for substance misuse. Panic disorder was the subtype of anxiety that was most highly comorbid with depression. Social phobia was the specific phobic type with the strongest association with the affective disorders. The magnitude of associations between substance misuse and affective disorders generally was quite low and less consistent across sites. No major differences were found in the patterns of comorbidity by gender or age group, affective subtype or prevalence period. The onset of anxiety disorders generally preceded that of depression, whereas alcohol misuse was equally likely to pre-or post-date the onset of affective disorders. Finally, comorbidity was associated with an elevation in treatment rates across all sites, confirming Berkson's paradox on an international level.

A short computer interview for obtaining psychiatric diagnoses.

OBJECTIVE: To determine whether a short computer interview could be used in place of a full diagnostic interview to obtain psychiatric diagnoses, the authors examined the short interview's sensitivity, specificity, and diagnostic agreement with the full interview. METHODS: Patients recently discharged from a university psychiatric service were interviewed in two back-to-back sessions, one in which a full diagnostic interview was used and the other in which a short computer interview was used. Based on diagnoses derived from both interviews, the sensitivity and specificity of the short interview and kappa values reflecting the diagnostic agreement of the two interviews were calculated. RESULTS: The short interview had high sensitivity and specificity and excellent diagnostic agreement with the full interview for most disorders. It also had a significantly shorter administration time. However, it missed a substantial percentage of cases of generalized anxiety disorder and misclassified as in remission a substantial proportion of patients with active cases of post-traumatic stress disorder. CONCLUSIONS: With few exceptions, the short interview may be substituted for the full interview when missing an active case is not important or when a count of individual symptoms and subtyping of disorders are not needed. Such uses include screening subjects for inclusion in a study and obtaining an overview of a patient's lifetime psychiatric status.

The Diagnostic Interview Schedule for Children (PC-DISC v.3.0): parents and adolescents suggest reasons for expecting discrepant answers.

To identify reasons for discrepancies between parent and child reports of child/adolescents's psychiatric symptoms, parents and adolescents (51 pairs) were asked to guess what the other would answer to questions from the PC-DISC about the adolescent's psychiatric symptoms, and to explain why they expected disagreement when the answer they provided for the other was different from their own. Adolescents' explanations for expecting (1) parental denial of symptoms the adolescent reported were: the parent was unaware of, forgot about, assumed the adolescent could not have, or trivialized the symptom; and (2) parental report of symptoms the adolescent denied were: the parent misread or exaggerated the adolescent's symptom, had too high expectations for the adolescent's behavior, put a negative label on or did not trust the adolescent. Parents' reasons for expecting their children to (1) deny symptoms the parents reported were: the adolescent did not remember how s/he felt, lied, did not recognize or minimized the importance or frequency of the symptom; and (2) report symptoms the parents denied were: the adolescent lied, exaggerated the importance of or interpreted the symptom differently.

Perceived barriers to care in St. Louis (USA) and Christchurch (NZ): reasons for not seeking professional help for psychological distress.

This paper examines perceived barriers to mental health care reported in two very similar community surveys in two cities that are not only on opposite sides of the world but that differ substantially in their health care systems, their size, and their mix of ethnic groups, namely, St. Louis in the United States and Christchurch in New Zealand. Respondents were asked about mental health care ever received, any failure to seek care when required, and symptoms of 14 psychiatric disorders according to DSM-III. The frequency with which respondents reported not seeking care and the popularity of specific reasons for not seeking care were almost identical in the two sites. A common reason offered for not seeking care was doubt about the need for professional help; this appeared to be particularly common for people with alcohol disorder. Respondents who said that they had failed to seek care when needed gave reasons that were mainly attitudinal, such as believing they should be strong enough to cope without professional help. Structural characteristics of services such as cost, times open, and travel distance were given less often. Sociodemographic factors had small or negligible effect on care seeking.

The sixth Thomas James Okey Memorial Lecture. Vietnam veterans' rapid recovery from heroin addiction: a fluke or normal expectation?

Between 1972 and 1974, the outcomes of army enlisted men who had served in Vietnam during 1970-71 were evaluated and compared with that of a matched group. This paper reports the major findings of that study with respect to frequency of narcotic addiction in and after Vietnam, and the major risk factors for Vietnam addiction and later relapse. Extraordinary access to records facilitated drawing the sample, locating it, and verifying interview responses. The surprisingly low levels of readdiction and the rarity of addiction to narcotics alone as compared with poly-substance dependence are findings still not entirely incorporated into public and scientific views of heroin addiction. Some defenses against that incorporation are examined.

One-month prevalence of mental disorders in the United States and sociodemographic characteristics: the Epidemiologic Catchment Area study.

The associations between the one-month prevalence rates of mental disorders and sociodemographic characteristics were investigated for 18,571 people interviewed in the first-wave community samples of all 5 sites in the US National Institute of Mental Health (NIMH) Epidemiologic Catchment Area program. Men were found to have a significantly higher rate of cognitive impairment than women after controlling for the effects of age, race or ethnicity, marital status and socioeconomic status. Marital status was one of the most powerful correlates of mental disorder risk: the odds of separated or divorced people having any NIMH Diagnostic Interview Schedule disorder were twice that of married people after controlling for age, gender, race or ethnicity and socioeconomic status. The odds of those in the lowest socioeconomic status group having any Diagnostic Interview Schedule disorder was about 2.5 times that of those in the highest socioeconomic status group, controlling for age, gender, race or ethnicity and marital status. For all disorders except cognitive impairment, race or ethnicity did not remain statistically significant after controlling for age, gender, marital status and socioeconomic status.

Clinical observation of assessment using the Composite International Diagnostic Interview (CIDI). An analysis of the CIDI Field Trials--Wave II at the St Louis site.

Two clinicians scored the ICD-10 Research Criteria Checklist either while observing or after administering CIDI interviews to a sample of 20 subjects. Overall diagnostic concordance between clinical and CIDI assessments was found to be good (overall kappa = 0.77). Assessment of the specific diagnoses could be done only for the three most commonly represented in the studied sample: anxiety/phobic disorders (kappa = 0.73), depressive disorders (kappa = 0.78), and psychoactive substance use disorders (kappa = 0.83). While the lack of independence of the two assessments and the small, non-randomly selected sample might have exaggerated the concordance, this study shows that the CIDI provides all the data needed to score diagnoses in the ICD-10 nomenclature, as indicated by the small number of questions clinicians needed to ask following completion of the CIDI.

Comparison of Composite International Diagnostic Interview and clinical DSM-III-R criteria checklist diagnoses.

This article describes a comparison of Composite International Diagnostic Interview (CIDI) diagnostic results and results based on clinicians' observation of CIDI assessments. Psychiatrists scored a DSM-III-R criteria checklist either while observing or after administering 20 CIDI interviews. Overall diagnostic concordance between the checklist and CIDI diagnoses was found to be good (kappa = 0.78). Good diagnostic agreement was also found for 3 groups of DSM-III-R disorders: depressive disorders (kappa = 0.84), psychoactive substance use disorders (kappa = 0.83) and anxiety phobic disorders (kappa = 0.76). These results are consistent with the results from a similar comparison between the CIDI and checklist results for ICD-10 diagnoses.

A comparison of two computer-administered versions of the NIMH Diagnostic Interview Schedule.

This study compared three versions of the NIMH Diagnostic Interview Schedule (DIS): "traditional" interviewer-administered DIS; computer-administered DIS (subject interacting alone with computer); computer-prompted DIS (interviewer using computer program as a guide). Kappas for 20 diagnoses ranged from .15 to .94, and averages for the three method pairs ranged from .57 to .64, which are comparable to other DIS reliability studies. Agreement between pairs of methods were comparable. Subjects' attitudes toward the computer interview were positive. While they felt they could better describe their feelings and ideas to a human, they found the computer contact less embarrassing. Overall, subjects had no preference for one method over another. Measures of social desirability and deviant response biases were correlated with diagnostic results. Reading ability did not affect subject's ability to respond to the DIS, although subjects with lower reading levels preferred the computer interview more.

Cross-cultural feasibility, reliability and sources of variance of the Composite International Diagnostic Interview (CIDI). The Multicentre WHO/ADAMHA Field Trials.

The CIDI is a fully standardised diagnostic interview designed for assessing mental disorders based on the definitions and criteria of ICD-10 and DSM-III-R. Field trials with the CIDI have been conducted in 18 centres around the world, to test the feasibility and reliability of the CIDI in different cultures and settings, as well as to test the inter-rater agreement for the different types of questions used. Of 590 subjects interviewed across all sites and rated by an interviewer and observer, 575 were eligible for analysis. The CIDI was judged to be acceptable for most subjects and was appropriate for use in different kinds of settings. Many subjects fulfilled criteria for more than one diagnosis (lifetime and six-month). The most frequent lifetime disorders were generalised anxiety, major depression, tobacco use disorders, and agoraphobia. Percentage agreements for all diagnoses were above 90% and the kappa values were all highly significant. No significant numbers of diagnostic disconcordances were found with lifetime, six-month, and four-week time frames.

The CIDI-core substance abuse and dependence questions: cross-cultural and nosological issues. The WHO/ADAMHA Field Trial.

The CIDI is a fully standardised, structured interview for the assessment of psychiatric disorders according to DSM-III-R and proposed ICD-10 criteria. The development of this interview has been the collaborative effort of researchers from 18 sites around the world. In a field trial to test the cross-cultural acceptability and reliability of the questions, there was found to be high acceptance and excellent reliability for the substance use questions, problems with the lengthy alcohol section, and difficulties translating relevant substance use concepts into different languages. There is therefore room for further improvement in the substance-related questions. There proved to be differences between ICD-10 and DSM-III-R regarding substance abuse and dependence disorders.

Retrospective postmortem dementia assessment. Validation of a new clinical interview to assist neuropathologic study.

Neuropathologic studies of dementia and normal aging suffer from a lack of individuals examined for the presence and severity of dementia before death. To increase clinical information in such cases, a retrospective collateral interview was developed. Thirty-nine individuals were studied; 27 had autopsies. In all cases, the autopsy confirmed the Retrospective Collateral Dementia Interview (RCDI) diagnosis of the presence or absence of dementia; the RCDI had a sensitivity of 88% and a specificity of 80% for specifically detecting probable Alzheimer's disease. Agreement between the RCDI and premortem diagnosis was 96%; between RCDI and medical records, 100%. Agreement between RCDI staging of dementia severity and the last assessment of the living subject was 70%; between the RCDI and a brief staging at death, 86%. This validation confirms the value of postmortem interviews with close informants to assess dementia presence and severity.

Adult disorders predicted by childhood conduct problems: results from the NIMH Epidemiologic Catchment Area project.

Children with conduct disorder have long been known to be at high risk for developing externalizing disorders, alcohol and drug abuse, and antisocial personality. Relationships of conduct disorder to other adult psychiatric disorders, on the other hand, have not been definitively shown. Taking advantage of the large community sample (N = 19,482) interviewed in the NIMH Epidemiologic Catchment Area Program, the authors examined the effects of childhood conduct problems on ten DSM-III psychiatric disorders: somatization, phobia, panic, obsessive-compulsive, depression, mania, alcohol use disorder, drug use disorder, schizophrenia and antisocial personality. Each of the ten adult disorders showed an increase in prevalence with an increasing number of conduct problems, although effects were stronger for externalizing disorders. The predictive power of conduct problems was similar for males and females. The effect of conduct problems on nonexternalizing disorders was found to be largely mediated through externalizing disorders, particularly for men but direct effects also occurred for both sexes. These findings raise questions about the conventional view of psychiatric disorders as divisible into externalizing and internalizing disorders. They also suggest that the increasing rates of conduct problems in younger cohorts may be responsible in part for the rising rates of other disorders. Thus, prevention of and early intervention with conduct disorder may hold promise for reducing rates of a broad range of disorders.