The management of patients with undiagnosed psychiatric illness.

The results of using formal diagnostic criteria on a series of newly admitted inpatients are presented. Several strategies were employed in the management of the undiagnosed patients. The percent of undiagnosed patients significantly decreased with time during the course of hospitalization.

Concurrent diagnostic validity of a structured psychiatric interview.

In order to estimate the concurrent validity of a structured psychiatric interview, we compared interview diagnoses obtained for 101 psychiatric inpatients to those recorded in the same patients' hospital charts. For most diagnoses considered, concordance was found to be high. For those in which concordance was low, we examined the reasons for the diagnostic discrepancy. Diagnostic errors that were judged to have occurred on the basis of the structural interview often seemed to have resulted from a lack of longitudinal clinical observation. However, more errors were judged to have occurred in the hospital charts, apparently because of physician oversight. We conclude that the concurrent validity of this structured interview is high and that such examinations might be useful not only for research but also for the routine initial evaluation of psychiatric patients.

Reliability of psychiatric diagnosis. II. The test/retest reliability of diagnostic classification.

In a study of interrater diagnostic reliability, 101 psychiatric inpatients were independently interviewed by physicians using a structured interview. Newly admitted patients were randomly selected and examined by one of three psychiatrists. A second psychiatrist reexamined the same patient about 24 hours later. Interviews from the two examinations were evaluated independently and diagnoses were made on the basis of objective criteria. The degree of diagnostic agreement for the two examinations were calculated using the kappa statistic. Agreement was found to be high as compared to other studies in the psychiatric literature, despite the fact that in most previous investigations diagnoses were not made independently. The results were also compared to studies of reliability of medical judgments. Possible reasons for the high interrater reliability are discussed and include the use of a structured interview and objective diagnostic criteria.

Evaluation of a screening interview for Briquet syndrome (hysteria) by the study of medically ill women.

A screening interview for Briquet syndrome consisting of 14 symptom questions was administered to a group of 50 medically ill women. No patient was found eligible for a diagnosis of Briquet syndrome, a frequency less than the estimated general population prevalence of 1% to 2%. When symptoms explainable by known organic disorder were considered positive, 14% of patients became eligible for the diagnosis. We consider this a low enough rate to allow screening by lay interviewers. A frequency distribution of symptoms comparing the medically ill women and a group of psychiatric clinic women with Briquet syndrome shows that the Briquet group had both more symptoms and distinctive patterns of symptoms.

Reliability of psychiatric diagnosis. I. A methodological review.

This article reviews some methodological aspects of studies of diagnostic reliability in psychiatry. We define and discuss the concept of interrater reliability and review some of the ways in which the design of the reliability study can influence the results. Three basic methodological issues are raised, including: importance of structured interviews and objective diagnostic criteria, the importance of a test/retest vs an interviewer/observer design, and the calculation of reliability in a way that takes chance agreement into account.

A brief method of screening for alcoholism.

Subjects given a research diagnosis of alcoholism were evaluated to determine whether key symptoms exist which provide a means of rapid screening for alcoholism. Alcoholic subjects were compared with a large control group of non-alcoholics. A very high percent of alcoholics was identified by the subject's report that he or others believed the subject drank too much. Few non-alcoholic subjects reported that either they or others had such beliefs. Thus, several easy questions can serve as highly reliable screening tests for alcoholism.

Psychiatric illness and the irritable bowel syndrome. Practical implications for the primary physician.

Twenty-nine consecutive outpatients with irritable bowel syndrome were given structured psychiatric interviews, as were 33 consecutive medical controls who did not have irritable bowel syndrome. All were from an internal medicine group practice. Seventy-two percent of irritable bowel syndrome subjects had psychiatric illness, with hysteria and depression the most prevalent syndromes. Only 18% of controls had psychiatric illness. The primary physician made an accurate psychiatric assessment in only 28% of the subjects. An awareness of his patient's psychiatric illness is necessary for the physician to provide effective treatment, as for depression, and to spare the patient needless medications, hospitalizations, and surgery, as with hysteria.

The effect of modified ECT on serum creatine phophokinase, I. With intravenous atropine.

Interpretation of serum creatine phosphokinase (CPK) levels is frequently difficult because of complicating circumstances known themselves to raise CPK; for instance, intramuscular injections. One such circumstance among psychiatric patients is said to be administration of electroconvulsive therapy (ECT). In a series of 22 patients who received drug modified ECT, four had CPK elevations beyond the normal range. These findings indicate that CPK elevations among patients receiving ECT should be interpreted cautiously.

The effect of modified ECT on serum creatine phosphokinase. II. With subcutaneous atropine.

In the previous study, the effect of modified ECT on serum CPK was investigated. In that study, atropine was administered intravenously two minutes prior to ECT being given. In this study, the more usual clinical procedure in which atropine is administered subcutaneously is investigated. In a series of nineteen patients, four had CPK elevations beyond the normal range. These findings resemble the findings of the previous study closely, and indicate again that elevations of CPK in patients receiving ECT should be interpreted with caution.

The significance of psychotic affective disorders.

A study of 253 patients with primary and secondary affective disorders disclosed that psychotic features were more frequent among bipolar patients. Except for more frequent psychiatric hospitalization among unipolar patients with psychotic features, no demographic, family history, or parental home variable was found to distinguish between those with and without psychotic features. Chance variation probably accounted for the few symptoms whose frequencies were different depending on the presence or absence of psychotic features. The results failed to support the validity of a classification of affective disorders based on the presence or absence of psychotic features.

Computer-assisted derivation of a screening interview for alcoholism.

A short screening interview for the diagnosis of alcoholism has been developed with the assistance of the automatic interaction detector (AID) program (a multivariate sequential analysis strategy) that is part of the OSIRIS statistical package. Retrospective and prospective tests of the effectiveness of the interview have shown that it permits a diagnosis of alcoholism with less effort than a larger, more comprehansive research interview. The performance of the screening and research interviews have been compared to assess the effects of severity of illness and reliability of individual replies on the diagnoses made by each interview.

Is everyone depressed?

The authors collected a large number of research interviews with relatives of patients from a psychiatric research clinic. Half of these patients were clinically depressed; their relatives as well as the rest of the relatives interviewed were therefore at high risk for depression. However, few of the relatives reported memorable dysphoria or any clustered episodes of other affective symptoms. The authors conclude from these data that, contrary to the opinions expressed by some, not everyone has episodes of depression. Everybody is not depressed.