Biometrics Research

Biometrics Research

Robert L. Spitzer, M.D., Chief of Psychiatric Research
Janet B.W. Williams, D.S.W., Deputy Chief and Research Scientist VI
Michael B. First, M.D., Psychiatrist (Research) I
Miriam Gibbon, M.S.W., Research Scientist IV

The lifetime prevalence of bipolar disorder is usually reported to be 1%, but there is ample evidence that this estimate includes only a small portion of those in the bipolar spectrum, which includes bipolar I, bipolar II, and cyclothymia. The lifetime prevalence of bipolar spectrum is reported to be between 3 and 8%. Thus, the prevalence of bipolar spectrum in the community is in the general range of drug abuse and many anxiety disorders. Unfortunately, bipolar spectrum disorders are often unrecognized and undiagnosed, largely due to the wide range of symptoms with which bipolar patients may present, including impulsive behavior, alcohol and substance abuse, changes in energy level, legal problems, and mood swings. The consequences of a delayed diagnosis or a misdiagnosis of a bipolar disorder can be disastrous.

One method of increasing recognition of an illness is to screen for it. There are a number of screening instruments for a variety of psychiatric disorders, particularly depression, but unfortunately, no screening instrument currently exists for bipolar disorder. With Dr. Robert Hirschfeld and other colleagues, Drs. Williams and Spitzer have developed and validated a brief and easy-to-use screening instrument for bipolar spectrum disorders, called the Mood Disorder Questionnaire (MDQ). The hope is that the MDQ will be used to screen for bipolar disorders in a variety of settings, including mental health, primary care, and publicly available places.

One hundred and ninety eight patients attending five outpatient clinics that primarily treat patients with mood disorders completed the MDQ. A mental health professional, blind to the MDQ results, conducted a telephone research diagnostic interview using the manic, hypomanic, and manic disorder NOS modules of the Structured Clinical Interview for DSM-IV (SCID). An MDQ screening score of seven or more manic/hypomanic symptom items yielded good sensitivity (.73) and specificity (.90). These results suggest that the MDQ is a useful screen for bipolar spectrum disorder in a psychiatric outpatient population. It may also prove useful in primary care and community settings for identifying individuals who might benefit from further evaluation.

Mental disorders in primary care are common, disabling, costly, and treatable; however, they are frequently unrecognized and not treated. Therefore, there has been considerable interest in developing standardized instruments that could facilitate the recognition of mental disorders in the busy primary care setting. Although there have been many screening instruments developed, PRIME-MD (Primary Care Evaluation of Mental Disorders), developed by this department, was the first instrument designed for use in primary care that actually diagnoses specific disorders using diagnostic criteria from the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R and DSM-IV).

PRIME-MD has been widely used in clinical research, but its clinical use has been limited because of the time that it takes for the physician to administer the interview component of the system. For that reason, Drs. Spitzer and Williams and collaborators have developed several self-administered versions of PRIME-MD, called the Patient Health Questionnaire. The physician scans the completed questionnaire, verifies positive responses, and applies diagnostic algorithms that are abbreviated at the bottom of each page of the questionnaire. In several studies, conducted at seven primary care sites and five ob/gyn sites around the country, the validity of these self-report versions of PRIME-MD have been demonstrated and researchers in primary care are increasingly using the new versions in a variety of studies.

With Dr Larry K Mauksch and other collaborators, the PRIME-MD PHQ was used to compare the prevalence of mental illness and its impact on functional status in an indigent uninsured primary care population in Colorado, with the general primary care sample used in validating the PRIME-MD PHQ. Patient preferences about mental health and medical service integration were also studied. The results indicated that a low-income uninsured population had a higher prevalence of one or more psychiatric disorders, and that having psychiatric disorders was associated with lower functional status and more disability days compared with not having mental illness. Patients indicated a preference for mental health providers and medical providers to communicate about their care. This suggests that it may be important in low-income primary care settings to include collaborative care designs to effectively treat common mental disorders, improve functional status, and enhance patient self-care.

Dr. First has initiated a project to investigate the issues surrounding a previously unrecognized mental disorder, to which he has given the name "Amputee Identity Disorder." Individuals with this condition have a preoccupying desire to become an amputee. This desire is so strong that a number of individuals have attempted self-amputation and a couple have successfully arranged to have a surgeon conduct a voluntary amputation of a healthy limb in order to "cure" their condition. Individuals with this condition feel that their true core identity is as an amputee. The surgery serves to match their anatomical configuration with their true selves, thus eliminating the conflict that plagues their lives. This condition appears to be analogous to Gender Identity Disorder, in which individuals feel that they have been erroneously born into the body of the other gender, and which has been successfully treated by sex-reassignment surgery. Dr. First's study consists of conducting structured interviews with these individuals over the telephone in order to understand the nature of their feelings and to investigate whether their problem is already covered by one of the existing DSM-IV categories.

As editor of the DSM-IV and Chief Consultant for Diagnosis and Assessment to the American Psychiatric Association, Dr. First continues his work as one of the leading participants in several important APA projects. He continues to be the liaison person between the APA and the National Committee on Health Statistics, providing ongoing consultation regarding the ICD-9-CM diagnostic codes for mental disorders (which form the basis of the DSM-IV diagnostic codes) as well as the development of the next diagnostic coding system, ICD-10-CM. Although implementation of the ICD-10-CM has been delayed by the U.S. Government, the mental disorders section has been finalized under the direction of Dr. First.

The text revision of DSM-IV (DSM-IV-TR) was published by the American Psychiatric Association in July 2000, a project co-chaired by Dr. First. Given the expected 12-14 year gap between DSM-IV and DSM-V, the APA decided to update the DSM-IV text to reflect new research findings that have accumulated since 1992, when the DSM-IV literature review process effectively ended.

Dr. First also continued in his role as editor of the APA Handbook on Psychiatric Measures, which was published in May 2000. This compendium is designed to serve as a guide to clinicians regarding which of the many psychiatric measures and tests that are used by researchers may be useful in their clinical practice. Finally, Dr. First also continues to serve as co-editor of a new book to be published by the American Psychiatric Press that discusses some of the diagnostic dilemmas that arose during DSM-IV.

Dr. First was invited to be the Medical Editor for the Quick Reference Guides to the APA's Practice Guideline Project. This project has been underway since 1992 with the goal of providing empirically-based practice guidelines for a number of topics in psychiatry. To date, guidelines have been published for 13 different topics. Because of their complexity, however, utilization of these guidelines by clinicians and educators has been disappointing. For this reason, the APA has decided to undertake a project to create Quick Reference Guides to the guidelines, which would condense the guidelines down into their most essential components. Dr. First is in charge of developing these Quick Reference Guides for the APA.

Preliminary work has begun on DSM-V in 2000. The APA convened six workgroups with the task of developing a series of white papers to identify and formulate a research agenda for the next several years in advance of the development of DSM-V. This joint project between the APA and the NIMH is intended to stimulate research efforts by encouraging research submissions that might address the issues identified in the white papers. Dr. First was appointed to be chair of the working group focusing on gaps in the DSM-IV classification of personality and relational disorders.

Dr. First and Ms. Gibbon continue their work with ongoing development and maintenance of the Structured Clinical Interview for DSM-IV (SCID), the most widely used diagnostic assessment tool in psychiatry. Dr. First and Ms. Gibbon have continued to consult with investigators around the US and internationally regarding diagnostic assessment issues in their studies and continue to provide SCID training for research groups in the US and abroad. Furthermore, Ms. Gibbon continues to review SCID audio and videotapes for the purpose of quality control and rater certification.

In response to the publication of DSM-IV-TR in July 2000, the SCID was revised during the fall of 2000 to accommodate several changes in the criteria sets as well as to correct errors and omissions that have been identified in the SCID over the past couple of years. The SCID Web page continues to be a valuable resource for the SCID user community, providing information regarding SCID training, computerized versions, and SCID reliability and validity. Finally, work continues in ongoing development and debugging on the computer-administered versions of the SCID, which are currently being distributed by MHS, a mental health software company in Canada.

Collaborations Dr. Williams has continued her role as senior co-investigator in the Center for Hispanic Mental Health Studies at the Fordham University Graduate School of Social Service, where she is a Visiting Professor. She has joined the Editorial Board of the Social Workers' Desk Reference, and has agreed to serve as Consulting Editor on the journal Social Work Research. She continues to consult on the NIMH clinical trial on the efficacy of St. John's wort, and on a task force to improve the administration of the Hamilton Depression Rating Scale.

Honors Dr. Williams was awarded the Lifetime Achievement Award by the Society for Social Work and Research. Dr. Spitzer was awarded the Thomas William Salmon Medal for outstanding contributions to psychiatry by the New York Academy of Medicine.