Joseph B. McGlinchey

Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression

Antidepressant medication is considered the current standard for severe depression, and cognitive therapy is the most widely investigated psychosocial treatment for depression. However, not all patients want to take medication, and cognitive therapy has not demonstrated consistent efficacy across trials. Moreover, dismantling designs have suggested that behavioral components may account for the efficacy of cognitive therapy. The present study tested the efficacy of behavioral activation by comparing it with cognitive therapy and antidepressant medication in a randomized placebo-controlled design in adults with major depressive disorder (N = 241). In addition, it examined the importance of initial severity as a moderator of treatment outcome. Among more severely depressed patients, behavioral activation was comparable to antidepressant medication, and both significantly outperformed cognitive therapy. The implications of these findings for the evaluation of current treatment guidelines and dissemination are discussed.

Assessing Clinical Significance: Does it Matter which Method we Use?.

Measures of clinical significance are frequently used to evaluate client change during therapy. Several alternatives to the original method devised by N. S. Jacobson, W. C. Follette, & D. Revenstorf (1984) have been proposed, each purporting to increase accuracy. However, researchers have had little systematic guidance in choosing among alternatives. In this simulation study, the authors systematically explored data parameters (e.g., reliability of measurement, pre-post effect size, and pre-post correlation) that might yield differing results among the most widely considered clinical significance methods. Results indicated that classification across methods was far more similar than different, especially at greater levels of reliability. As such, the existing methods of clinical significance appear highly comparable; future directions for clinical significance use and research are discussed.

Screening for Bipolar Disorder and Finding Borderline Personality Disorder

OBJECTIVE Bipolar disorder and borderline personality disorder share some clinical features and have similar correlates. It is, therefore, not surprising that differential diagnosis is sometimes difficult. The Mood Disorder Questionnaire (MDQ) is the most widely used screening scale for bipolar disorder. Prior studies found a high false-positive rate on the MDQ in a heterogeneous sample of psychiatric patients and primary care patients with a history of trauma. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we examined whether psychiatric outpatients without bipolar disorder who screened positive on the MDQ would be significantly more often diagnosed with borderline personality disorder than patients who did not screen positive. METHOD The study was conducted from September 2005 to November 2008. Five hundred thirty-four psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV and Structured Interview for DSM-IV Personality Disorders and asked to complete the MDQ. Missing data on the MDQ reduced the sample size to 480. Approximately 10% of the study sample were diagnosed with a lifetime history of bipolar disorder (n = 52) and excluded from the initial analyses. RESULTS Borderline personality disorder was 4 times more frequently diagnosed in the MDQ positive group than the MDQ negative group (21.5% vs 4.1%, P < .001). The results were essentially the same when the analysis was restricted to patients with a current diagnosis of major depressive disorder (27.6% vs 6.9%, P = .001). Of the 98 patients who screened positive on the MDQ in the entire sample of patients, including those diagnosed with bipolar disorder, 23.5% (n = 23) were diagnosed with bipolar disorder, and 27.6% (n = 27) were diagnosed with borderline personality disorder. CONCLUSIONS Positive results on the MDQ were as likely to indicate that a patient has borderline personality disorder as bipolar disorder. The clinical utility of the MDQ in routine clinical practice is uncertain.

Diagnosing Major Depressive Disorder I: A Psychometric Evaluation of the Dsm-iv Symptom Criteria

The diagnostic criteria for depression were developed on the basis of clinical experience rather than empirical study. Although they have been available and widely used for many years, few studies have examined the psychometric properties of the DSM criteria for major depression. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we examined whether criteria such as insomnia, fatigue, and impaired concentration that are also diagnostic criteria for other disorders are less specific than the other DSM-IV depression symptom criteria. We also conducted a regression analysis to determine whether all criteria are independently associated with the diagnosis of major depressive disorder. A total of 1538 psychiatric outpatients were administered a semistructured diagnostic interview. We inquired about all of the symptoms of depression for all patients. All of the DSM-IV symptom criteria for major depressive disorder were significantly associated with the diagnosis. Contrary to our prediction, symptoms such as insomnia, fatigue, and impaired concentration, which are also criteria of other disorders, generally performed as well as the criteria that are unique to depression such as suicidality, worthlessness, and guilt. The results of the regression analysis, which controlled for symptom covariation, indicated that five symptoms (increased weight, decreased weight, psychomotor retardation, indecisiveness, and suicidal thoughts) were not independently associated with the diagnosis of depression. The implications of these results for revising the diagnostic criteria for major depression are discussed.

A clinically useful depression outcome scale

If the optimal delivery of mental health treatment ultimately depends on examining outcome, then precise, reliable, valid, informative, and user-friendly measurement is the key to evaluating the quality and efficiency of care in clinical practice. Self-report questionnaires are a cost-effective option because they are inexpensive in terms of professional time needed for administration, and they correlate highly with clinician ratings. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we describe the reliability and validity of the Clinically Useful Depression Outcome Scale (CUDOS). The CUDOS was designed to be brief (completed in less than 3 minutes), quickly scored (in less than 15 seconds), clinically useful (fully covering the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition symptoms of major depressive disorder and dysthymic disorder), reliable, valid, and sensitive to change. We studied the CUDOS in more than 1400 psychiatric outpatients and found that the scale had high internal consistency and test-retest reliability. The CUDOS was more highly correlated with another self-report measure of depression than with measures of anxiety, substance use problems, eating disorders, and somatization, thereby supporting the convergent and discriminant validity of the scale. The CUDOS was also highly correlated with interviewer ratings of the severity of depression, and CUDOS scores were significantly different in depressed patients with mild, moderate, and severe levels of depression. The CUDOS was a valid measure of symptom change. Finally, the CUDOS was significantly associated with a diagnosis of major depressive disorder. Thus, the results of this large validation study of the CUDOS shows that it is a reliable and valid measure of depression that is feasible to incorporate into routine clinical practice.

Diagnosing Major Depressive Disorder X: Can the Utility of the Dsm-iv Symptom Criteria Be Improved?

There are two practical problems with the DSM-IV symptom criteria for major depressive disorder (MDD)—they are somewhat lengthy and therefore difficult to remember, and there are difficulties in applying some of the criteria in patients with comorbid medical illnesses because of symptom nonspecificity. Therefore, in the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we attempted to develop a briefer definition of major depression that is composed entirely of mood and cognitive symptoms. Our goal was to develop an alternative set of diagnostic criteria for major depression that did not include somatic symptoms but would nonetheless demonstrate a high level of concordance with the current DSM-IV definition. We examined several alternative definitions of MDD. After eliminating the somatic criteria from the DSM-IV MDD criteria and adding the symptom “reduced drive,” there was a very high level of concordance with DSM-IV classification (95%). This new definition thus offers two advantages over the current DSM-IV definition—it is briefer and it is free of somatic symptoms, thereby making it easier to apply with medically ill patients. We discuss using improvement in the clinical utility, rather than validity of diagnostic criteria, as the basis for making revisions in the nomenclature.

Diagnostic co-morbidity in 2300 psychiatric out-patients presenting for treatment evaluated with a semi-structured diagnostic interview

BACKGROUND The largest clinical epidemiological surveys of psychiatric disorders have been based on unstructured clinical evaluations. However, several recent studies have questioned the accuracy and thoroughness of clinical diagnostic interviews; consequently, clinical epidemiological studies, like community-based studies, should be based on standardized evaluations. The Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project is the largest clinical epidemiological study using semi-structured interviews assessing a wide range of psychiatric disorders conducted in a general clinical out-patient practice. In the present report we examined the frequency of DSM-IV Axis I diagnostic co-morbidity in psychiatric out-patients. METHOD A total of 2300 out-patients were interviewed with the Structured Clinical Interview for DSM-IV (SCID) upon presentation for treatment. RESULTS The mean number of current and lifetime DSM-IV Axis I disorders in the 2300 patients was 1.9 (s.d.=1.5) and 3.0 (s.d.=1.8) respectively. The majority of patients were diagnosed with two or more current disorders, and more than one-third were diagnosed with three or more current disorders. Examination of the most frequent current disorders in the patients with the 12 most common principal diagnoses indicated that the pattern of co-morbidity differed among the disorders. The highest mean number of current co-morbid disorders was found for patients with a principal diagnosis of post-traumatic stress disorder and bipolar disorder. CONCLUSIONS Clinicians should assume that psychiatric patients presenting for treatment have more than one current diagnosis. The pattern of co-morbidity varies according to the principal diagnosis.

Diagnosing major depressive disorder VIII: are some symptoms better than others?

The present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project examined whether symptoms that are not part of the DSM-IV definition of major depressive disorder (MDD) are better at discriminating depressed from nondepressed patients than the current criteria. Symptoms assessed included diminished drive, helplessness, hopelessness, nonreactive mood, psychic anxiety, somatic anxiety, subjective anger, and overtly expressed anger. A total of 1538 psychiatric outpatients were administered a semistructured diagnostic interview. We inquired about all of the symptoms of depression for all patients. Diminished drive exhibited stronger performance in differentiating MDD from non-MDD relative to all DSM-IV criteria except depressed mood, reduced interest/pleasure, and impaired concentration/indecisiveness. A compound criterion combining diminished drive with loss of energy was endorsed by nearly all MDD patients. Helplessness and hopelessness, when combined into a single criterion, performed more strongly than some of the DSM-IV criteria. Lack of reactivity, anxiety, and anger symptoms failed to differentiate more strongly than current DSM-IV criteria. The implications of these results for revising the diagnostic criteria for major depression are discussed.

Diagnosing major depressive disorder XI: a taxometric investigation of the structure underlying DSM-IV symptoms.

Psychopathologists have long debated the latent structure of mental disorders, and a number of researchers have suggested that depression may be best characterized as a continuous, rather than categorical, phenomenon. Nonetheless, attention has been drawn to limitations permeating existing research and the need for studies using more appropriate statistical methods developed expressly to tease apart taxonic (categorical) and dimensional (continuous) structural models. The present study examined the structure underlying the DSM-IV symptoms of major depressive disorder in a large outpatient sample rigorously assessed using semistructured clinical interviews. The results of a series of taxometric procedures and consistency tests supported a taxonic structural model, consistent with the only previous taxometric study of DSM-IV symptoms in an adult outpatient sample. In addition to the need for further replication and clarification, these results have implications for the assessment and diagnosis of major depressive disorder. Suggestions for several additional avenues of research are discussed.

A simpler definition of major depressive disorder

BACKGROUND The DSM-IV symptom criteria for major depressive disorder (MDD) are somewhat lengthy, with many studies showing that treatment providers have difficulty recalling all nine symptoms. Moreover, the criteria include somatic symptoms that are difficult to apply in patients with medical illnesses. In a previous report, we developed a briefer definition of MDD that was composed of the mood and cognitive symptoms of the DSM-IV criteria, and found high levels of agreement between the simplified and full DSM-IV definitions. The goal of the present study was to replicate these findings in another large sample of psychiatric out-patients and to extend the findings to other patient samples. METHOD We interviewed 1100 psychiatric out-patients and 210 pathological gamblers presenting for treatment and 1200 candidates for bariatric surgery. All patients were interviewed by a diagnostic rater who administered a semi-structured interview. We inquired about all symptoms of depression for all patients. RESULTS In all three samples high levels of agreement were found between the DSM-IV and the simpler definition of MDD. Summing across all 2510 patients, the level of agreement between the two definitions was 95.5% and the kappa coefficient was 0.87. CONCLUSIONS After eliminating the four somatic criteria from the DSM-IV definition of MDD, a high level of concordance was found between this simpler definition and the original DSM-IV classification. This new definition offers two advantages over the current DSM-IV definition--it is briefer and it is easier to apply with medically ill patients because it is free of somatic symptoms.