Juan E. Mezzich

Developing an efficient clinical information system for a comprehensive psychiatric institute: II. Initial evaluation form

This paper describes the objectives, design, organization, content, evaluation, and implementation of the initial evaluation form, first component of a comprehensive psychiatric institute’s clinical information system. Major features of this effort are the involvement of a large number of clinicians in the form’s development, the use of complementary narrative and standardized components, the use of an expanded DSM-III multiaxial diagnostic format, pilot testing with over 1,000 patients, the evaluation of the form’s usefulness and interrater reliability, the form’s computerization, facilitating data retrieval and coordination with other institutional data bases, and the form’s monitoring.

Black-white differences in psychopathology in an urban psychiatric population

The study was conducted in a psychiatric setting that services a large metropolitan population. It relied on the semi-structured Initial Evaluation Form which is completed by expert trained clinicians and which is geared to a comprehensive evaluation along the lines stipulated in DSM-III. The symptoms of a large sample of white and black patients are compared. The study relied on an Analysis of Variance (ANOVA) procedure which controlled for age, gender and education and concentrated exclusively on ethnic differences in clinically homogenous subgroups. The sample was partitioned into relatively pure groups of DSM-III diagnoses that are frequent in the population, including schizophrenia, affective and anxiety disorders, dementia, paranoid and manic disorders. Prominent black/white differences in psychopathology were noted, but in only a few instances included items generally thought of as typical of a specific disorder. Some differences appeared to be due to selection factors and others raised the question of alternate expressions of psychopathology among blacks as versus whites. The significance of the results obtained is discussed together with questions requiring further research. Some of the issues involved in the study of black/white differences in psychopathology are critically analyzed.

Racial effects on the clinical presentation of alcoholics at a psychiatric hospital.

Little is known about the effects of age on the clinical presentation of alcoholism in various treatment settings, despite the clinical importance of this factor. This study evaluates the effects of age on the clinical profile of 604 alcoholics who presented for initial evaluation and treatment at a psychiatric hospital. Young alcoholics displayed the most prominent substance use, antisocial behavior, depressive symptoms (including suicidality), and impulsivity. Early middle-aged alcoholics displayed the highest levels of drinking. Elderly alcoholics displayed the highest levels of cognitive dysfunction, although some level of cognitive dysfunction was present among even the youngest alcoholics. These findings confirm and clarify the effects of age on the clinical profile of alcoholics presenting for initial evaluation at a psychiatric hospital.

Do Caucasian and Black Adolescents Differ at Psychiatric Intake

A large sample of adolescents brought for psychiatric evaluation to a public University based facility are the subjects of the study. Material incorporated in a DSM-III multiaxial formulation plus symptoms constituted the dependent variables. Analyses concentrated on ethnic differences, with variation associated with gender and social class controlled statistically. Caucasians showed comparatively greater clinical morbidity: higher number of Axis I definite diagnoses and level of symptoms. Eating disorder diagnoses were more common in Caucasians. There were no significant differences pertaining to level of stress or social impairment. Blacks showed higher levels of symptoms scored as social aggression and diagnosed as conduct disorders. The pattern of results raised the question of a possible referral bias, with blacks shunted to the psychiatric facility with lower levels of standard clinical psychopathology, but higher levels of social oppositional behavior. Further research is needed to verify if such a bias does exist.

Reliability of DSM-III vs. DSM-II in Child Psychopathology

A comparative evaluation of the reliability of DSM-III vs. DSM-II diagnoses was conducted by having geographic random samples of child psychiatrists and clinical child psychologists utilize either system to diagnose 27 child and adolescent case histories. The overall reliabilities of Axes I and II of DSM-III were found to be similar to those of DSM-II, although certain specific categories in DSM-III obtained higher reliabilities than corresponding ones in DSM-II. Axis V had the highest reliability among all DSM-III axes, while Axis IV had the lowest. No significant differences in reliability were noted between psychologists and psychiatrists.

Clinical profile of comorbid major depression and alcohol use disorders in an initial psychiatric evaluation

This study evaluated the clinical profile of patients who presented with both DSM-III major depression (MD) and alcohol use disorder (AUD) as compared with that of patients with either diagnosis alone. Comparison of these three groups (MD without AUD, AUD without MD, and comorbid AUD-MD) selected from a large sample (8,139) of general adult psychiatric patients showed that the historical, cross-sectional, and dispositional profile of AUD-MD patients occupied an intermediate position between that of the other two groups. The symptomatology of AUD-MD patients was somewhat closer to that of MD patients, whereas the premorbid personal and social history and dispositional status were more similar to those of AUD patients. AUD-MD patients had a strikingly higher rate of suicidal indicators as compared with AUD or MD patients.

Comprehensively diagnosing geriatric patients

Abstract An attempt to explore and document the descriptive usefulness of a biopsychosocial diagnostic approach represented by the Diagnostic and Statistical Manual of Mental Disorders (ed 3) (DSM-III) multiaxial system was conducted by comparing semistructured evaluations of 494 new consecutive geriatric patients with those of 4,354 younger adult counterparts. A wide diversity of psychiatric disorders were found among geriatric patients, almost as wide as among younger adults. Organic mental disorders (except those induced by substances) and recurrent major depression were the most frequently diagnosed conditions in the geriatric sample, in which 19% of the patients had dementia and depressive disorders listed together as either firm or rule/out diagnoses. A combined salience was also found in this sample for physical disorders (particularly, circulatory, endocrine and neurological conditions), their high psychosocial impact, and poorer levels of adaptive functioning. The findings emphasize the importance of comprehensive diagnostic models for geriatric patients and their implications for multidimensional intervention strategies.

Multiaxial characterization of depressive patients.

A review of the literature on the comprehensive description of depressive patients revealed prominent concern with syndromic subtypes, course of illness, and personality factors, followed by severity, concomitant physical disorders, psychosocial stressors, and adaptive functioning. The descriptive value of multiaxial approaches for depression was illustrated through the application of an extended DSM-III formulation to all 3455 depressive (bipolar depression, major depression, dysthymic disorder, and atypical depression) and 7837 nondepressive patients of all ages and sexes presenting for evaluation and care at the Psychiatric Institute of the University of Pittsburgh during a period of 53 months. Twenty-six percent of the depressive patients received an additional diagnosis in axis I, the most frequent of which were substance use disorder, anxiety disorder, and condition not attributable to a mental disorder. In axis II, depressive patients presented a differentially higher frequency of dependent personality disorder and the “anxious/fearful” cluster of personality disorders. In axis III, 47% of the depressive us. 40% of the nondepressive patients had a positive diagnosis of physical illness, with a significantly higher frequency among depressive patients attained by acquired hypothyroidism, migraine, essential hypertension, unspecified abdominal hernia, and unspecified arthropathies. Specific stressors differentially more frequent among depressive patients were those of conjugal, parenting, and occupational types and those reflecting the impact of physical illness. Overall stressor severity was at severe, extreme, or catastrophic levels for 42% of the depressive and 31% of the nondepressive patients. The highest level of adaptive functioning in the past year was good, very good, or superior for 44% of the depressive and 29% of the nondepressive patients. The broad distribution of depressive patients in the various axes points out the usefulness of the multiaxial formulation for preparing a comprehensive treatment plan. Promising multiaxial prospects include consideration of course and severity of illness in axis I, listing specific stressors in axis IV, and assessing current functioning in axis V.

Descriptive validity of DSM-III depressions.

There are five categories of psychiatric disorders in DSM-III that embrace depressive moods: adjustment disorder with depressed mood (group 1), bipolar depression (group 2), major depression (group 3), dysthymic disorder (group 4), and atypical depression (group 5). A large sample of patients seen in a metropolitan university psychiatric referral center, with these categories as primary diagnoses in axis I, constitute the subjects studied (N = 2988). The study includes a comparison of the cross-sectional clinical properties of these patients, including an inventory of psychopathological symptoms, entries in axes II to V (i.e., as described in DSM-III, plus a sixth axis measuring current adjustment) and immediate dispositions rendered by clinicians. This study addresses the descriptive validity of DSM-III diagnostic categories of depression. A clustering of depressions based on a continuum of severity is uncovered as well as unique features of certain subtypes that point to categorical aspects of DSM-III mood disorders. The nature and implication of these findings are discussed.

Developing an efficient clinical information system for a comprehensive psychiatric institute: I. Principles, design, and organization

The principles, design considerations, and components of a clinical information system intended to support and enhance the patient care, educational, and research missions of a comprehensive psychiatric institute are presented. Major characteristics of the system are its emphases on efficiency, simplicity, and intensive user involvement throughout the development of the system.