Kathy Harnett Sheehan

Reliability and validity of the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID).

OBJECTIVE To investigate the concurrent validity and reliability of the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID), a short structured diagnostic interview for DSM-IV and ICD-10 psychiatric disorders in children and adolescents. METHOD Participants were 226 children and adolescents (190 outpatients and 36 controls) aged 6 to 17 years. To assess the concurrent validity of the MINI-KID, participants were administered the MINI-KID and the Schedule for Affective Disorders and Schizophrenia for School Aged Children-Present and Lifetime Version (K-SADS-PL) by blinded interviewers in a counterbalanced order on the same day. Participants also completed a self-rated measure of disability. In addition, interrater (n = 57) and test-retest (n = 83) reliability data (retest interval, 1-5 days) were collected, and agreement between the parent version of the MINI-KID and the standard MINI-KID (n = 140) was assessed. Data were collected between March 2004 and January 2008. RESULTS Substantial to excellent MINI-KID to K-SADS-PL concordance was found for syndromal diagnoses of any mood disorder, any anxiety disorder, any substance use disorder, any ADHD or behavioral disorder, and any eating disorder (area under curve [AUC] = 0.81-0.96, kappa = 0.56-0.87). Results were more variable for psychotic disorder (AUC = 0.94, kappa = 0.41). Sensitivity was substantial (0.61-1.00) for 15/20 individual DSM-IV disorders. Specificity was excellent (0.81-1.00) for 18 disorders and substantial (> 0.73) for the remaining 2. The MINI-KID identified a median of 3 disorders per subject compared to 2 on the K-SADS-PL and took two-thirds less time to administer (34 vs 103 minutes). Interrater and test-retest kappas were substantial to almost perfect (0.64-1.00) for all individual MINI-KID disorders except dysthymia. Concordance of the parent version (MINI-KID-P) with the standard MINI-KID was good. CONCLUSIONS The MINI-KID generates reliable and valid psychiatric diagnoses for children and adolescents and does so in a third of the time as the K-SADS-PL.

Assessing treatment effects in clinical trials with the discan metric of the Sheehan Disability Scale.

The Sheehan Disability Scale (SDS) is a patient-rated, discretized analog measure of functional disability in work, social, and family life. Its increasing use in clinical trials in psychiatry suggests a need to assess its responsiveness and interpretability. In this paper we identify and review studies in which the SDS was used as a treatment outcome measure. Our objectives are (i) to evaluate the sensitivity of the SDS to treatment effects and (ii) to examine potential thresholds or cutoff scores for remission and response. Studies for the review were retrieved from the National Library of Medicines PubMed database (1966 to 21 March 2007) and other sources. All studies had to use the SDS, be double-blind, controlled or large open-label trials in English. Studies assessing nonpharmacological treatments, long-term trials (>12 weeks), small n trials (less than 20 patients per treatment arm) and trials for conditions other than one of the anxiety disorders, depression, or premenstrual dysphoric disorder were excluded. Extracted data included the diagnostic target of treatment, n, study design, and method of analysis. Initial, endpoint and/or mean change scores were extracted from tables, text, or extrapolated from figures. In all, 37 studies meeting the inclusion criteria were retrieved and reviewed. All of the studies treated the SDS as a numeric scale and analyzed mean change or endpoint differences with parametric statistics. Three provided additional outcome data using nonparametric response or remission criteria. Overall, the SDS performed well in discriminating between active and inactive treatments. The results indicate that the SDS is sensitive to treatment effects. To establish reliable and valid cutoff scores for remission and response, there is a need to supplement parametric analyses using mean change and endpoint differences with nonparametric analyses showing the percentage meeting specified response and remission criteria. In addition, the percentages with endpoint scores of zero should be reported.

Multicenter, Double-Blind, Placebo-Controlled Study of Mecamylamine Monotherapy for Tourette's Disorder

OBJECTIVE The safety and efficacy of mecamylamine as a monotherapy in children and adolescents with Tourettes disorder (TD) was investigated in an 8-week multicenter, double-blind, placebo-controlled study. METHOD Eligible subjects included subjects with TD (DSM-IV), with a naturalistic mix of comorbid diagnoses, nonsmokers, aged 8 to 17 years, whose behavioral and emotional symptoms (according to parents) were more disturbing than tics. After a washout period of all psychotropic medication, subjects were randomly assigned to either mecamylamine (n = 29) or placebo (n = 32). Mecamylamine doses ranged from 2.5 to 7.5 mg/day. Primary efficacy measures included the Tourettes Disorder Scale-Clinician Rated (TODS-CR) and 21-point Clinical Global Improvement scale; secondary efficacy measures included the Yale Global Tic Severity Scale and a rage-attack scale (RAScal). RESULTS Of the 61 subjects who were randomized, 50 (82%) completed at least 3 weeks on medication and 38 (62%) completed the full 8-week trial. Study withdrawals included 12/29 on mecamylamine and 11/32 on placebo. For the total sample, mecamylamine was no more effective than placebo on any of the outcome measures. However, an item analysis of the TODS-CR suggested that mecamylamine may have reduced sudden mood changes and depression in moderately to severely affected subjects. Except for a slight increase in heart rate during the 1st week in both the mecamylamine and the placebo groups, there where no significant mecamylamine-related changes in vital signs, electrocardiogram, complete blood cell count, or blood chemistry values. CONCLUSIONS Mecamylamine, in doses up to 7.5 mg/day, is well tolerated in children and adolescents, but as a monotherapy it does not appear to be an effective treatment for tics or for the total spectrum of symptoms associated with TD. However, further studies should be conducted to investigate its possible therapeutic effects in subjects with comorbid mood disorders and as an adjunct to neuroleptic medication.

The Tourette's Disorder Scale (TODS): development, reliability, and validity.

To address the lack of a simple and standardized instrument to assess overall illness severity of Tourettes disorder (TD), the authors developed and tested a 15-item scale to measure a broad range of common symptoms including tics, inattention, hyperactivity, obsessions, compulsions, aggression, and emotional symptoms. Independent investigators used the 15-item Tourettes Disorder Scale (TODS) to assess 60 TD patients who were taking part in a double-blind placebo-controlled multicenter 8-week treatment study. Interrater reliability, internal consistency, convergent and discriminant validity, and sensitivity to change were examined. The TODS was associated with good interrater reliability, excellent internal consistency, and favorable levels of validity and sensitivity to change. Individual TODS items showed good convergent and discriminant validity against other measures. The TODS is a simple, efficient way for clinicians and parents to rate the severity of multiple symptoms commonly found in patients with Tourettes disorder.

The classification of anxiety and hysterical states. Part I. Historical review and empirical delineation.

The history of the classification of anxiety, hysterical, and hypochondriacal disorders is reviewed. Problems in the ability of current classification schemes to predict, control, and describe the relationship between the symptoms and other phenomena are outlined. Existing classification schemes failed the first test of a good classification model—that of providing categories that are mutually exclusive. The independence of these diagnostic categories from each other does not appear to hold up on empirical testing. In the absence of inherently mutually exclusive categories, further empirical investigation of these classes is obstructed since statistically valid analysis of the nominal data and any useful multivariate analysis would be difficult if not impossible. It is concluded that the existing classifications are unsatisfactory and require some fundamental reconceptualization.

Psychiatric Aspects of Oral Contraceptive Use

Studies of mood and behavioral changes associated with oral contraceptives are reviewed. It was found that studies finding a link between depression and oral contraceptive usage had methodological defects enumerated in the article. It is concluded that there is no unambiguous relationship between oral contraceptive use and depression or psychologic symptoms. These effects seem to be the result of the psychosocial-cultural impact of the drug on the patient not a pharmacological effects. The oral contraceptive like other revolutionary medicines demands new decisions provides new freedoms and promotes new fears all leading to anxieties associated with pill usage.

A survey of United States general psychiatry residency programs : Program characteristics and relationship to the 1994 national residency matching program results

We developed a questionnaire regarding issues in psychiatric residency training and distributed it to the chief residents at all United States general psychiatry residency training programs. We hoped to examine psychiatry residency program characteristics and see if any particular characteristics had a significant relationship to improved success in the 1994 National Residency Matching Program (NRMP) results. We found that those programs with six or more PGY-1 positions available in the NRMP, those programs with an associated child and adolescent psychiatry residency training program, and those programs offering a research elective had a higher PGY-1 match through the NRMP than programs without these features.

Anxiety and Anxiety Disorders

Phenomenologically, anxiety may refer to an emotion, a feeling, a symptom, or a cluster of cognitive and somatic symptoms. Etiologically, it may describe reactions to danger, stress, or conflict, the results of trauma or frightening memories, the toxic withdrawal reactions to many drugs and illnesses, a habit (a persistent pattern of maladaptive behavior acquired by learning), or the symptomatic expression of a genetically inherited metabolic disease. The prevailing opinion in psychiatry views anxiety as a cluster of symptoms that impairs normal functioning.