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Biomedical subjects

Iwona Chelminski

Publications and source records attributed to Iwona Chelminski.

At least 37 records · Page 2Linked to original sources
PubMed2006

Should self-defeating personality disorder be revisited in the DSM?

Self-defeating personality disorder (SDPD) was proposed for consideration in the DSM-III-R, but was eventually removed from the manual because of the lack of evidence to support its validity. Yet, after DSM-IV was published, some studies suggested that SDPD may be a viable diagnosis. The purpose of this study was to evaluate SDPD's viability as a diagnostic category. Consequently, SDPD's internal consistency, comorbidity with other Axis I and II disorders, association with psychosocial impairment, and its ability to predict overall impairment in past, current, and global levels of functioning beyond other personality disorder symptomatology was assessed in 1,200 psychiatric evaluated with the Structured Clinical Interview for DSM-IV Personality (Pfohl, Blum, & Zimmerman, 1997). Cronbach's alpha for SDPD criteria was 0.61, and item-total correlations ranged between 0.22-0.38. There was substantial comorbidity of SDPD with depressive, avoidant, and borderline personality disorders, as well as major depression and anxiety disorders. The SDPD group did not significantly differ from psychiatric controls on multiple measures of psychosocial impairment, global functioning, and suicidality. SDPD did not meaningfully add to the prediction of impairment above and beyond other measures of Axis II pathology. It is concluded that the data do not support the reliability, validity, and utility of the SDPD diagnosis.

Adult↗
PubMed2006

Developing brief scales for use in clinical practice: the reliability and validity of single-item self-report measures of depression symptom severity, psychosocial impairment due to depression, and quality of life.

OBJECTIVE: Reliable, valid, user-friendly measurement is necessary to successfully implement an outcomes evaluation program in clinical practice. Self-report questionnaires, which generally correlate highly with clinician ratings, are a cost-effective assessment option. However, even self-administered questionnaires can be burdensome to patients because many are lengthy. Consequently, we developed and determined the reliability and validity of ultra-brief, single-item assessments of 3 domains important to consider when treating depressed patients: symptom severity, psychosocial functioning, and quality of life. METHOD: In the first study (conducted June 1997 to March 2002), 1278 psychiatric outpatients with various DSM-IV diagnoses completed single-item assessments of psychosocial functioning and quality of life as well as more detailed measures of these constructs. In the second study (conducted August 2003 to July 2004), 562 psychiatric outpatients who were in ongoing treatment for a DSM-IV major depressive episode completed a depression symptom scale and a measure of global severity of depression. RESULTS: The test-retest reliability of the psychosocial functioning and quality-of-life items was high. The single-item measures of symptom severity, psychosocial functioning, and quality of life were significantly correlated with the total scores and individual item scores of longer measures of the same constructs (p < .001). The single-item measures significantly discriminated between depressed patients in full remission, in partial remission, and in a current depressive episode (p < .001). CONCLUSION: These studies provide evidence of the reliability and validity of single-item measures of symptom severity, psychosocial functioning, and quality of life. Very brief measures, such as the ones described in the present report, are not burdensome for patients to complete and can be easily incorporated into a busy clinical practice in order to collect data on treatment effectiveness.

Adaptation, Psychological↗
PubMed2005

Standardized clinical outcome rating scale for depression for use in clinical practice.

The integration of research into clinical practice to conduct effectiveness studies faces multiple obstacles. One obstacle is the burden of completing research measures of outcome. A simple, reliable, and valid measure that could be rated at every visit, incorporated into a clinician's progress note, and reflect the DSM-IV definition of a major depressive episode (including partial and full remission from the episode) would enhance the ability to conduct effectiveness research. The goal of the present study was to examine the reliability and validity of such a measure. Three hundred and three psychiatric outpatients who were being treated for a DSM-IV major depressive episode were rated on the Standardized Clinical Outcome Rating for Depression (SCOR-D), 17-item Hamilton Rating Scale for Depression, Montgomery-Asberg Depression Rating Scale, and the Global Assessment of Functioning. We examined the correlation between the SCOR-D and the other measures, and conducted an analyses of variance to compare mean values on these measures for each rating point on the SCOR-D. The inter-rater reliability of the SCOR-D dimensional ratings and categorical determination of remission were high. The SCOR-D was highly correlated with the other scales, and there were significant differences on the other measures of depression severity between each adjacent rating level of the SCOR-D. The SCOR-D is a brief standardized outcome measure linked to the DSM-IV approach toward defining remission that can be incorporated into routine clinical practice without adding undue burden to the treating clinician with some evidence of reliability and validity. This measure could make it more feasible to conduct effectiveness studies in clinical practice.

Adolescent↗
PubMed2005

Is the cutoff to define remission on the Hamilton Rating Scale for Depression too high?

The Hamilton Rating Scale for Depression (HRSD) is the most frequently used measure of outcome in antidepressant efficacy trials. More than a decade ago, a consensus panel recommended that remission be defined on the 17-item version of the HRSD as a cutoff <or=7. This recommendation was accompanied by a call for research to validate this cutoff value; however, little research in this area has been performed since then. The goal of the present study was to compare the validity of different HRSD cutoffs for defining remission. Three hundred three depressed psychiatric outpatients were rated on the 17-item HRSD, the Global Assessment of Functioning (GAF) scale, and the Standardized Clinical Outcome Rating for Depression, an index of DSM-IV remission status. We examined the sensitivity, specificity, and overall classification rate of the HRSD for identifying a broad and narrow interpretation of the DSM-IV definition of remission, and the association between the breadth of the definition of remission on the HRSD and self-report ratings of global psychosocial functioning and quality of life. Based on a narrow definition of DSM-IV remission, which requires an absence of clinically significant symptoms of depression, the optimal 17-item HRSD cutoff was <or=2. Compared with patients scoring 3 through 7 on the HRSD, those who scored 0 to 2 reported significantly less psychosocial impairment and better quality of life. Our results thus support the use of a lower cutoff on the HRSD than has been traditionally used to define remission.

Adolescent↗
PubMed2005

The prevalence of DSM-IV personality disorders in psychiatric outpatients.

OBJECTIVE: The largest clinical epidemiological surveys of personality 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 project is one of the largest clinical epidemiological studies to use semistructured interviews to assess a wide range of psychiatric disorders conducted in general clinical outpatient practice. In the present report, the authors examined the frequency of DSM-IV personality disorders in a patient group and the comorbidity among them. METHOD: Eight hundred fifty-nine psychiatric outpatients were interviewed with the Structured Interview for DSM-IV Personality upon presentation for treatment. RESULTS: Slightly less than one-third of the patients were diagnosed with one of the 10 official DSM-IV personality disorders (N=270, 31.4%). When the patients with personality disorder not otherwise specified were included, the rate of any personality disorder increased to almost half of the group (N=391, 45.5%). The majority of patients meeting criteria for one of the specific personality disorders were diagnosed with more than one. Avoidant, borderline, and obsessive-compulsive personality disorder were the most frequent specific diagnoses. CONCLUSIONS: Personality disorders, as a group, are among the most frequent disorders treated by psychiatrists. They should be evaluated in all psychiatric patients because their presence can influence the course and treatment of the axis I disorder that patients typically identify as their chief complaint.

Adult↗
PubMed2005

Generalizability of antidepressant efficacy trials: differences between depressed psychiatric outpatients who would or would not qualify for an efficacy trial.

OBJECTIVE: In recent years the generalizability of antidepressant efficacy trials has been questioned. Central to the question of generalizability is whether there are differences in clinical, demographic, and psychosocial characteristics between patients who would qualify for an antidepressant efficacy trial and those who would not qualify. METHOD: The authors compared three groups: 123 depressed patients who would qualify for an antidepressant efficacy trial, 289 whose symptom severity was too mild to qualify for an antidepressant efficacy trial, and 187 who would be excluded because they were suicidal or had a comorbid anxiety or substance use disorder. RESULTS: Compared with patients who would qualify for an antidepressant efficacy trial, patients who would be excluded because of comorbidity or suicidality were a more chronically ill group with more previous episodes, greater psychosocial impairment, and more personality pathology. CONCLUSIONS: These findings support further caution in generalizing the results from antidepressant efficacy trials to clinical populations.

Adult↗
PubMed2005

Why isn't bupropion the most frequently prescribed antidepressant?

OBJECTIVE: Reviews of antidepressant medication efficacy suggest that all antidepressants are equally effective. Bupropion is less likely than other antidepressants to cause weight gain and sexual dysfunction, the 2 side effects that are of greatest concern to patients and that have the greatest impact on long-term compliance. If bupropion is as effective as other antidepressants, and it does not cause the side effects that are the most frequent causes of long-term noncompliance, then why isn't it the most frequently prescribed antidepressant medication? To understand psychiatrists' decision making at the time an antidepressant is chosen, we conducted the Rhode Island Factors Associated With Antidepressant Choice Survey (FAACS). METHOD: For 1137 DSM-IV-diagnosed depressed patients initiated on an antidepressant, the treating psychiatrist completed a 43-item questionnaire listing factors that might have influenced the choice of medication. The questionnaire was filled out immediately after the antidepressant was prescribed to treat a depressive disorder. This study was conducted from August 2001 to February 2002. RESULTS: Because the reasons for choosing a medication to augment an existing regimen might be different from those used in monotherapy, augmentation trials were excluded from the analysis, leaving a sample of 965 patients. Bupropion was rarely prescribed when the presence of comorbid anxiety disorders or symptoms reflecting central nervous system activation influenced antidepressant selection. When the desire to avoid side effects, especially sexual dysfunction and weight gain, were the basis of selection, then bupropion was significantly more often prescribed than other antidepressants (p < .001). CONCLUSIONS: Although there is little evidence that patient factors predict differential medication response, psychiatrists are strongly inclined to base antidepressant selection on clinical profiles and avoid prescribing bupropion for depressed patients with high anxiety. Possible reasons for the discrepancy between psychiatrists' prescribing habits and the results of empirical study are discussed.

Adult↗
PubMed2004

An illustration of how a self-report diagnostic screening scale could improve the internal validity of antidepressant efficacy trials.

BACKGROUND: During the past 20 years semi-structured diagnostic interviews have been the standard for diagnostic evaluations in research relying on reliable and valid psychiatric assessment and diagnosis; however, only a minority of antidepressant efficacy trials (AETs) employ these interviews. This might be important insofar as several studies have found that clinicians conducting unstructured clinical interviews underrecognize diagnostic comorbidity. Because of the financial incentives to recruit patients into AETs quickly, there is little incentive to vigorously determine the presence of comorbid conditions that should result in exclusion from the trial. In the present report we demonstrate how a self-report diagnostic screening scale could be used to identify systematic differences in diagnostic practice across settings, and how such a scale could be used to compare samples of patients who pass screening evaluations and are accepted into an AET. METHODS: Depressed patients completed the Psychiatric Diagnostic Screening Questionnaire (PDSQ), and were evaluated with either an unstructured clinical interview or with the Structured Clinical Interview for DSM-IV (SCID). RESULTS: The two samples were clinically comparable based on their scores on the self-administered PDSQ. Consistent with the greater thoroughness of the SCID, compared to unstructured diagnostic evaluations, more patients administered the SCID were diagnosed with comorbid conditions. After excluding patients with disorders that might be the basis for exclusion from an AET, the two samples then differed in their scores on the PDSQ. That is, more patients in the sample evaluated by an unstructured interview had 'occult' pathology than patients evaluated with the SCID. CONCLUSION: These findings demonstrate how systematic differences in diagnostic practice might be detected across sites when conducting AETs. LIMITATIONS: The study was conducted with patients in a single outpatient clinical practice rather than participants of a multi-site trial.

Adult↗
PubMed2004

Screening for psychiatric disorders in outpatients with DSM-IV substance use disorders.

Psychiatric disorders are frequent in patients with substance use disorders, and have been associated with increased morbidity and poorer treatment outcome. Because of the clinical importance of comorbid mental disorders, concerns have been raised about the detection of psychiatric disorders in patients with substance use disorders. The Psychiatric Diagnostic Screening Questionnaire (PDSQ) is a brief, psychometrically strong, self-report scale designed to screen for the most common DSM-IV Axis I disorders encountered in outpatient mental health settings. Previously we described the diagnostic performance of the PDSQ in a large sample of psychiatric outpatients. For the present report, we examined the performance of the PDSQ in psychiatric outpatients with drug and alcohol abuse and dependence, and determined whether its performance in patients with substance use disorders is as good as it is in patients without substance use disorders. For the patients with a substance use disorder, 92% of the comorbid mental disorders were detected by the PDSQ subscales (i.e., mean sensitivity across subscales equals 92%) and 97% of the patients who screened negative did not have a disorder (i.e., mean negative predictive value equals 97%). For patients without a substance use disorder, the mean sensitivity and negative predictive values were 88% and 95%, respectively. Receiver Operating Characteristic curves were plotted for each PDSQ subscale for both patient groups, and all areas under the curve were significant and similar in the two groups.

Adolescent↗
PubMed2004

A review of studies of the Montgomery-Asberg Depression Rating Scale in controls: implications for the definition of remission in treatment studies of depression.

The Montgomery-Asberg Depression Rating Scale (MADRS) is one of the most commonly used symptom severity scales to evaluate the efficacy of antidepressant treatment Various cut-offs have been employed in antidepressant efficacy trials to define remission, although little empirical work has been carried out to determine the validity of various thresholds. One approach towards deriving a valid cut-off score for defining remission is to determine whether a patient's level of symptoms falls within the normal range of values after treatment We therefore conducted a literature review of studies of the MADRS in healthy controls to determine the normal range of values. We identified 10 studies of 14 samples that included data on the MADRS for 569 controls. Across all studies, the mean (+/- SD) weighted MADRS score, adjusting for sample size, was 4.0 (5.8) (95% confidence interval 3.5-4.5). These results are consistent with the findings of our study of the validity of different cut-offs to define remission on the MADRS-based on a narrow definition of remission, which required a complete absence of clinically significant symptoms of depression, the optimal MADRS cut-off was < or = 4 whereas based on a broader definition, the optimal cut-off was < or = 9. The findings can be used for normative comparisons in which post-treatment group mean scores are compared to mean scores from normative samples. A limitation of the review is that none of the studies was based on a randomly selected sample from the general population. In addition, the rigor of the screening used to exclude individuals with psychopathology in most studies is unknown; thus, some of the controls may have had diagnosable depression, thereby elevating the mean scores in the presumptively healthy control group.

Antidepressive Agents↗
PubMed2004

Exclusion criteria used in antidepressant efficacy trials: consistency across studies and representativeness of samples included.

The inclusion and exclusion criteria used to select subjects for participation in antidepressant efficacy trials (AETs) vary from study to study. It is unknown how much impact different sets of exclusion criteria have on the representativeness of subjects treated in AETs. In the present study, we applied the inclusion and exclusion criteria used in 39 recently published AETs to patients evaluated in routine clinical practice to evaluate the range and extent of the representativeness of samples treated in AETs. Nearly 600 patients with DSM-IV major depressive disorder (MDD) or bipolar depression underwent a thorough diagnostic evaluation. Inclusion and exclusion criteria used in AETs were applied to determine how many patients from our sample would have qualified for each AET had they applied. Approximately one sixth of the 596 depressed patients would have been excluded from an efficacy trial because they had a bipolar or psychotic subtype of depression. In the remaining 503 outpatients with nonpsychotic, unipolar MDD, the rates of exclusion ranged from 0% to 95.0% (mean=65.8%). Thus, the findings suggest that there is much variability in the generalizability of AETs, although, in general, subjects treated in AETs represent only a minority of patients treated for MDD in a community-based psychiatry outpatient practice.

Adolescent↗
PubMed2004

Assessing past treatment history: test-retest reliability of the Treatment Response to Antidepressant Questionnaire.

A reliable and valid instrument has yet to be developed that elicits antidepressant treatment history via patient interview. The goal of the present study was to establish the test-retest reliability of the Treatment Response to Antidepressant Questionnaire (TRAQ). The TRAQ is a semistructured interview that was designed to collect systematically information regarding previous antidepressant treatment, adequacy of trials, and nature of response. Fifty subjects who sought outpatient treatment as part of the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project participated in the study. Patients were interviewed initially by a psychologist, who administered the TRAQ. An average of 5 to 6 days later, a psychiatrist who was blind to the results of the initial evaluation readministered the TRAQ to each of these patients. Reliability of recall of antidepressant trials, trial adequacy, and nature of response were evaluated using the kappa statistic. The mean duration of the TRAQ interviews was 3.30 minutes (SD=2.03 minutes). The reliability of recall of antidepressant trials ranged from 0.81 to 0.95, with an overall kappa of 0.91. The kappa for trial adequacy, depending on the definition used, ranged from 0.72 to 0.84. The kappa for determining positive versus negative response was 0.72. Thus, the test-retest reliability of the TRAQ was found to be in the good to excellent range for each of the principal outcome measures. The TRAQ can be administered by non-MDs as a reliable measure for collecting standardized information regarding antidepressant treatment history via patient interview.

Adult↗
PubMed2004

A review of studies of the Hamilton depression rating scale in healthy controls: implications for the definition of remission in treatment studies of depression.

The Hamilton Rating Scale for Depression (HRSD) is the most commonly used symptom severity scale to evaluate the efficacy of antidepressant treatment. On the basis of an expert consensus panel, an HRSD score of < or = 7 was recommended as a cutoff to define remission. Since that recommendation, little empirical work has been conducted to confirm the validity of this threshold. One approach toward determining a cutoff score for defining remission is to establish the range of values for healthy controls. We therefore conducted a literature review of studies of the HRSD in healthy controls to determine the normal range of values. Studies of the HRSD in healthy control groups were identified in two ways. First, a MEDLINE search for the years 1966 to 2002 was conducted using the key words Hamilton, depression, and controls, and articles were reviewed. Second, the 69 studies included in two review articles written by the authors were examined. We identified 27 studies that included data on the HRSD for 1014 healthy controls. Across all studies, the weighted mean (SD) HRSD score, adjusting for sample size, was 3.2 (3.2; 95% CI, 3.0 to 3.4). HRSD scores were similar in geriatric and nongeriatric samples, and in men and women. Because HRSD scores in healthy controls are more likely to follow a skewed than a normal distribution, based on a mean of 3.2 and a SD of 3.2, at least 84% of healthy controls scored 7 or less on the HRSD, and 97.5% scored 10 or less. Thus, these results can be taken as support for the recommended cutoff of 7 on the HRSD to define remission. The results can also be used for normative comparisons in which posttreatment group mean scores are compared with mean scores from normative samples.

Adult↗
PubMed2004

Implications of using different cut-offs on symptom severity scales to define remission from depression.

A fundamental question in the medical management of disease is how well treatment works. Although there are many ways of defining improvement, one endpoint of definite interest is the resolution or remission of the disorder. In short-term antidepressant treatment trials, remission is usually defined according to post-treatment scores on symptom severity measures, such as the Hamilton Rating Scale for Depression (HRSD) or the Montgomery-Asberg Depression Rating Scale (MADRS). However, there is uncertainty as to what cut-offs should be used on these measures to define remission. During the past 2 years, as part of the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, our laboratory has examined the question of how to define remission on the HRSD and MADRS. In the present report from the MIDAS project, we examined the impact of the cut-off score used to define remission on the percentage of depressed outpatients in ongoing treatment who are considered to be in remission. In addition, we examined the association between remission status and psychosocial impairment for different cut-off scores. Three hundred and three depressed psychiatric outpatients were rated on the MADRS, 17-item HRSD, and an index of DSM-IV remission status. Approximately one-third of patients completed a measure of psychosocial impairment. For both the HRSD and the MADRS, we examined four cut-off scores for remission. For each cut-off, we determined the percentage of patients who met the definition of remission, the percentage of patients who continued to meet DSM-IV criteria for major depressive disorder (MDD), and the percentage of patients without any self-reported impairment from depression. For both scales, the range of cut-off scores was associated with more than a two-fold difference in prevalence of remission. Based on higher thresholds to define remission, a small percentage of patients met criteria for MDD, whereas no patients scoring below the low thresholds had MDD. The threshold to define remission was associated with psychosocial impairment: higher cut-off scores were associated with lower rates of no impairment. The cut-offs used to define remission from depression considerably influence the percentage of patients considered to be in remission. Lower cut-off scores than those most commonly used to define remission appear to be more valid.

Adolescent↗
PubMed2004

Using a self-report depression scale to identify remission in depressed outpatients.

OBJECTIVE: Some have suggested that standardized rating scales be used in clinical practice to monitor the course of treatment; however, the time demands of clinical practice make it difficult to use such measures. This study derived a cutoff on a self-report depression questionnaire corresponding to the most widely used definition of remission (a score < or =7 on the 17-item Hamilton Depression Rating Scale). METHOD: Two hundred sixty-seven depressed outpatients were rated on the Hamilton depression scale and completed the Clinically Useful Depression Outcome Scale (CUDOS). The authors used receiver operating curve analysis to examine the ability of the CUDOS to identify remission on the Hamilton depression scale. RESULTS: A high level of agreement was found between the self-report and Hamilton depression scale assessments of remission. CONCLUSIONS: Self-report questionnaires represent a practical option for thoroughly and objectively evaluating the course of treatment and determining remission in depressed patients.

Adolescent↗
PubMed2004

Defining remission on the Montgomery-Asberg depression rating scale.

OBJECTIVE: In antidepressant efficacy trials, it is common to define treatment remission as a score below a cutoff on symptom severity measures. No consensus has emerged regarding an appropriate cutoff for defining remission on the Montgomery-Asberg Depression Rating Scale (MADRS). The goal of the present study was to establish an empirically based cutoff on the MADRS for defining remission. METHOD: 303 psychiatric outpatients being treated for a DSM-IV major depressive episode were rated on the Standardized Clinical Outcome Rating for Depression, an index of DSM-IV remission status; the MADRS; and the Global Assessment of Functioning (GAF) scale. We examined the sensitivity, specificity, and overall classification rate of the MADRS for identifying a broad and narrow interpretation of the DSM-IV definition of remission, as well as the association between the breadth of the definition of remission and psychosocial functioning. RESULTS: On the basis of a narrow definition of remission, which requires a complete absence of clinically significant symptoms of depression, the optimal MADRS cutoff was < or = 4. On the basis of a broader definition, the optimal cutoff was < or = 9. Compared with patients scoring 5 through 9 on the MADRS, those who met the narrow definition of remission were rated higher, indicating better functioning, on the GAF and reported significantly less psychosocial impairment (p <.05). CONCLUSION: Our results support the use of a low cutoff on the MADRS to define remission. Because the choice of cutoff will impact the percentage of patients who are considered to be in remission and thus impact conclusions about treatment effectiveness, more empirical study should be directed toward this issue.

Activities of Daily Living↗