Development of

Diagnostic Variables • Diagnoses have been created for both the DSM-

IV and ICD-10 systems• WMH CIDI Advisory Committee instrumental in

this process• Instrument Development Phase

– During development phase of survey, CIDI questions were designed to assess each criterion necessary for a diagnosis.

– Experts in each field were consulted for best way to assess each aspect of the diagnosis

– Studied existing CIDI 2.1 as well as all standard research instruments for assessing diagnoses

Diagnostic Algorithms

• Algorithm Development Phase– Once CIDI 3.0 was finalized, a team of researchers and programmers developed

SAS code to operationalize each diagnostic criterion from questions in instrument

• Clinical Calibration– Validity studies have been done in:

• US, Italy, France, Spain, China, Nigeria, India– Iterative process continues to date

• Updates/Improvements to the recent versions of the CIDI 3.0• Revisions to the diagnostic algorithms are made based on this analysis.

– Minor revisions when a particular item does not work or a threshold should be modified to improve concordance (SO)

– Major revisions when analysis proves that the cidi was grossly overestimating a particular disorder (bipolar I and bipolar II)

– Algorithms released are the most recent as of Feb, 2006. We will not be updating the diagnostic data file available for public release, however, changes will be posted in the diagnostic algorithm section of the ncs website.

Diagnostic Variables available through the Public Release dataset

• ATTENTION DEFICIT DISORDER • AGORAPHOBIA • ALCOHOL ABUSE with or without dependence• ALCOHOL DEPENDENCE with Abuse • ADULT SEPARATION ANXIETY DISORDER • BIPOLAR I • BIPOLAR II • BIPOLAR SUBTHRESHOLD • CONDUCT DISORDER • DRUG ABUSE with or without dependence• DRUG DEPENDENCE with abuse• DYSTHYMIA • GENERALIZED ANXIETY DISORDER • HYPOMANIA • INTERMITTENT EXPLOSIVE DISORDER • MANIA • MAJOR DEPRESSIVE DISORDER • MAJOR DEPRESSIVE EPISODE • OPPOSITIONAL DEFIANT DISORDER • PANIC ATTACK • PANIC DISORDER • POST-TRAUMATIC STRESS DISORDER • SEPARATION ANXIETY DISORDER • SOCIAL PHOBIA • SPECIFIC PHOBIA • NICOTINE DEPENDENCE

Diagnostic Hierarchy Rules

• Some DSM-IV diagnoses contain a criterion called a “hierarchy rule”.

• E.g. If meet GAD but only during a mood disorder – do not receive gad diagnosis. (SEE DSM-IV GAD criterion F)

“The disturbance does not occur exclusively during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder”

• In these cases, we create two diagnostic variables: one with hierarchy (narrow definition) and one without hierarchy (broad definition that does not operationalize the hierarchy criterion).

• Important for studies of comorbidity. Researchers discretion which version to use – but version must be clearly stated in all reports.

Hierarchy Example

• Criterion F.• Part 2. The disturbance does not occur exclusively

during a Mood Disorder, a Psychotic Disorder, or a Pervasive Developmental Disorder.

• Note: Psychotic Disorder and Pervasive Developmental Disorder hierarchies are not operationalized.

1. (Major Depression = No(5) AND Minor Depression = No(5) AND Dysthymia = No(5) AND Mania = No(5)) OR

2. ((Major Depression = Yes(1) OR Minor Depression = Yes(1) OR Dysthymia = Yes(1) OR Mania = Yes(1)) AND ( (GAD onset < Mood onset) OR (GAD recency > Mood recency) OR (GAD persistence > Mood persistence))) OR

3. G10e = No(5)

Diagnostic Variables w/Hierarchy

DSM-IV Disorder Hierarchical Disorder

Alcohol Abuse with hierarchy Alcohol dependence

Drug Abuse with hierarchy Drug dependence

Dysthymia with hierarchy MDE, Mania, Hypomania

GAD with hierarchy MDE, MND, DYS, Mania

IED with hierarchy Mania, ALA, ALD, DRA,

DRD, MDE, hypomania

MDD with hierarchy Mania, hypomania

ODD with hierarchy MDE, MND, Mania, CD

Organic Exclusion• Many DSM-IV diagnoses contain a criterion called “organic exclusion”.

• This criterion has been operationalized using a standard format across CIDI sections.– DXA. Episodes of this sort sometimes occur as the results of physical causes such as

physical illness or injury or the use of medication, drugs, or alcohol. Do you think your episodes ever occurred as the result of such physical causes?

– DXB. Do you think your episodes were always the result of physical causes?

• In any interview schedule where this question (DXB) is “yes” we ask the follow-up question :

– DXC. Briefly, what were the physical causes?

• All open ended text from the organic exclusion item DXC have been reviewed by a psychiatrist for the NCS-R and a determination has been made as to whether it is a qualifying organic exclusion.

• If, it was determined that there is no qualifying organic exclusion, and the respondent meets all other criteria, then the respondent has be hard-coded as meeting the diagnostic criteria for the disorder in the SAS code .

Programming Conventions (1)

• Diagnostic assignment accomplished by a series of SAS macros

• We provide word documents that give detailed descriptions of the sas code but we do not release the code.

• Onset and Recency are determined by looking at the Minimum of any onset item and the Maximum of any recency item

Programming Conventions (2)

• Standard notation:

Lifetime Diagnosis dsm_dx icd_dx

12 M Diagnosis d_dx12 i_dx12

30 day Diagnosis d_dx30 i_dx30

Onset Age dx_ond dx_oni

Recency Age dx_recd dx_reci

Hierarchy example:Dx w/out hierarchy dsm_dx

Dx w/ hierarchy dsm_dxh d_dxh12 d_dxh30 icd_dxh i_dxh12 i_dxh30

• Presence/absence of each criterion established first

– Allowable values: yes/no/don’t know/refuse

– Hierarchy of yes/no/dk/ref for Criteria variables: if not yes: if any no no, if any dk dk, if any ref ref

• Standard rules to compile criteria into final diagnosis (yes/no)

– Must meet all criteria for yes. If any criterion has value other than ‘YES’, then final diagnosis is “NO”

– Do not allow for indeterminacy in final diagnosis (dk/ref not carried through to this point)

Imputations of missing data

• No imputations of Diagnostic Disorders

• Imputation of onset and recency– “hot deck” imputation– Rational imputation

• Imputation of demographic/constructed variables.– Regression based, “hot deck” and rational

DSM-IV-TR Major Depressive Episode

Criteria for Major Depressive EpisodeA. Five (or more) of the following symptoms have been present during the same 2-week period and represent a change from previous functioning; at least one of the symptoms is either    (1) depressed mood or   (2) loss of interest or pleasure. Note: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations. (1) depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g., appears tearful). Note: In children and adolescents, can be irritable mood. (2) markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others) (3) significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains. (4) Insomnia or Hypersomnia nearly every day (5) psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down) (6) fatigue or loss of energy nearly every day (7) feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick) (8) diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others) (9) recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide B. The symptoms do not meet criteria for a Mixed Episode (see p. 335). C. The symptoms cause clinically significant distress or impairment in social, occupational, or other important areas of functioning. D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism). E. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than 2 months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.