Abstract
Background and ObjectivesThe use of “operational criteria” is a solution for low reliability, contrasting with a prototypical classification that is used in clinics. We aim to measure the reliability of prototypical and ICD-10 diagnoses.MethodsThis is a retrospective study, with a convenience sample of subjects treated in a university clinic. Residents reviewed their diagnosis using ICD-10 criteria, and Cohen's kappa statistic was performed on operational and prototype diagnoses.ResultsThree out of 30 residents participated, reviewing 146 subjects under their care. Diagnoses were grouped in eight classes: organic (diagnoses from F00 to F09), substance disorders (F10–F19), schizophrenia spectrum disorders (F20–F29), bipolar affective disorder (F30, F31, F34.0, F38.1), depression (F32, F33), anxiety-related disorders (F40–F49), personality disorders (F60–F69), and neurodevelopmental disorders (F70–F99). Overall, agreement was high [K = 0.77, 95% confidence interval (CI) = 0.69–0.85], with a lower agreement related to personality disorders (K = 0.58, 95% CI = 0.38–0.76) and higher with schizophrenia spectrum disorders (K = 0.91, 95% CI = 0.82–0.99).DiscussionUse of ICD-10 criteria did not significantly increase the number of diagnoses. It changed few diagnoses, implying that operational criteria were irrelevant to clinical opinion. This suggests that reliability among interviewers is more related to information gathering than diagnostic definitions. Also, it suggests an incorporation of diagnostic criteria according to training, which then became part of the clinician's prototypes. Residents should be trained in the use of diagnostic categories, but presence/absence checking is not needed to achieve operational compatible diagnoses.
Highlights
Unreliability among clinicians has haunted psychiatry at least since the 1940s [1]
All research in psychiatry is based on an operational criteria diagnosis, obtained through the use of structured diagnostic interviews (SDIs), such as “The Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders” (SCID) [4], neither SDIs nor operational checklists are used in everyday clinical practice [5]
We found 45 prototype-based diagnoses and 51 ICD-10 operational-based diagnoses using the entire four-digit ICD-10 descriptors
Summary
Unreliability among clinicians has haunted psychiatry at least since the 1940s [1] These problems continued to increase until they peaked during the 1970s, after the joint United States and United Kingdom schizophrenia reliability studies, which demonstrated a low agreement among North Americans and British psychiatrists for schizophrenia [2]. There are virtually no studies about DSM criteria use in clinical practice [6, 7], and many researchers advocate a return to a prototype-based diagnostic description [8, 9]. Some authors view this decision as a return to a problematic paradigm used in the pre-DSM-III era [10, 11], despite the fact that well-built prototypes are both reliable [12] and clinically useful [13]. We aim to measure the reliability of prototypical and ICD-10 diagnoses
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