Methods To Improve Diagnostic Assessment And Services Research Articles

Identifying the DSM-5 mixed features specifier in depressed patients: A comparison of measures

BackgroundA commonly used measure to assess mixed features in depressed patients is the Young Mania Rating Scale (YMRS), which only partially aligns with the DSM-5 criteria. Different algorithms on the YMRS have been used to approximate the DSM-5 mixed features criteria. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined the agreement and validity of different approaches towards assessing the mixed features specifier. MethodsThree hundred nine depressed psychiatric patients were interviewed with the Structured Clinical Interview for DSM-IV, the DSM-5 Mixed Features Specifier Interview (DMSI) and the YMRS. Seven definitions of mixed features were examined, two based on the DMSI and five from the YMRS. ResultsThe prevalence of mixed features varied 8-fold amongst the 7 definitions. The level of agreement between the YMRS definitions and the DMSI was poor. For each definition, mixed features were significantly more common in patients with bipolar disorder than major depressive disorder. A family history of bipolar disorder was significantly associated with the DMSI assessment of mixed features but none of the YMRS approaches. LimitationsThe ratings on the measures were not independent of each other. The sample size was too small to compare the patients with bipolar I and bipolar II disorder. ConclusionsWhile there was evidence of validity for both the DSM-5 and YMRS approaches towards identifying mixed features, the 2 approaches are not interchangeable. The algorithm on the YMRS used to classify patients has a significant impact on prevalence.

Does the Five Facet Mindfulness Questionnaire measure the same constructs before and after ACT-based treatment? Examination of the longitudinal measurement invariance of the 24-item FFMQ-SF

Violations of longitudinal measurement invariance (LMI) suggest “response shifts” in individuals’ understanding and appraisal of items over time and result in misinterpretation of observed changes in outcome measures. These concerns are crucial to the validity of outcome measures and are particularly relevant in examining the effectiveness of mindfulness and other process-based interventions. In the current report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examine the LMI of the 24-item short form of the Five Factor Mindfulness Questionnaire from intake to discharge in a large, diagnostically heterogeneous sample of psychiatric patients (n = 2928) participating in an acceptance and commitment therapy-based partial hospitalization program. The original five-factor structure required correlated error terms for items with similar wording (Nonjudging of Experience and Describe scales) to achieve acceptable fit. Following these modifications, we found evidence of configural and weak invariance for all scales. We found evidence for strong invariance for Nonjudging of Experience, Nonreactivity to Inner Experiences, Describe, and Observing, but not for Acting with Awareness. Strict invariance was not supported. Results highlight the challenges of measuring constructs involving overt metacognitive processes via self-report. Implications for scale development and clinical practice are discussed.

Depressed patients who do not believe they deserve to get better: Prevalence, clinical characteristics, and treatment outcomes.

The aim of the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project was to examine the demographic and clinical features that distinguished depressed patients who did and did not indicate they deserved to feel better. A total of 490 depressed patients completed a clinical history questionnaire that included a question about whether the patient thought they deserved to feel better, as well as a self-report questionnaire assessing symptoms, positive mental health, coping ability, functioning, and well-being. Approximately 20% of patients indicated they were unsure or undeserving of feeling better. Patients who did not believe they deserved to get better reported more cognitive symptoms of depression, were more likely to drop out of treatment due to nonattendance, more pessimistic about outcomes upon treatment initiation, more frequently reported suicidal ideation, more frequently reported a history of multiple suicide attempts, and experienced less improvement in their depressive symptoms during treatment. A meaningful number of depressed patients seeking treatment did not assert that they deserved to feel better. Efforts to treat individuals who do not believe they deserve to feel better may be less productive if this perspective is not addressed.

Telehealth treatment of patients with major depressive disorder during the COVID-19 pandemic: Comparative safety, patient satisfaction, and effectiveness to prepandemic in-person treatment

BackgroundThe COVID-19 pandemic impelled a transition from in-person to telehealth psychiatric treatment. There are no studies of partial hospital telehealth treatment for major depressive disorder (MDD). In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compared the effectiveness of partial hospital care of patients with MDD treated virtually versus in-person. MethodsOutcome was compared in 294 patients who were treated virtually from May 2020 to December 2021 to 542 patients who were treated in the in-person partial program in the 2 years prior to the pandemic. Patients completed self-administered measures of patient satisfaction, symptoms, coping ability, functioning, and general well-being. ResultsIn both the in-person and telehealth groups, patients with MDD were highly satisfied with treatment and reported a significant reduction in symptoms from admission to discharge. Both groups also reported a significant improvement in positive mental health, general well-being, coping ability, and functioning. A large effect size of treatment was found in both treatment groups. Contrary to our hypothesis, the small differences in outcome favored the telehealth-treated patients. The length of stay and the likelihood of staying in treatment until completion were significantly greater in the virtually treated patients. LimitationsThe treatment groups were ascertained sequentially, and telehealth treatment was initiated after the COVID-19 pandemic began. Outcome assessment was limited to a self-administered questionnaire. ConclusionsIn an intensive acute care setting, delivering treatment to patients with MDD using a virtual, telehealth platform was as effective as treating patients in-person.

Treatment engagement of depressed patients with and without psychosis in a partial hospital program: Dropout, symptom reduction, and satisfaction

The ways patients with psychosis and depression engage in therapeutic treatment is not well understood. To determine if an intensive outpatient psychotherapy program could benefit patients experiencing psychotic symptoms, it is important to know how these individuals engage with psychotherapeutic treatment. The present study from the Rhode Island Hospital Methods to Improve Diagnostic Assessment and Services (MIDAS) project compared dropout rates, treatment response, and satisfaction among 219 individuals with psychosis and major depressive disorder (MDD) to 2,545 individuals with MDD at a general, Acceptance and Commitment Therapy-based partial hospital program (PHP). Those with psychosis were significantly less likely to complete treatment. Approximately one-fifth of all patients experienced at least a 50% reduction in depressive and anxiety symptoms. The vast majority of patients with psychosis were highly satisfied with treatment. Findings suggest patients with psychosis have a higher risk of premature dropout. Patients with psychosis demonstrated a reduction in symptoms during PHP treatment and self-reported high satisfaction with treatment. This study calls for the implementation of practices to reduce premature dropout for patients with psychosis, and for future research on the effectiveness of general psychiatric treatment for those with psychotic symptoms.

Telehealth Treatment of Patients With Borderline Personality Disorder in a Partial Hospital Setting During the COVID-19 Pandemic: Comparative Safety, Patient Satisfaction, and Effectiveness of In-Person Treatment.

There are no studies of the safety and effectiveness of telehealth psychiatric treatment of partial hospital level of care, in general, and for borderline personality disorder (BPD) in particular. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, the authors compared the effectiveness of their partial hospital treatment program in treating patients with BPD. For both the in-person and telehealth partial hospital level of care, patients with BPD were highly satisfied with treatment and reported a significant reduction in symptoms from admission to discharge. Both groups reported a significant improvement in functioning, coping ability, positive mental health, and general well-being. A large effect size of treatment was found in both treatment groups. No patients attempted suicide. Telehealth partial hospital treatment was as effective as in-person treatment in terms of patient satisfaction, symptom reduction, and improved functioning and well-being for patients with BPD.

The Clinical Characteristics of Patients With Borderline Personality Disorder in Different Treatment Settings.

The present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) Project compares patients with borderline personality disorder (BPD) in an outpatient practice (n = 390) and a partial hospital setting (n = 358) on diagnostic comorbidities, symptoms experienced, suicidality, and occupational impairment. The patients in the partial program were diagnosed with significantly more psychiatric disorders and were more frequently diagnosed with dysthymia, generalized anxiety disorder, alcohol and substance use disorders, adjustment disorders, and posttraumatic stress disorder. Those at the partial hospital had significantly higher levels of suicidal ideation than those in the outpatient practice. The samples did not differ on utilization of disability or suicide attempts. Treatment setting may have implications in the recognition of the disorder in clinical practice, the development and support of etiological theories, identification of core deficits, and evaluation of psychosocial morbidity associated with BPD.

A Clinically Useful Anger Outcome Scale

In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we describe the development and validation of the Clinically Useful Anger Outcome Scale (CUANGOS). Current anger measures vary in their psychometric quality, clinical utility, and clinically relevant content coverage, and no one scale addresses all three of these key considerations. We aimed to develop a brief, clinically useful anger scale that (a) assesses clinically relevant aspects of anger, (b) performs well across different patient populations, and (c) is brief, accessible, and easy to use in routine clinical practice either as a stand-alone measure or as part of an assessment battery. Analyses included data from 2710 psychiatric outpatients and 1397 partial hospitalization patients. We used data from randomly drawn subsamples to select items with good psychometric properties and sufficient distinction from measurements of other emotional dysfunction, resulting in a 5-item scale. In reliability and validity analyses using the remaining participants, CUANGOS scores showed high internal consistency and appropriate test-retest reliability, as well as excellent discriminant validity from measurements of depression and anxiety. CUANGOS scores converged strongly with clinician ratings of subjective and overt anger and differentiated across all or almost all levels of clinician-rated anger severity. CUANGOS scores were also significantly higher in patients with anger-related disorders versus patients with other psychiatric disorders. Results provide promising evidence for the CUANGOS as a reliable and valid measurement of anger in clinical populations. Moreover, the CUANGOS is brief and feasible to incorporate into routine clinical practice.

Patient satisfaction with partial hospital telehealth treatment during the COVID-19 pandemic: Comparison to in-person treatment

Most research evaluating telehealth psychiatric treatment has been conducted in outpatient settings. There is a lack of research assessing the efficacy of telehealth treatment in more acute, intensive treatment settings such as a partial hospital. In the face of the COVID-19 pandemic, much of ambulatory behavioral health treatment has transitioned to a telehealth, or virtual, format. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compared patient satisfaction of partial hospital services delivered via telehealth to in-person treatment provided to patients treated prior to the COVID-19 outbreak. The sample included 240 patients who were treated virtually from May, 2020 to October, 2020, and a comparison group of 240 patients who were treated in the in-person partial program a year earlier. Patients completed self-administered measures of patient satisfaction after the initial evaluation and at the end of treatment. For both the in-person and telehealth methods of delivering partial hospital level of care, patients were highly satisfied with the initial diagnostic evaluation and were optimistic at admission that treatment would be helpful. At the completion of treatment, both groups were highly satisfied with all components of the treatment program and almost all would recommend treatment to a friend or family member. Thus, patient satisfaction was as high with telehealth partial hospital treatment as with in-person treatment.

Is the DSM-5 Anxious Distress Specifier Interview a valid measure of anxiety in patients with generalized anxiety disorder: A comparison to the Hamilton Anxiety Scale

DSM-5 includes criteria for an anxious distress specifier for major depressive disorder, and measures have been developed to assess these criteria. The validity of measures of the severity of anxious distress has been established in depressed patients. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined whether a severity measure of anxious distress was as valid as the Hamilton Anxiety Scale (HAMA) as a measure of the severity of anxiety in patients with generalized anxiety disorder (GAD). Eighty-five patients with GAD were interviewed by trained raters who administered the DSM-5 Anxious Distress Specifier Interview (DADSI), HAMA, and Hamilton Depression Rating Scale (HAMD). The patients completed self-report measures of depression, anxiety, and irritability. The DADSI and HAMA were significantly correlated (r 0.52, p < .001). Both the DADSI and HAMA were more highly correlated with measures of anxiety than with measures of the other symptom domains. The HAMD was significantly more highly correlated with the HAMA than with the DADSI. Both measures were significantly correlated with measures of positive mental health, functioning, life satisfaction, and general well-being. Both measures were sensitive to change in response to treatment. Both the DADSI and HAMA were valid measures of anxiety severity in patients with GAD, though the HAMA was more highly confounded with the HAMD than the DADSI. The DADSI is briefer than the HAMA, and thus may be more practical to use in research studies as well as clinical practice.

How should the severity of depression be rated on self-report depression scales?

Almost all depression measures have been developed without discussing how to best conceptualize and assess the severity of depression. The most valid rating format of depression severity scales is unsettled and has been little studied. In the present study from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compared the validity of alternative approaches towards rating the severity of depressive symptoms. Data was collected using TurkPrime. One hundred eighty-five participants currently in treatment for a mental health problem completed a self-report measure of depression and rated the symptoms on two 4-point ordinal scales assessing symptom frequency and symptom intensity. The respondents also rated their global level of depression severity and completed a measure of psychosocial functioning and quality of life. The symptom ratings based on intensity and frequency were highly correlated with each other, and equally highly correlated with subjects’ global rating of overall severity of depression, as well as ratings of psychosocial functioning and quality of life. A composite index of severity based on the sum of frequency and severity ratings was no more highly correlated with the external validators. The results of the present study suggest that ratings of depressive symptoms based on either symptom intensity or symptom frequency are equally valid.

Symptom presence versus symptom intensity in understanding the severity of depression: Implications for documentation in electronic medical records

BackgroundData mining efforts have been applied to research data bases to develop statistical models for predicting outcomes. Electronic medical records have the potential to enable efforts to apply statistical techniques to mine large clinical data bases. Of course, such prediction algorithms will only be as good as the data that is available to input. The question that we address in the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project is how much information might be gained from dimensional ratings of symptom severity over and above that which is accounted for when determining symptom presence. Such results could have implications for how medical record documentation should be established. MethodsPatients were evaluated with a semi-structured interview, and the presence of each symptom of major depressive disorder (MDD) was recorded. Patients were also rated on the Clinical Global Index of Severity (CGI-S). ResultsA multiple regression analysis entering the presence of MDD symptoms as predictors of the CGI had a cumulative R2 of 0.26. A multiple regression analysis entering all symptom severity ratings as predictors of the CGI had a cumulative R2 of 0.40. LimitationsThe study was based on patients presenting for outpatient treatment to a single clinical practice. Symptoms that are not diagnostic criteria for MDD were not examined. DiscussionResearch institutions interested in using data mining statistical approaches of electronic medical records should consider having the clinicians rate whether symptoms are mild, moderate or severe and not just whether they are present or absent.

Have Treatment Studies of Depression Become Even Less Generalizable? Applying the Inclusion and Exclusion Criteria in Placebo-Controlled Antidepressant Efficacy Trials Published over 20 Years to a Clinical Sample

Background: Antidepressants are amongst the most frequently prescribed medications. More than a decade ago, our clinical research group applied a prototypic set of inclusion/exclusion criteria used in an antidepressant efficacy trial (AET) to patients presenting for treatment in our outpatient practice and found that most patients would not qualify for the trial. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we apply the psychiatric inclusion/exclusion criteria used in 158 placebo-controlled studies to a large sample of depressed patients who presented for outpatient treatment to determine the range and extent of the representativeness of samples treated in AETs and whether this has changed over time. Method: We applied the inclusion and exclusion criteria used in 158 AETs to 1,271 patients presenting to an outpatient practice who received a principal diagnosis of major depressive disorder. The patients underwent a thorough diagnostic evaluation. Results: Across all 158 studies, the percentage of patients that would have been excluded ranged from 44.4 to 99.8% (mean = 86.1%). The percentage of patients that would have been excluded was significantly higher in the studies published in 2010 through 2014 compared to the studies published from 1995 to 2009 (91.4 vs. 83.8%, t(156) = 3.74, p < 0.001). Conclusions: Only a minority of depressed patients seen in clinical practice are likely to be eligible for most AETs. The generalizability of AETs has decreased over time. It is unclear how generalizable the results of AETs are to patients treated in real-world clinical practice.

Screening for Borderline Personality Disorder in Psychiatric Outpatients With Major Depressive Disorder and Bipolar Disorder.

Borderline personality disorder (BPD) is a serious illness that is frequently underdiagnosed. A previous psychometric analysis of the 9 BPD criteria in DSM-IV/DSM-5 found that the affective instability criterion functioned well as a screen for the disorder. A limitation of that initial study was that the performance of the BPD criteria was examined in a diagnostically heterogeneous sample, including those with a low likelihood of having BPD. The present study from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project examined the operating characteristics of the BPD criteria in patients with major depressive disorder (MDD) and bipolar disorder. From December 1995 to April 2014, 3,674 psychiatric outpatients were evaluated with a semistructured diagnostic interview for DSM-IV BPD. The operating characteristics of the BPD criteria were examined in 3 nonoverlapping groups of patients: those with a principal diagnosis of MDD, those with a principal diagnosis of bipolar disorder, and all remaining patients. The sensitivity and negative predictive value of the affective instability criterion were greater than 90% in patients with MDD, bipolar disorder, or other diagnoses. Of the 9 BPD criteria, the affective instability criterion achieved the highest sensitivity and negative predictive value in all 3 diagnostic groups. Despite the phenomenological overlap between BPD and mood disorders, inquiry about affective instability functions well as a clinically useful screen for BPD in patients with MDD and bipolar disorder. In patients presenting for the treatment of MDD or bipolar disorder, clinicians should screen for BPD in the same way that they screen for other comorbid psychiatric disorders-by inquiring about a single feature of the disorder (ie, affective instability), the presence of which captures almost all patients with the disorder and the absence of which rules out the disorder.

Reliability and validity of a self-report scale for daily assessments of the severity of anxiety symptoms

BackgroundTo evaluate the efficacy of rapidly effective treatments it is necessary to use measures that are designed to assess symptom severity over short intervals. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we modified our previously published anxiety scale and examined the reliability and validity of a daily version of the Clinically Useful Anxiety Outcome Scale (CUXOS-D, D indicates daily version). MethodsTwo thousand four hundred and ninety-one patients presenting for treatment to a partial hospital program completed the CUXOS-D as part of their initial paperwork and on a daily basis thereafter. Test-retest reliability was examined in 50 patients who completed the CUXOS-D twice on the same day. A subset of 73 patients was interviewed by a trained rater who administered the Hamilton Anxiety Rating Scale (HAMA) at baseline and on the day of discharge. ResultsThe CUXOS-D had high internal consistency and test-retest reliability and was more highly correlated with another measure of anxiety symptoms than depressive symptoms. CUXOS-D scores progressively declined during the course of treatment, and scores on each successive day were significantly lower than the preceding day. The change in CUXOS-D scores was significantly correlated with a change in HAMA scores (r = 0.61, p < .001). A large effect size was found for both measures (CUXOS-D: d = 1.22; HAMA: d = 0.93). DiscussionIn a large sample of partial hospital patients mostly diagnosed with mood and anxiety disorders, we demonstrated some aspects of the reliability and validity of the CUXOS-D.

What is anxious depression? Overlap and agreement between different definitions

Anxiety is common in depressed patients. However, a problem with the research on the significance of anxiety in depressed patients is that anxiety has been characterized in different ways. Little research has examined the concordance and overlap between the various definitions of anxious depression. With research on the DSM-5 anxious distress specifier just beginning, it will be important to understand how defining anxious depression according to DSM-5 agrees with previously studied definitions. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project we examined the association between the DSM-5 anxious distress specifier and 6 other approaches towards defining anxious depression. Three hundred thirty-one patients with a principal diagnosis of major depressive disorder were evaluated with semi-structured diagnostic interviews. The mean number of anxious depression definitions met was 4.7 (SD = 2.1). Only 4.2% (n = 14) of the 331 patients did not meet any anxious depression definition, and 28.1% (n = 93) met all 7 definitions. The level of agreement between the definitions was significant, albeit modest (median kappa = .28). The modest association between the different definitions of anxious depression suggests that the results based on one approach towards subtyping may not generalize to the DSM-5 anxious distress specifier. It therefore cannot be assumed that the DSM-5 anxious distress specifier is valid just because other definitions of anxious depression have been shown to be valid.

Validity of the DSM-5 anxious distress specifier for major depressive disorder.

DSM-5 introduced the anxious distress specifier in recognition of the clinical significance of anxiety in depressed patients. Recent studies that supported the validity of the specifier did not use measures that were designed to assess the criteria of the specifier but instead approximated the DSM-5 criteria from scales that were part of an existing data base. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined the validity of the specifier diagnosed with a semistructured interview. Two hundred sixty patients with a principal diagnosis of major depressive disorder were evaluated with semistructured diagnostic interviews. The patients were rated on clinician rating scales of depression, anxiety and irritability, and completed self-report measures. Approximately three-quarters of the depressed patients met the criteria for the anxious distress specifier. Patients with anxious distress had a higher frequency of anxiety disorders, particularly panic disorder and generalized anxiety disorder, as well as higher scores on measures of anxiety, depression, and anger. The patients meeting the anxious distress subtype reported higher rates of drug use disorders, poorer functioning during the week before the evaluation, and poorer coping ability compared to the patients who did not meet the anxious distress specifier. Moreover, anxious distress was associated with poorer functioning and coping after controlling for the presence of an anxiety disorder. The results of the present study indicate that anxious distress is common in depressed patients and support the validity of the DSM-5 anxious distress specifier.

Reliability and validity of a self-report scale for daily assessments of the severity of depressive symptoms

To evaluate the efficacy of rapidly effective treatments for depression it is necessary to use measures that are designed to assess symptom severity over short intervals. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we modified our previously published depression scale and examined the reliability and validity of a daily version of the Clinically Useful Depression Outcome Scale (CUDOS-D). One thousand one hundred and fifteen patients presenting for treatment of DSM-IV/DSM-5 major depressive disorder (MDD) to a partial hospital program completed the CUDOS-D as part of their initial paperwork and on a daily basis thereafter. Test-retest reliability was examined in 50 patients who completed the CUDOS-D twice on the same day. A subset of 69 patients were interviewed by a trained diagnostic rater who administered the 17-item Hamilton Depression Rating Scale (HAMD) at baseline and on the day of discharge. The CUDOS-D had high internal consistency (Cronbach's alpha at intake = 0.82; Cronbach's alpha at follow-up = 0.93) and test-retest reliability (r = 0.91 and 0.98 at intake and follow-up, respectively), and was more highly correlated with another measure of depressive than nondepressive symptoms. CUDOS-D scores progressively declined during the course of treatment, and scores on each successive day were significantly lower than the preceding day. The change in CUDOS-D scores was significantly correlated with a change in HAMD scores (r = 0.65, p < 0.001). A large effect size was found for both measures (CUDOS-D: d = 1.63; HAMD: d = 1.56). In a large sample of partial hospital patients, the CUDOS-D was a reliable and valid measure of the DSM-5 symptoms of MDD assessed on a daily basis.

Understanding the severity of depression: Which symptoms of depression are the best indicators of depression severity?

BackgroundIn DSM-5, all symptoms of depression are considered equal representations of severity. In ICD-10, the type of symptom is considered in classifying severity. It is important to better understand if the defining symptoms of depression are differentially associated with overall severity so that severity categorization in diagnostic systems is most valid. In the present study from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project we examined the association between the individual diagnostic criteria for major depressive disorder (MDD) and global ratings of depression severity. We thus examined whether there is support for the ICD-10 approach in which some symptoms are better indicators of severity than are other symptoms. MethodsPatients were evaluated with a semi-structured interview and the presence of each symptom of MDD was recorded. Patients were also rated on the Clinical Global Index of severity (CGI-S). ResultsAll 9 DSM-5 criteria were significantly correlated with the CGI with suicidality having the highest correlation. A regression analysis found that all 9 criteria were significant predictors of the CGI. At the symptom level, 15 of the 17 symptoms were significantly correlated with the CGI (all except increased appetite and increased weight). DiscussionThere were differences between the symptoms of depression in their association with severity with suicidal ideation, depressed mood, and anhedonia having the highest correlations with severity whereas some symptoms were not significantly associated with severity distinctions. Future descriptions of the severity of depression should not consider all criteria as equal representations of severity.

Screening for Bipolar Disorder and Finding Borderline Personality Disorder: A Replication and Extension.

The authors' group previously reported that patients who screened positive on the Mood Disorders Questionnaire (MDQ), the most frequently studied screening scale for bipolar disorder, were as likely to be diagnosed with borderline personality disorder (BPD) as with bipolar disorder. A limitation of that study was that the authors examined the performance of the MDQ in patients presenting for various psychiatric disorders, including depression. The recognition of bipolar disorder and its differential diagnosis with BPD is of greatest clinical relevance in depressed patients. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, the authors attempted to replicate their initial findings in a new sample of psychiatric outpatients, and they also examined the performance of the MDQ in depressed patients. The results of the present study were consistent with the original report, thereby indicating that the MDQ is not effective in helping distinguish bipolar disorder from BPD.