Transcript Development of Diagnostic Variables

Development of
Diagnostic Variables
• Diagnoses have been created for both the DSMIV 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
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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
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Clinical Calibration
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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
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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
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Some DSM-IV diagnoses contain a criterion called a “hierarchy rule”.
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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”
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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).
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Important for studies of comorbidity. Researchers discretion which version
to use – but version must be clearly stated in all reports.
Hierarchy Example
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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.
2.
3.
(Major Depression = No(5) AND Minor Depression =
No(5) AND Dysthymia = No(5) AND Mania = No(5)) OR
((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
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
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Many DSM-IV diagnoses contain a criterion called “organic exclusion”.
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This criterion has been operationalized using a standard format across CIDI sections.
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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?
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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 :
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DXC. Briefly, what were the physical causes?
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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.
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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)
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Standard notation:
Lifetime Diagnosis
12 M Diagnosis
30 day Diagnosis
Onset Age
Recency Age dx_recd
dsm_dx
d_dx12
d_dx30
dx_ond
dx_reci
icd_dx
i_dx12
i_dx30
dx_oni
Hierarchy example:
Dx w/out hierarchy
Dx w/ hierarchy
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dsm_dx
dsm_dxh d_dxh12 d_dxh30 icd_dxh i_dxh12 i_dxh30
Presence/absence of each criterion established first
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Allowable values: yes/no/don’t know/refuse
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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)
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Must meet all criteria for yes. If any criterion has value other than ‘YES’, then final diagnosis is “NO”
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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 Episode
A. 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 selfreproach 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.