Measurement-based care training curriculum in psychiatry residency programs: I: Description of the curriculum and demonstration of implementation.

BACKGROUND: Recent literature shows that most practicing psychiatrists do not receive training in measurement-based care (MBC). Among the primary barriers to MBC implementation are the lack of formal training and curriculums. We present the first comprehensive MBC curriculum for use in adult psychiatric practice, and describe how the curriculum is adapted and implemented in psychiatry residency training programs. METHODS: The Standard for Clinicians' Interview in Psychiatry (SCIP) was developed as a measurement-based care tool for clinicians' use. The SCIP is the only instrument that includes 18 reliable and validated clinician-rated scales covering most adult psychiatric disorders. The SCIP has simple, unified rules of measurement that apply to the 18 scales. The MBC curriculum includes 2 instruction manuals, 4 didactic lectures, and 12 videotaped interviews. We describe the annual learning and implementation of MBC curriculum in residency programs. RESULTS: The curriculum implementation at West Virginia University and Delaware Psychiatric Center began in 2019 and is ongoing. We present 3 case demonstrations of the implementation of MBC in clinical settings. CONCLUSIONS: Comprehensive implementation of MBC curriculum in residency programs has the potential to facilitate research and create a "culture" of MBC in future generations of psychiatrists.

Measurement-based Care in Psychiatry-Past, Present, and Future.

The authors define measurement-based care (MBC) in psychiatry as the use of validated clinical measurement instruments to objectify the assessment, treatment, and clinical outcomes, including efficacy, safety, tolerability, functioning, and quality of life, in patients with psychiatric disorders. MBC includes two processes: routine assessments, such as measuring the severity of symptoms with rating scales, and the use of assessments in decision-making. MBC implementation was tested in the Texas Medication Algorithm Project and the German Algorithm Project and has been shown to improve patient outcomes. Even though more recent research has shown the many benefits of MBC compared to the usual care, MBC is still not the standard of care in psychiatric practice. This review article addresses the advantages of MBC, the barriers to implementing MBC in clinical practice, and the basic properties of MBC instruments. Recent developments in the 21st century that are expected to accelerate the adoption of MBC in clinical practice, including electronic health records, health information technology, and the development of the Standard for Clinicians' lnterview in Psychiatry (SCIP) as an MBC tool, will be reviewed. The authors recommend including MBC in psychiatry residency training to promote its use in future generations.

A novel approach to measuring response and remission in schizophrenia in clinical trials.

BACKGROUND: Pharmaceutical companies conduct clinical trials to show the efficacy and safety of new medications for the treatment of schizophrenia. After the new medications are marketed, clinicians treating patients with schizophrenia discover that a considerable number of patients do not respond to these new medications. The goals of the review are to examine the methodology and design of recent antipsychotic clinical trials, identify common flaws, and propose guidelines to fix the flaws and improve the quality of future clinical trials of antipsychotic medications. METHODS: A review of recent antipsychotic clinical trials was conducted using a PubMed search. Ten recent trials published in the past four years were reviewed and their methods analyzed and critiqued. RESULTS: The authors identified six major methodological flaws that may explain the suboptimal response in many patients after a drug is approved. Most of the flaws are related to eligibility criteria, the misuse of the Positive and Negative Syndromes Scale (PANSS) and the lack of consensus on how to define remission, response and exacerbation in schizophrenia. Proposed guidelines for a more rigorous use of the PANSS are presented and recommendations are proposed for using uniform criteria for remission, response and exacerbation in schizophrenia. CONCLUSIONS: The authors recommend using standardized diagnostic interviews to screen patients for eligibility criteria and using the PANSS according to the author's recommendations and the proposed guidelines. Uniform criteria to define remission, response and exacerbation are recommended for clinical trials examining the efficacy and safety of antipsychotic drugs in schizophrenia.

The Standard for Clinicians' Interview in Psychiatry (SCIP): A Clinician-administered Tool with Categorical, Dimensional, and Numeric Output-Conceptual Development, Design, and Description of the SCIP.

Existing standardized diagnostic interviews (SDIs) were designed for researchers and produce mainly categorical diagnoses. There is an urgent need for a clinician-administered tool that produces dimensional measures, in addition to categorical diagnoses. The Standard for Clinicians' Interview in Psychiatry (SCIP) is a method of assessment of psychopathology for adults. It is designed to be administered by clinicians and includes the SCIP manual and the SCIP interview. Clinicians use the SCIP questions and rate the responses according to the SCIP manual rules. Clinicians use the patient's responses to questions, observe the patient's behaviors and make the final rating of the various signs and symptoms assessed. The SCIP method of psychiatric assessment has three components: 1) the SCIP interview (dimensional) component, 2) the etiological component, and 3) the disorder classification component. The SCIP produces three main categories of clinical data: 1) a diagnostic classification of psychiatric disorders, 2) dimensional scores, and 3) numeric data. The SCIP provides diagnoses consistent with criteria from editions of the Diagnostic and Statistical Manual (DSM) and International Classification of Disease (ICD). The SCIP produces 18 dimensional measures for key psychiatric signs or symptoms: anxiety, posttraumatic stress, obsessions, compulsions, depression, mania, suicidality, suicidal behavior, delusions, hallucinations, agitation, disorganized behavior, negativity, catatonia, alcohol addiction, drug addiction, attention, and hyperactivity. The SCIP produces numeric severity data for use in either clinical care or research. The SCIP was shown to be a valid and reliable assessment tool, and the validity and reliability results were published in 2014 and 2015. The SCIP is compatible with personalized psychiatry research and is in line with the Research Domain Criteria framework.

Perspectives on the Positive and Negative Syndrome Scale (PANSS): Use, misuse, drawbacks, and a new alternative for schizophrenia research.

BACKGROUND: In 1987, Kay et al published the Positive and Negative Syndrome Scale (PANSS) and the PANSS manual to address the limitations of existing instruments for schizophrenia research. The PANSS has been one of the most widely used instruments in schizophrenia research-until now. Because of recent advances in neuroscience research, it has become essential to reevaluate the performance of the PANSS since its development 3 decades ago. METHODS: A comprehensive literature review of the PANSS from 1987 to 2015 using a PubMed search was conducted. RESULTS: Five drawbacks to the PANSS have been cited in the literature. Although several authors have pointed out flaws of the PANSS, no revisions or modifications have been attempted to address them. In addition, some researchers do not use the PANSS as intended by the authors, and other researchers misuse it. CONCLUSIONS: The PANSS is a reliable and valid instrument that has served the scientific research community well for decades. New advances in experimental psychopathology and personalized psychiatry and the new National Institute of Mental Health paradigm of Research Domain Criteria necessitate a new instrument compatible with advances in clinical neuroscience research.

The reliability of the standard for clinicians' interview in psychiatry (SCIP): a clinician-administered tool with categorical, dimensional and numeric output.

BACKGROUND: Existing standardized diagnostic interviews are not used by psychiatrists in clinical settings. There is an urgent need for a clinician-administered tool for assessment of adult psychopathology that produces dimensional measures, in addition to categorical diagnoses. METHODS: The Standard for Clinicians' Interview in Psychiatry (SCIP) was designed to be used in clinical settings and generates dimensional measures. The reliability of the SCIP was tested at six sites: one hospital and two clinics in USA, two hospitals in Egypt and one clinic in Canada. Participants were adult patients who were admitted for inpatient psychiatric treatment or came for regular office visits in the outpatient clinic. Refusal rate was <1%. Missing data were <1.1%. Patients with dementia, mental retardation or serious medical conditions were excluded. A total of 1,004 subjects were interviewed between 2000 and 2012. RESULTS: Inter-rater reliability (Kappa) was measured for 150 SCIP items: 116 items (77.3%) had good reliability (Kappa>0.7), 28 items (18.7%) had fair reliability (Kappa ranges from 0.5 to 0.7) and six items (4%) had poor reliability (Kappa<0.5). Cronbach's alpha for internal consistency was measured for the SCIP dimensions: anxiety, posttraumatic stress, depression, mania, hallucinations, Schneider first-rank symptoms, delusions, disorganized thoughts, disorganized behavior, negative symptoms, alcohol addiction, drug addiction, attention and hyperactivity. All of the SCIP dimensions had substantial Cronbach's alpha values (>0.7) with the exception of disorganized thoughts (Cronbach's alpha=0.375). CONCLUSIONS: The SCIP is a reliable tool for assessing psychological symptoms, signs and dimensions of the main psychiatric diagnoses.

Scientific Forum on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V)-An Invitation.

The publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) is anticipated in May 2013 with many new additions and changes. In this article, the author summarizes the phases of psychiatric classification from the turn of the 20th century until today. Psychiatry 2010 offers a DSM-V Scientific Forum and invites readers to submit comments, recommendations, and articles to Psychiatry 2010 and DSM-V Task Force.

Recommendation for DSM-V: A Proposal for Adding Causal Specifiers to Axis I Diagnoses.

Causal specifiers are certain and possible causes of mental disorders and can be biological, genetic, environmental, developmental, social, psychodynamic, behavioral, cognitive, or personality characteristics. Depending upon the clinical judgment of the degree of certainty, a causal specifier can be a definite etiopathogenesis or a factor contributing to manifestations of mental disorders. The author recommends adding causal specifiers to Axis I diagnoses in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition to improve communication among clinicians.

Use of Structured Interviews by Psychiatrists in Real Clinical Settings: Results of an Open-question Survey.

Psychiatry (Edgemont) readers were surveyed about whether or not they use structured interviews in real clinical settings. Forty psychiatrists responded to the survey: six psychiatrists in private practices and 34 faculty psychiatrists. The majority of psychiatrists (72.5%) do not use structured interviews and 27.5 percent use some structured interviews in clinical settings. The three most commonly cited reasons for not using structured interviews were "constraints of time," "structured interviews are research tools," and "structured interviews interfere with establishing rapport with patients." Other reasons why psychiatrists do not use structured interviews are analyzed and discussed.

The Reliability of Psychiatric Diagnosis Revisited: The Clinician's Guide to Improve the Reliability of Psychiatric Diagnosis.

BACKGROUND: The authors reviewed the topic of reliability of psychiatric diagnosis from the turn of the 20th century to present. The objectives of this paper are to explore the reasons of unreliability of psychiatric diagnosis and propose ways to improve the reliability of psychiatric diagnosis. METHOD: The authors reviewed the literature on the concept of reliability of psychiatric diagnosis with emphasis on the impact of interviewing skills, use of diagnostic criteria, and structured interviews on the reliability of psychiatric diagnosis. RESULTS: Causes of diagnostic unreliability are attributed to the patient, the clinician and psychiatric nomenclature. The reliability of psychiatric diagnosis can be enhanced by using diagnostic criteria, defining psychiatric symptoms and structuring the interviews. CONCLUSIONS: The authors propose the acronym 'DR.SED,' which stands for diagnostic criteria, reference definitions, structuring the interview, clinical experience, and data. The authors recommend that clinicians use the DR.SED paradigm to improve the reliability of psychiatric diagnoses.

Evaluating risk factors for violence at the inpatient unit level: combining young adult patients and those with mental retardation.

The current study demonstrates the use of patient case mix to evaluate the probability of aggression occurring on an inpatient psychiatric unit. The impact of combining young adult psychiatric patients with patients classified with mental retardation on the overall negative events and injuries on an inpatient psychiatric unit was evaluated. Results suggest when the combined number of young adults and patients classified with mental retardation exceeds 10 the unit is at high risk for aggressive behavior occurring. Recommendations for evaluating violence at a unit level using case mix are provided.

The Validity of Psychiatric Diagnosis Revisited: The Clinician's Guide to Improve the Validity of Psychiatric Diagnosis.

BACKGROUND: The authors reviewed the types and phases of validity of psychiatric diagnosis. In 1970, Robins and Guze proposed five phases to achieve valid classification of mental disorders: clinical description, laboratory study, exclusion of other disorders, follow-up study, and family study. OBJECTIVES: The objectives of this paper are to review what has been learned since Robins and Guze's influential article as well as examine the impact of the new discoveries in neurosciences and neuroimaging on the practicing clinician. METHOD: The authors reviewed the literature on the concept of validity in psychiatry with emphasis on the role of clinical training, the use of structured interviews and rating scales, and the importance of the new discoveries in neurosciences. RESULTS: Robins and Guze's phases have been the cornerstone of construct validity in psychiatry at the level of researchers. In the absence of the gold standard of psychiatric diagnosis, Spitzer proposed the "LEAD," which is an acronym for longitudinal evaluation, and is done by expert clinicians utilizing all the data available. The LEAD standard is construct validity at the level of experts; however, guidelines are lacking to improve the validity skills of the practicing clinicians. CONCLUSIONS: The authors propose the acronym DR.SEE, which stands for data, reference definitions, rating scales, clinical experience, and external validators. The authors recommend that clinicians use the DR.SEE paradigm to improve the validity of psychiatric diagnoses.

Hyperprolactinemia associated with risperidone: a case report and review of literature.

This case report describes a 19-year-old Caucasian woman who presented to a state psychiatric facility with symptoms of depression and auditory hallucinations. She was diagnosed with schizoaffective disorder, depressed type, and was treated with risperidone and sertraline. Soon after initiation of drug therapy, the patient developed galactorrhea and dysmenorrhea, and her prolactin level was 171.6ng/mL (normal level 2.8-29.2ng/mL in adult women). Upon discontinuation of risperidone, the prolactin level dropped to 17.2ng/mL within one week. The patient was treated with quetiapine and titrated up to 800mg daily. Repeated prolactin levels continued to be normal during treatment with quetiapine. This case report and others from literature suggest that risperidone is associated with hyperprolactinemia, and that quetiapine is less likely to be associated with hyperprolactinemia.

Branded versus generic clozapine for treatment of schizophrenia.

OBJECTIVE: To report clinical findings resulting from a switch from branded to generic clozapine. METHODS: Twenty patients diagnosed with schizophrenia were followed in this naturalistic outpatient study. The Positive and Negative Syndrome Scale (PANSS), Beck Anxiety Inventory (BAI), Abnormal Involuntary Movement Scale, and the Movement Disorder Assessment were used to assess differences in the clinical status of patients before and after switching from Clozaril to generic clozapine (Mylan Pharmaceuticals). Results were analyzed by means of the paired t-test and by calculation of the percent change in mean scores. A clinically significant change as measured by the PANSS was defined as a +/- 20% change in mean scores at final evaluation. The design was open-label and non-blinded. RESULTS: At the final evaluation, the t-test revealed no significant differences between branded and generic clozapine for the total PANSS, the positive symptom, negative symptom, and the general psychopathology subscales of the PANSS, and the BAI. There were no clinically significant changes for any measure. CONCLUSIONS: In this small group of patients with schizophrenia, no deterioration in clinical status in several domains was noted after changing from branded to generic clozapine. This finding is consistent with pharmacologic data suggesting bioequivalence of the 2 products. Results, however, must be interpreted cautiously due to the lack of optimal study controls and small sample size.

Hierarchical and nonhierarchical approaches in psychiatric diagnosis: a case report of change in psychiatric symptoms and diagnosis over time.

The article reports the case of a 39-year-old male who was diagnosed with and treated for bipolar disorder. Over the past 18 months, the patient has experienced new onset of auditory hallucinations and worsening of his psychotic symptoms. The treating psychiatrists changed the diagnosis from bipolar disorder to schizoaffective disorder. The authors discuss hierarchical and nonhierarchical approaches to psychiatric diagnosis in relation to this case report.