Onset of schizophrenia diagnoses in a large clinical cohort.

We aimed to describe the diagnostic patterns preceding and following the onset of schizophrenia diagnoses in outpatient clinics. A large clinical sample of 26,163 patients with a diagnosis of schizophrenia in at least one outpatient visit was investigated. We applied a Continuous Time Hidden Markov Model to describe the probability of transition from other diagnoses to schizophrenia considering time proximity. Although the most frequent diagnoses before schizophrenia were anxiety and mood disorders, direct transitions to schizophrenia usually came from psychotic-spectrum disorders. The initial diagnosis of schizophrenia was not likely to change for two of every three patients if it was confirmed some months after its onset. When not confirmed, the most frequent alternative diagnoses were personality, affective or non-schizophrenia psychotic disorders. Misdiagnosis or comorbidity with affective, anxiety and personality disorders are frequent before and after the diagnosis of schizophrenia. Our findings give partial support to a dimensional view of schizophrenia and emphasize the need for longitudinal assessment.

Spanish adaptation of the Dimensional Anhedonia Rating Scale (DARS).

BACKGROUND: Anhedonia is defined as the lack of enjoyment, engagement in, or energy for life's experiences. Only two scales to measure anhedonia have been adapted for use in Spanish-speaking populations. The aim of this study was to determine the reliability and validity of the Dimensional Anhedonia Rating Scale (DARS) following translation and adaptation for Spanish population. METHOD: The study sample included 134 patients over 18 years of age with a range of psychiatric diagnoses. Those with substance use, decompensated medical conditions, illiteracy, or lack of fluency in Spanish were excluded. The structure of the Spanish adaptation was evaluated through factor analysis. Internal reliability was assessed through Cronbach's alpha and validity was measured using Pearson's correlation between total scores for DARS and its subscales and SHAPS score. RESULTS: A strong internal consistency was observed (Cronbach alpha = 0.92 for total scale score and 0.91-0.92 for subscale scores). Similarly, a significant and strong correlation between total scores for DARS and SHAPS was found (r = 0.51, p < 0.01). LIMITATIONS: The heterogeneous distribution of diagnoses included in the study may limit our results. CONCLUSIONS: The Spanish DARS maintains the psychometric properties of the original questionnaire, with strong internal consistency and adequate validity. DARS is a specific questionnaire for evaluating anhedonia, incorporating elements that reflect motivation, interest, and effort, and one which offers possible advantages over other anhedonia scales.

WHODAS 2.0 as a Measure of Severity of Illness: Results of a FLDA Analysis.

WHODAS 2.0 is the standard measure of disability promoted by World Health Organization whereas Clinical Global Impression (CGI) is a widely used scale for determining severity of mental illness. Although a close relationship between these two scales would be expected, there are no relevant studies on the topic. In this study, we explore if WHODAS 2.0 can be used for identifying severity of illness measured by CGI using the Fisher Linear Discriminant Analysis (FLDA) and for identifying which individual items of WHODAS 2.0 best predict CGI scores given by clinicians. One hundred and twenty-two patients were assessed with WHODAS 2.0 and CGI during three months in outpatient mental health facilities of four hospitals of Madrid, Spain. Compared with the traditional correction of WHODAS 2.0, FLDA improves accuracy in near 15%, and so, with FLDA WHODAS 2.0 classifying correctly 59.0% of the patients. Furthermore, FLDA identifies item 6.6 (illness effect on personal finances) and item 4.5 (damaged sexual life) as the most important items for clinicians to score the severity of illness.

Estudio comparativo de los formatos en lápiz y papel y electrónicos de los cuestionarios GHQ-12, WHO-5 y PHQ-9 / Comparative study of pencil-and-paper and electronic formats of GHQ-12, WHO-5 and PHQ-9 questionnaires

Introducción. El auge de la telemedicina en el campo de la salud mental está haciendo que el uso de instrumentos psicométricos, tradicionalmente basados en un soporte de «lápiz-y-papel», se adapte al formato electrónico. El objetivo de este trabajo es verificar si los 2 formatos de conocidos instrumentos como las escalas GHQ-12, WHO-5 y PHQ-9 son intercambiables. Material y métodos. Cuarenta y siete voluntarios completaron los cuestionarios GHQ-12, WHO-5 y PHQ-9 en papel y en las siguientes 24h en su versión electrónica a través de la web www.memind.net (24 en formato electrónico-Likert y 23 en formato electrónico-slider). Se midió la consistencia interna mediante el índice α-Cronbach y el coeficiente omega, la fiabilidad test-retest mediante el coeficiente de correlación intraclase (CCI), el grado de acuerdo de los ítems mediante el coeficiente kappa ponderado y comparamos la estructura dimensional de los 2 formatos con el índice de ajuste comparativo (IAC). Resultados. La consistencia interna de los instrumentos fue mayor de 0,8 para todos los instrumentos a excepción del PHQ-9. Los CCI oscilaron entre 0,655 para PHQ-9 lápiz-y-papel/electrónico-slider y 0,901 para GHQ-12 lápiz-y-papel/electrónico-slider. El acuerdo entre los ítems en las versiones en lápiz-y-papel y electrónica-Likert fue variable, desde acuerdos muy bajos en el del ítem PHQ-1 (κ ponderada=0,143; p=0,384) hasta acuerdos altos en el ítem PHQ-5 (κ ponderada=0,769; p=0,000). La equivalencia arrojada con el IAC fue adecuada. Conclusiones. Con la excepción del PHQ-9 electrónico-Likert, los cuestionarios mantienen su estructura en la versión electrónica. Encontramos discrepancias en el acuerdo entre los ítems, lo que apoya la idea de que el paso de un instrumento diseñado en papel al medio digital no es un proceso automático, sino que requiere un proceso de adaptación y de verificación sobre el tipo de diseño en formato electrónico (AU)

Introduction. The increase in telemedicine in the mental health field has led to psychometric instruments changing from paper-and-pencil administration to an electronic format. A study is performed to determine if both formats are equivalent for well-known questionnaires such as GHQ-12, WHO-5, and PHQ-9. Material and methods. Forty-seven volunteers completed GHQ-12, WHO-5 and PHQ-9 questionnaires in paper-and-pencil format, and in the following 24h they completed their electronic versions via the web site www.memind.net. An electronic-Likert format was used by 24 participants, and 23 used an electronic-slider format. Internal consistency was measured by α-Cronbach index and omega coefficient, and test-retest was measured by the intraclass correlation coefficient (ICC). Agreement between individual items was compared using Weighted Kappa coefficients, and dimensional structure between formats using the Comparative Fit Index (CFI). Results. Internal consistency was higher than 0.8 for GHQ-12 and WHO-5. The ICC ranged between 0.655 for PHQ-9 paper-and-pencil/electronic-slider and 0.901 for GHQ-12 paper-and-pencil/electronic- slider. Agreement for individual items in paper-and-pencil and electronic-Likert versions was variable, ranging from low agreement in PHQ-1 (weighted κ=0.143; P=.384) to high agreement in PHQ-5 (weighted κ=0.769; P=.000). The CFI results showed an adequate equivalence between formats. Conclusions. Except for the PHQ-9 electronic-Likert, questionnaires keep their structure in electronic formats. Discrepancies were found in items agreement. This study supports previous works indicating that the change from paper-and-pencil to electronic formats is not an immediate process, and needs a proper adaptation (AU)

User profiles of an electronic mental health tool for ecological momentary assessment: MEmind.

Ecological momentary assessment (EMA) is gaining importance in psychiatry. This article assesses the characteristics of patients who used a new electronic EMA tool: the MEmind Wellness Tracker. Over one year, 13811 adult outpatients in our Psychiatry Department were asked to use MEmind. We collected information about socio-demographic data, psychiatric diagnoses, illness severity, stressful life events and suicidal thoughts/behavior. We compared active users (N = 2838) and non-active users (N = 10,973) of MEmind and performed a Random Forest analysis to assess which variables could predict its use. Univariate analyses revealed that MEmind-users were younger (42.2 ± 13.5 years versus 48.5 ± 16.3 years; χ2  = 18.85; P < 0.001) and more frequently diagnosed with anxiety related disorders (57.9% versus 46.7%; χ2  = 105.92; P = 0.000) than non-active users. They were more likely to report thoughts about death and suicide (up to 24% of active users expressed wish for death) and had experienced more stressful life events than non-active users (57% versus 48.5%; χ2  = 64.65; P < 0.001). In the Random Forest analysis, 31 variables showed mean decrease accuracy values higher than zero with a 95% confidence interval (CI), including sex, age, suicidal thoughts, life threatening events and several diagnoses. In the light of these results, strategies to improve EMA and e-Mental Health adherence are discussed.

Comparative study of pencil-and-paper and electronic formats of GHQ-12, WHO-5 and PHQ-9 questionnaires. / Estudio comparativo de los formatos en lápiz y papel y electrónicos de los cuestionarios GHQ-12, WHO-5 y PHQ-9.

INTRODUCTION: The increase in telemedicine in the mental health field has led to psychometric instruments changing from paper-and-pencil administration to an electronic format. A study is performed to determine if both formats are equivalent for well-known questionnaires such as GHQ-12, WHO-5, and PHQ-9. MATERIAL AND METHODS: Forty-seven volunteers completed GHQ-12, WHO-5 and PHQ-9 questionnaires in paper-and-pencil format, and in the following 24h they completed their electronic versions via the web site www.memind.net. An electronic-Likert format was used by 24 participants, and 23 used an electronic-slider format. Internal consistency was measured by α-Cronbach index and omega coefficient, and test-retest was measured by the intraclass correlation coefficient (ICC). Agreement between individual items was compared using Weighted Kappa coefficients, and dimensional structure between formats using the Comparative Fit Index (CFI). RESULTS: Internal consistency was higher than 0.8 for GHQ-12 and WHO-5. The ICC ranged between 0.655 for PHQ-9 paper-and-pencil/electronic-slider and 0.901 for GHQ-12 paper-and-pencil/electronic- slider. Agreement for individual items in paper-and-pencil and electronic-Likert versions was variable, ranging from low agreement in PHQ-1 (weighted κ=0.143; P=.384) to high agreement in PHQ-5 (weighted κ=0.769; P=.000). The CFI results showed an adequate equivalence between formats. CONCLUSIONS: Except for the PHQ-9 electronic-Likert, questionnaires keep their structure in electronic formats. Discrepancies were found in items agreement. This study supports previous works indicating that the change from paper-and-pencil to electronic formats is not an immediate process, and needs a proper adaptation.

Factores de riesgo de la conducta suicida asociados a trastornos depresivos y ansiedad / Suicide risk factors related to depressive and anxiety disorders

Introducción El suicidio es una de las 10 principales causas de muerte a nivel mundial. La conducta suicida es resultado de la interrelación de factores psicopatológicos (depresión, psicosis, drogas), sociales (aislamiento, situación laboral), biólogicos (heredabilidad del 50%, hipofunción serotoninérgica) y ambientales (sucesos estresantes, situaciones de maltrato). El objetivo de este trabajo es valorar el riesgo de intentos de suicidio con presencia de trastornos de ansiedad, depresión mayor y depresión comórbida con ansiedad. Método Se reclutaron 505 pacientes con historia de intentos de suicidio y 277 pacientes sin ella, como controles, en tres hospitales generales de Madrid, España. Se realizó una regresión logística utilizando como variable dependiente la existencia o no de historia de intentos de suicidio, como variables independientes el diagnóstico y los factores de riesgo vinculados a los intentos de suicidio según la literatura médica. Resultado El modelo clasificó correctamente el 80% de los pacientes. El riesgo de suicido fue mayor en pacientes con depresión (OR=3.4; IC 95%=1.8-4.8) y con comorbilidad ansiedad-depresión (OR=4.3; IC 95%=2.4-7.8) a diferencia de los pacientes no diagnosticados con éstos. Los pacientes que no tenían hijos presentaron un riesgo de intentos de suicidio mayor respecto a quienes sí los tenían (OR=3.8; IC 95%=2.3-6.2). La edad del paciente menor de 35 años y la historia familiar de conducta suicida incrementó el riesgo de intento de suicidio (OR=2.2; IC 95%=1.1-4.5). Conclusiones La comorbilidad depresión-ansiedad es un factor de riesgo para la conducta suicida más importante que estas condiciones por separado u otros diagnósticos, esta asociación confiere mayor riesgo que otros factores como la historia familiar de conducta suicida, el no tener hijos o la edad menor a 35 años. Los clínicos deben prestar atención a pacientes con depresión y ansiedad comórbidas en presencia de factores de riesgo para la conducta suicida.

Introduction Suicide is among the most prevalent causes of death in the world. A history of past suicide attempts is the most important of all the risk factors to show suicidal behavior (attempts and completed suicides). The objective of this study is to assess the effect of anxiety disorders, major depressive disorder, and comorbid major depression with anxiety on the risk for suicide attempts. Methods We recruited 505 patients with a history of suicide attempts and a control group of 277 patients without a history of suicide attempt from three hospitals in Madrid, Spain. We performed a logistic regression analysis using a progressive elimination method with the presence or absence of a history of suicide attempts as the dependent variable. As independent variables we included the diagnosis (anxiety, major depression, anxiety comorbid with major depression, and other diagnoses) and other risk factors for suicide attempts recognized in the literature. Results The regression model correctly classified more than 80% of the patients. Patients with depression (OR=3.4; CI 95%=1.8-4.8) and with anxiety-depression comorbidity (OR=4.3; CI 95%=2.4-7.8) had higher risk for suicide attempt compared to patients with other diagnoses. Patients without children had a higher risk for suicide attempt than those with children (OR=3.8; 95% CI=2.3-6.2), while patients with a family history of suicide had a higher risk than those without it (OR=2.2; 95% CI=1.1-4.5). Conclusions In clinical populations, the comorbidity of depression and anxiety is a higher risk factor for suicide attempts than having either condition separately or having other diagnoses. It also seems to be more important than other risk factors, such as family history.

[Brief Suicide Questionnaire. Inter-rater reliability]. / Protocolo breve de evaluación del suicidio: fiabilidad interexaminadores.

INTRODUCTION: Inter-rater agreement is a crucial aspect in the planning and performance of a clinical trial in which the main assessment tool is the clinical interview. The main objectives of this study are to study the inter-rater agreement of a tool for the assessment of suicidal behavior (Brief Suicide Questionnaire) and to examine whether the inter-examiner agreement when multiple ratings are made on a single subject is an efficient method to assess the reliability of an instrument. METHOD: In the context of designing a multicenter clinical trial, 32 psychiatrists assessed a videotaped clinical interview of a patient with suicidal behavior. In order to identify those items in which a greater level of discordance existed and detect the examiners whose ratings differed significantly from the average ratings, we used the DOMENIC method (Detecion of Multiple Examiners Not in Consensus). RESULTS: Inter-rater agreement was between poor (<70%) to excelent (90-100%. Inter-rater agreement in Brugha's list of threatening experiences ranged from 75.5 and 100%; in the Global Assessment of Functioning (GAF) Scale was 82.58%; in the Beck's Suicidal Intent Scale, ranged from 67.5 and 97%; in the Beck's Scale for Suicide Ideation, ranged from 63.5 and 100%; and in the Lethality Rating Scale was 88.39%. On the whole, the level of agreement among raters, both in general scores and in particular items, was appropriate. CONCLUSION: The proposed design allows the assessment of the inter-rater agreement in an efficient way (only in one session). In addition, regarding the Brief Suicide Questionnaire, inter-raters agreement was appropriate.

Protocolo breve de evaluación del suicidio: fiabilidad interexaminadores / Brief Suicide Questionnaire. Inter-rater reliability

Introducción. El acuerdo entre-examinadores es un aspecto fundamental en la planificación de cualquier trabajo de investigación donde la principal herramienta diagnóstica es la entrevista clínica. El objetivo de este estudio es valorar el acuerdo entre-examinadores de un instrumento de evaluación de la conducta suicida (Protocolo breve de evaluación del suicidio) utilizando las valoraciones de múltiples observadores en una sola sesión. Método. Durante la fase piloto de un estudio clínico multicéntrico centrado en la monitorización de intentos de suicidio, 32 examinadores evaluaron el vídeo de la entrevista clínica a un paciente simulado con conducta suicida. Para identificar los ítems en los que existía una mayor discordancia y a los examinadores cuyo criterio se alejaba más del acuerdo general, se utilizó el método Detection Of Multiple Examiners Not In Consensus (DOMENIC). Resultado. El acuerdo interexaminadores osciló entre pobre (<70%) y excelente (90-100%). En la escala de acontecimientos vitales estresantes el nivel de acuerdo osciló entre 48,4 y 97%; en la escala problemas psicosociales del DSM-IV, entre 75,5 y 100%; en la escala de evaluación de la actividad global fue de 82,58%; en la escala de intencionalidad suicida, osciló entre 67,5 y 97%; en la escala de ideación suicida, entre 63,5 y 100% y en la escala de letalidad del intento de suicidio fue de 88,39%. En general, los examinadores mostraron un nivel de acuerdo adecuado tanto en las puntuaciones globales de cada escala como en cada ítem en particular. Conclusiones. El diseño propuesto permite evaluar el acuerdo entre-examinadores de una forma eficiente (en una única sesión). Además, con respecto al Protocolo breve de evaluación del suicidio, el acuerdo entre-examinadores fue apropiado(AU)

Introduction. Inter-rater agreement is a crucial aspect in the planning and performance of a clinical trial in which the main assessment tool is the clinical interview. The main objectives of this study are to study the inter-rater agreement of a tool for the assessment of suicidal behaviour (Brief Suicide Questionnaire) and to examine whether the inter-examiner agreement when multiple ratings are made on a single subject is an efficient method to assess the reliability of an instrument. Method. In the context of designing a multicenter clinical trial, 32 psychiatrists assessed a videotaped clinical interview of a patient with suicidal behaviour. In order to identify those items in which a greater level of discordance existed and detect the examiners whose ratings differed significantly from the average ratings, we used the DOMENIC method (Detecion of Multiple Examiners Not in Consensus). Results. Inter-rater agreement was between poor (<70%) to excellent (90-100%. Inter-rater agreement in Brugha's list of threatening experiences ranged from 75.5% to 100%; in the Global Assessment of Functioning (GAF) Scale was 82.58%; in Beck's Suicidal Intent Scale, ranged from 67.5% to 97%; in Beck's Scale for Suicide Ideation, ranged from 63.5% to 100%; and in the Lethality Rating Scale was 88.39%. On the whole, the level of agreement among raters, both in general scores and in particular items, was appropriate. Conclusion. The proposed design allows the assessment of the inter-rater agreement in an efficient way (only in one session). In addition, regarding the Brief Suicide Questionnaire, inter-raters agreement was appropriate(AU)