Mark Zimmerman, MD

Editorial note: Dr Zimmerman offers a response to Drs Ghaemi and Pies' letter, 

Screening Instruments Do Work for Bipolar Disorder, But Not by Themselves.

I thank Drs Ghaemi and Pies for the letter commenting upon 

 discussing the diagnosis of bipolar disorder (BD) and the use of screening scales.

1) Screening scales for BD are not needed if psychiatrists conduct an appropriate clinical evaluation;

2) Psychiatrists may not have the time to conduct appropriate clinical evaluations so screening scales can save time;

3) They believe that the use of multiple screening measures can further improve diagnostic accuracy; and

4) BD screening scales could be useful in primary care settings.

At the outset let me state that I agree that BD screening scales may be useful in primary care settings because patients who screen positive can be referred to a mental health professional for a diagnostic evaluation. My article focused on the use of these scales in mental health settings. I also agree that a competent clinical evaluation is the diagnostic gold standard and precludes the need for BD screening scales.

However, justifying the use of screening because of their time-saving benefit, thereby implying that clinicians have insufficient time to inquire about BD, is, in my opinion, a weak argument. As I noted in my initial article, BD screening scales have modest sensitivity; thus, a negative result does not preclude a clinical evaluation. BD screening scales also have modest positive predictive value; thus, a positive result does not preclude a clinical evaluation. In other words, a clinical evaluation is needed regardless of the results of the screening test. So, how is time saved? Further, I find it ironic that they have confidence in psychiatrists, who claim not to have sufficient time to conduct an appropriate clinical evaluation, to interpret the results of a screening scale appropriately.

There are several examples in the literature of prominent researchers misinterpreting data based on BD screening scales. For example, Frye and colleagues

 examined health service utilization in community respondents who screened positive for BD on the Mood Disorders Questionnaire (MDQ). They found that more than half of the screen-positives were not diagnosed with BD by treating clinicians, and they indicated that these clinicians “failed to detect” or “misdiagnosed” BD in these individuals. They further examined the medications received by the individuals who screened positive on the MDQ and found that a low percentage was prescribed mood stabilizers and a higher percentage was prescribed antidepressants. The authors indicated that these patients were “inappropriately treated.” The opening line of the discussion section was, “The results of this U.S.-population-based study suggest that bipolar disorder is frequently undetected or misdiagnosed, even among patients who consult psychiatrists.”

 Elsewhere in the discussion Frye and colleagues wrote, “The underuse of mood stabilizers among these patients with bipolar disorder is particularly worrisome . . .” Nowhere in their discussion of the results do the authors mention the limited positive predictive value of the MDQ in the general population. A review of the performance of the MDQ in general population samples found that the positive predictive value was 43%.

 Thus, the majority of individuals who screen positive do 

 discussion suggested that they viewed the MDQ as a diagnostic test rather than a screening measure, and their criticisms of diagnostic practices in the community were misguided.

In another report from this study of the general population, Calabrese et al

 compared MDQ-positive and MDQ-negative patients on indices of psychosocial impairment. The stated reason for the study was because “it is essential that health care providers fully understand the nature and intensity of the psychosocial impact of bipolar disorder in the United States, so that appropriate diagnostic procedures and treatments are offered earlier in the course of the disease to prevent human suffering and reduce the burden of illness.”

No mention was made of positive predictive value and that most individuals in a general population sample who screen positive on the MDQ will not have BD. Again, the authors interpreted the results in reference to diagnosable BD and this was reflected by the title of the paper: “Impact of Bipolar Disorder on a U.S. Community Sample.”

Other studies based on BD screening scales have been published with such titles as “Bipolar Disorders in Australia: A Population-based Study of Excess Costs”

; “Bipolar I and II Disorders in a Random and Representative Australian Population”

; “Bipolar Depression in a Low-Income Primary Care Clinic”

; and “Fibromyalgia and Bipolar Disorder: A Potential Problem?”

Drs Ghaemi and Pies do not discuss the potential problem of overdiagnosis of BD due to the limited positive predictive value of BD screening scales. They thus do not consider how many patients would be incorrectly diagnosed with BD because the clinician used the scale as a diagnostic test instead of as a screening measure. In evaluating whether to recommend routine screening, it is important to consider potential costs as well as benefits.

 To this end, it is important to determine whether screening efforts improve outcome in the population of interest. For example, reviews of research on screening for depression in primary care have found little evidence of improved outcomes and have therefore argued against routine screening.

While there is evidence that BD is sometimes underdiagnosed in clinical practice, the reasons for underdiagnosis have not been well investigated, and it is unknown whether the potentially improved detection resulting from screening will be offset by overdiagnosis of BD. A number of researchers have misinterpreted the results of studies using BD screening scales to suggest “caseness,” and this raises concerns that diagnostic errors could occur in clinical practice. Experts should therefore heed caution before recommending routine clinical use of any self-administered screening questionnaire for BD in the absence of studies simultaneously examining both the benefits (eg, improved detection and appropriate treatment) and costs (eg, overdiagnosis and unnecessary treatment) of screening. Despite the absence of data, Drs Ghaemi and Pies “believe” that the use of multiple screening instruments could even further improve diagnostic accuracy. Screening recommendations should be based scientific data rather than personal belief.

is professor of psychiatry and human behavior, Brown University; director of Outpatient Psychiatry and Partial Hospital Program, Rhode Island Hospital, Brown Medical School. He spoke at Psych Congress in a presentation titled “Does My Patient Have Bipolar Disorder? A Review of Diagnostic Concerns, Conundrums, and Confusion and What to Do About It.” The author reports no conflicts of interest concerning the subject matter of this article.

1. Zimmerman M. Diagnosing Bipolar Disorder in Clinical Practice: Underdiagnosis, Overdiagnosis, and Screening. 

 September 11, 2020. Accessed October 13, 2020. https://www.psychiatrictimes.com/view/diagnosing-bipolar-disorder-clinical-practice-underdiagnosis-overdiagnosis-and-screening

2. Frye MA, Calabrese JR, Reed ML, et al. Use of health care services among persons who screen positive for bipolar disorder. 

3. Zimmerman M, Galione J. Screening for bipolar disorder with the Mood Disorders Questionnaire: A review. 

4. Calabrese JR, Hirschfeld RM, Reed M, et al. Impact of bipolar disorder on a U.S. community sample. 

5. Fisher LJ, Goldney RD, Dal Grande E, Taylor AW, Hawthorne G. Bipolar disorders in Australia. A population-based study of excess costs. 

6. Goldney RD, Fisher LJ, Grande ED, Taylor AW, Hawthorne G. Bipolar I and II disorders in a random and representative Australian population. 

7. Olfson M, Das AK, Gameroff MJ, et al. Bipolar depression in a low-income primary care clinic. 

8. Wilke WS, Gota CE, Muzina DJ. Fibromyalgia and bipolar disorder: a potential problem? 

9. Thombs BD, Ziegelstein RC, Roseman M, Kloda LA, Ioannidis JP. There are no randomized controlled trials that support the United States Preventive Services Task Force Guideline on screening for depression in primary care: a systematic review. 

Articles

Bipolar disorder screening scales have modest sensitivity; thus, a negative result does not preclude a clinical evaluation.

Faith Is Not Enough: Self-Administered Questionnaire Screening for Bipolar Disorder

Bipolar disorder is a serious illness resulting in significant psychosocial morbidity and excess mortality. Through the years a number of research reports, reviews, and commentaries have suggested that bipolar disorder is underrecognized, and that many patients, particularly those with 

 Even for those patients in whom bipolar disorder is eventually diagnosed, the lag between initial treatment seeking and the correct diagnosis is often more than 10 years.

 The treatment and clinical implications of the failure to recognize bipolar disorder in depressed patients include the underprescription of mood stabilizing medications, an increased risk of rapid cycling, and increased costs of care.

 Recommendations for improving the detection of bipolar disorder include careful clinical evaluations inquiring about a history of mania and hypomania and the use of screening questionnaires.

Although the research is less robust, some studies have also found that bipolar disorder is sometimes overdiagnosed. 

 evaluated 21 patients with a substance use disorder who were admitted for residential treatment and had been previously diagnosed with bipolar disorder. Only 9 (42.9%) were diagnosed with bipolar disorder when administered a semi-structured interview. The other 12 patients were diagnosed with a substance-induced mood disorder. 

 evaluated 85 patients admitted to an inpatient dual diagnosis unit specializing in the treatment of mood and substance use disorders who had been diagnosed with bipolar disorder by their outpatient psychiatrist. Similar to the results of Stewart and El-Mallakh, only a minority of the patients (32.9%) had the diagnosis of bipolar disorder confirmed.

As part of the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, our clinical-research group conducted the largest study of bipolar disorder underdiagnosis and overdiagnosis.

 We used the Structured Clinical Interview for DSM-IV (SCID) to interview 700 psychiatric outpatients presenting for treatment. Before the interview, the patients completed a self-administered questionnaire which asked them whether they had been previously diagnosed by a health care professional with bipolar or manic-depressive disorder. Family history information was obtained from the patients regarding their first-degree relatives. Slightly more than 20% of the sample reported that they had been previously diagnosed as having bipolar disorder (n = 145, 20.7%), significantly higher than the 12.9% rate based on the SCID. More than half (56.6%, n = 82) of 145 patients who reported that they had a previous diagnosis of bipolar disorder did not have a diagnosis of bipolar disorder based on the SCID. Bipolar disorder was also underdiagnosed in some patients, but three times as many patients had been overdiagnosed as had been underdiagnosed (82 

Patients with SCID diagnosed bipolar disorder had a significantly higher morbid risk of bipolar disorder in their first-degree relatives than patients who self-reported a previous diagnosis of bipolar disorder that was not confirmed by the SCID. A family history of bipolar disorder was similar in patients who self-reported a previous diagnosis of bipolar disorder that was not confirmed by the SCID and patients who were negative for bipolar disorder by self-report and the SCID. Thus, the results of the study suggested that bipolar disorder was sometimes underdiagnosed, more often overdiagnosed, and the family history analyses supported the validity of the diagnostic procedures.

In a follow-up to this initial study we examined whether there was a particular diagnostic profile associated with bipolar disorder overdiagnosis.

 We compared the diagnostic characteristics of 2 groups of patients who were not diagnosed with bipolar disorder based on the SCID interview—those who reported previously being diagnosed with bipolar disorder (n = 82) and those had not been so diagnosed in the past (n = 528). We conducted a logistic regression analysis to examine which diagnoses were independently associated with bipolar disorder overdiagnosis and found that borderline personality disorder, posttraumatic stress disorder and any impulse control disorder were independently associated with bipolar disorder overdiagnosis. Nearly 40% (20/52) of the patients diagnosed with DSM-IV borderline personality disorder had been overdiagnosed with bipolar disorder.

Thus, under- and overdiagnosis of bipolar disorder is possible. Recommendations for addressing the underdiagnosis problem include careful clinical evaluations inquiring about a history of mania and hypomania (which might include an interview with informants) and the use of screening questionnaires.

 Several scales have been developed to screen for bipolar disorder.

Administration of a screening scale is the first stage of a 2-stage diagnostic process. The more expensive and extensive second stage is only conducted when the patient screens positive. Consequently, it is important for a screening scale to have high sensitivity. Clinicians who rely on the screening scale as the first stage of a 2-stage diagnostic assessment, with the second stage being the more in-depth diagnostic interview, will miss the diagnosis in patients who are false negatives on the screening instrument.

 of studies of the Mood Disorders Questionnaire (MDQ), the most frequently studied screening scale for bipolar disorder, found that the MDQ’s sensitivity was 62% based on the recommended cutoff of 7.

 Thus, more than one-third of true cases of bipolar disorder would be missed if the MDQ was relied upon as the first stage of a 2-stage diagnostic process. In general psychiatric outpatient practices, the positive predictive value of the MDQ (ie, the likelihood of a patient who screens positive having bipolar disorder) is less than 50%.

Putting aside the performance statistics of bipolar disorder screening scales, the use of these scales can be questioned at a conceptual level. The reason for suggesting the use of these scales is that bipolar disorder is underdiagnosed. But the advocates for the use of screening questionnaires do not indicate how and why a paper-and-pencil questionnaire is expected to help improve diagnostic recognition? Are mental health clinicians often failing to inquire about a history of mania/hypomania in depressed patients, and will only do so when a screening scale is first completed? Do mental health clinicians not know what questions to ask to assess prior manic/hypomanic episodes and therefore these scales are needed because the scales ask the right questions that clinicians do not ask? Do mental health clinicians know what questions to ask, but ignore or discount positive responses from patients and this is the cause of bipolar disorder underdiagnosis?

That is, do the advocates of bipolar disorder screening scales believe that self-report screening questionnaires will improve bipolar disorder recognition because the results of these tests are less easily ignored than the responses of a patient to a clinical interview? Researchers of the performance of bipolar disorder screening scales have not addressed these questions in the Discussion sections of their papers.

I would argue that bipolar disorder screening questionnaires are superfluous. Because bipolar disorder screening scales have modest sensitivity, a clinical interview is necessary to reduce false negatives. Because bipolar disorder screening scales have modest positive predictive value, a clinical interview is necessary to reduce false positives. Thus, a clinical evaluation is always needed regardless of the results of the screening test. Consequently, it is not clear how a screening scale for bipolar disorder would be helpful in a psychiatric setting. The advocates of bipolar disorder screening, who suggest that such scales be routinely used in clinical practice, should indicate how these measures should interface with a clinician’s evaluation. By my reckoning a clinical evaluation is needed regardless of the results of the screening scale; thus, it is unclear what niche these measures should occupy.

is Professor of Psychiatry and Human Behavior, Brown University; Director of Outpatient Psychiatry and Partial Hospital Program, Rhode Island Hospital, Brown Medical School. He spoke at Psych Congress in a presentation titled “Does My Patient Have Bipolar Disorder? A Review of Diagnostic Concerns, Conundrums, and Confusion and What to Do About It.” The author reports no conflicts of interest concerning the subject matter of this article.

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13. Birnbaum HG, Shi L, Dial E, Oster EF, Greenberg PE, Mallett DA. Economic consequences of not recognizing bipolar disorder patients: a cross-sectional descriptive analysis. 

14. Shi L, Thiebaud P, McCombs JS. The impact of unrecognized bipolar disorders for patients treated for depression with antidepressants in the fee-for-services California Medicaid (Medi-Cal) program. 

15. Matza LS, Rajagopalan KS, Thompson CL, de Lissovoy G. Misdiagnosed patients with bipolar disorder: comorbidities, treatment patterns, and direct treatment costs. 

16. Isometsa E, Suominen K, Mantere O, et al. The Mood Disorder Questionniare improves recognition of bipolar disorder in psychiatric care. 

Is bipolar disorder overdiagnosed among patients with substance abuse?

18. Goldberg J, Garno J, Callahan A, et al. 

Overdiagnosis of bipolar disorder among substance use disorder inpatients with mood instability

19. Zimmerman M, Ruggero CJ, Chelminski I, Young D. Is bipolar disorder overdiagnosed? 

20. Zimmerman M, Ruggero CJ, Chelminski I, Young D. Psychiatric diagnoses in patients previoulsy overdiagnosed with bipolar disorder. 

21. Angst J, Adolfsson R, Benazzi F, et al. The HCL-32: towards a self-assessment tool for hypomanic symptoms in outpatients. 

22. Hirschfeld R, Williams J, Spitzer R, et al. Development and validation of a screening instrument for bipolar spectrum disorder: The Mood Disorder Questionnaire. 

23. Parker G, Fletcher K, Barrett M, et al. Screening for bipolar disorder: the utility and comparative properties of the MSS and MDQ measures. 

24. Ghaemi SN, Miller CJ, Berv DA, Klugman J, Rosenquist KJ, Pies RW. Sensitivity and specificity of a new bipolar spectrum diagnostic scale. 

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The validity of the Mood Disorder Questionnaire for screening bipolar disorder: A Meta-Analysis

26. Zimmerman M, Galione J. Screening for bipolar disorder with the Mood Disorders Questionnaire: A review. 

Overdiagnosis of bipolar disorder is as important to guard against as its underdiagnosis. The use of bipolar disorder screening tools is questioned.

Diagnosing Bipolar Disorder in Clinical Practice: Underdiagnosis, Overdiagnosis, and Screening 

A colleague approached me and said that she was referring a patient to the partial hospital program who had borderpolar. Having not previously heard this term, clarification was sought, and it was explained that the patient had both borderline personality disorder and bipolar disorder. My colleague further explained that this term is frequently used in the psychiatrist chat room she visits as a shorthand for patients with both disorders who are severely ill and have high levels of psychosocial morbidity. A Pubmed search on the term borderpolar did not turn up any citations.

Both bipolar disorder and borderline personality disorder (BPD) are significant public health problems. Both disorders are associated with impaired functioning, high utilization of psychiatric services, high rates of substance use disorders, and suicidality. Despite the psychosocial morbidity and risk for premature mortality, both disorders are frequently underdiagnosed. As a result, calls for improved recognition have been voiced for both disorders.

For years there has been debate as to how to conceptualize the relationship between BPD and bipolar disorder. Some experts have suggested that BPD is part of the bipolar spectrum. Review articles have summarized the evidence supporting and opposing the bipolar spectrum hypothesis, with most of the recent reviews concluding that BPD and bipolar disorder are valid and distinct diagnostic entities. And since each disorder suggests different treatment emphases-a focus on pharmacotherapy with possible adjunctive psychotherapy for patients with bipolar disorder versus a focus on psychotherapy with possible adjunctive medication for patients with BPD-making the differential diagnosis is that much more important. Meanwhile, many authors and clinicians have described the diagnostic uncertainty and the challenges in determining if a patient has bipolar disorder or BPD.

The most frequently researched aspect of the relationship between BPD and bipolar disorder has been the frequency of their co-occurrence. Several reviews report an estimated 20% overlap in diagnostic frequency.

 That is, approximately 20% of patients with bipolar disorder have comorbid BPD and approximately 20% of patients with BPD have bipolar disorder. Thus, while only a minority, there is a meaningful number of patients with a comorbid diagnosis.

Meanwhile, reviews and commentaries have focused on identifying clinical characteristics that distinguish the two disorders to help with differential diagnosis. This approach implies that the diagnosis is an either/or decision. Framing the discussion as a dichotomous choice underplays the fact that one-fifth of patients have both disorders. The almost exclusive focus on differential diagnosis might discourage clinicians from making both diagnoses when appropriate and can result in overlooking an important comorbidity in patients with the greatest need.

 reviewed the literature on the clinical impact of one disorder on the other. Overall, they found that there have been far more studies that compared patients who have bipolar disorder with and without BPD than there have been of patients with BPD who do and do not have bipolar disorder. The researchers also noticed that amongst patients with bipolar disorder, those with comorbid BPD reported more mood episodes, an earlier age of onset of bipolar disorder, greater suicidality, greater hostility, and a higher prevalence of substance abuse. Of note, they found little research that examined treatment response, psychosocial functioning, time unemployed, disability payments, or prospectively observed longitudinal course.

It has been my clinical experience that patients with both bipolar disorder and BPD (hereafter referred to as 

) are a group at elevated risk for suicide and marked impairment; they also are high utilizers of the most costly levels of care. My colleagues and I recently examined this issue in the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project. We compared psychiatric outpatients with borderpolar to patients with BPD without bipolar disorder and patients with bipolar disorder without BPD. We hypothesized that the borderpolar patients would exhibit significantly more psychosocial morbidity than patients with only one of these disorders.

The Rhode Island MIDAS project represents an integration of research methodology into a community-based outpatient practice affiliated with an academic medical center.

 Psychiatric outpatients presenting for treatment were evaluated with semi-structured interviews. We compared the demographic, family history, and clinical characteristics of three nonoverlapping groups of patients: borderpolar (n = 59), BPD without bipolar disorder (n = 330), and bipolar disorder without BPD (n = 128).

The results showed that significantly more patients with borderpolar had diagnoses of three or more Axis I disorders than patients with bipolar disorder. Borderpolar patients also reported significantly more PTSD, obsessive-compulsive disorder (OCD), substance use disorder, and somatoform disorder compared with the patients with bipolar disorder. Similarly, patients with borderpolar reported significantly more OCD than patients with BPD.

In terms of risk factors, the MIDAS study found that borderpolar patients had the most psychopathology in their first-degree relatives. Compared with patients with bipolar disorder, the morbid risk for depression, bipolar disorder, PTSD, specific phobia, drug and alcohol use disorders was significantly higher in the borderpolar patients. Compared with patients with BPD, borderpolar patients had significantly higher morbid risks for bipolar disorder, PTSD, and drug and alcohol use disorder.

Furthermore, psychosocial morbidity was greatest in the borderpolar patients. Compared with bipolar disorder patients, the borderpolar patients reported more episodes of depression, more anger, suicidal ideation, history of suicide attempts, childhood trauma, chronic and persistent unemployment, impaired social functioning, and psychiatric hospitalizations. These patients were also more likely to receive disability payments and they exhibited significantly more psychosocial morbidity than the patients with BPD. The borderpolar patients reported more episodes of depression, childhood trauma, chronic and persistent unemployment, history of suicide attempts, and psychiatric hospitalizations.

The results from the MIDAS project indicate that patients with both bipolar disorder and BPD are more severely ill than patients with only one of these disorders. While clinicians might seek diagnostic parsimony and diagnose only one disorder, it is important that they not overlook the potential presence of the other disorder.

During the past decade, significant effort has been put forth to improve the recognition of bipolar disorder in depressed patients. Several screening scales for bipolar disorder have been developed, and they have been extensively researched. Similarly, peer reviewed journals have published review articles and commentaries about the importance of recognizing bipolar disorder in patients presenting for treatment of depression. Much less has been written about the importance of improving the recognition of BPD. Just as it is important for clinicians to include questions to screen for a history of manic or hypomanic episodes in their evaluation of depressed patients, it is important to screen for the presence of BPD in patients with mood disorders.

To date, practically no research has examined potential treatments for patients with both diagnoses. There are only a small number of open-label trials of medication, one controlled medication trial, and no controlled psychotherapy trials of patients with both disorders.

While the literature has clearly demonstrated that bipolar disorder and BPD are distinct disorders, the importance of diagnosing both disorders when comorbid has gotten lost in the dialogue. It is our hope that by giving this group of severely ill patients a unique name-borderpolar-the recognition of this comorbidity will increase. And, as such, there will be increased efforts to identify the most effective treatment approaches.

The ongoing debate as to whether BPD belongs on the bipolar spectrum, which has generated a robust empirical data base establishing that these are distinct diagnostic entities, has sidetracked researchers and clinicians from recognizing the importance of diagnosing both disorders when both are present. Patients with comorbid bipolar disorder and BPD (ie, borderpolar) represent a group with severe psychosocial morbidity who are often unemployed, suicidal, and utilize more costly forms of health care services. Efforts to identify effective approaches towards treating these patients have been minimal and are needed.

This article was originally published on 10/4/19 and has since been updated.

Dr Zimmerman is Professor of Psychiatry and Human Behavior at The Warren Alpert Medical School of Brown University and Director, Partial Hospital Program and Adult Outpatient Psychiatry at Lifespan. He presented “Borderpolar: Diagnosis and Treatment of Patients With Bipolar Disorder and Borderline Personality Disorder”at the 2019 Psych Congress in San Diego, CA.

1. Dunner DL. Clinical consequences of under-recognized bipolar spectrum disorder. 

2. Zimmerman M. Borderline personality disorder: a disorder in search of advocacy. 

3. Zimmerman M, Morgan TA. The relationship between borderline personality disorder and bipolar disorder. 

4. Frias A, Baltasar I, Birmaher B. Comorbidity between bipolar disorder and borderline personality disorder: Prevalence, explanatory theories, and clinical impact. 

5. Zimmerman M. Integrating the assessment methods of researchers in routine clinical practice: The Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project. First M, Ed. 

Standardized Evaluation in Clinical Practice

. Washington, DC: American Psychiatric Publishing, Inc; 2003: 29-74.

6. Zimmerman M, Balling C, Dalrymple K, et al. Screening for borderline personality disorder in psychiatric outpatients with major depressive disorder and bipolar disorder. 

7. Frankenburg FR, Zanarini MC. Divalproex sodium treatment of women with borderline personality disorder and bipolar II disorder: a double-blind placebo-controlled pilot study. 

The most frequently researched aspect of the relationship between BPD and bipolar disorder has been the frequency of their co-occurrence. Several reviews have estimated a 20% overlap in diagnostic frequency.

Borderpolar: Patients with Borderline Personality Disorder and Bipolar Disorder

Imagine going to your primary care physician with a fever and symptoms of an upper respiratory tract infection. The doctor puts his or her palm to your forehead and agrees that you feel warm. A course of treatment is recommended, you return in a couple of days, and he or she again feels your forehead and notes that you are cooler. Would you be happy with this approach to care? Would you continue to see a doctor who evaluated your body temperature in this way? We would not accept this level of care from an internist, a family practitioner, or a pediatrician-and yet this is the community standard of care provided by most behavioral health clinicians when treating psychiatric disorders.

To determine the impact of treatment, it is necessary to evaluate outcome. In mental health clinical settings, this typically is based on unstructured interactions that yield unquantified judgments of progress. This is at variance with other areas of medical care in which outcome is determined, in part, on the change of a numerical value. Body temperature, blood pressure, cholesterol values, blood sugar levels, cardiac ejection fraction, and white blood cell counts are examples of quantifiable variables that are used to evaluate treatment progress. In the mental health field, standardized, quantifiable outcome measures exist for most major psychiatric disorders, yet they are rarely used in routine clinical practice. To determine the impact of treatment it is not simply a matter of 

The results of two surveys of psychiatrists, however, suggest that standardized scales are not being used to evaluate outcome in clinical practice.

 surveyed 340 psychiatrists in the United Kingdom regarding their use of outcome measures. Only 11.2% of the psychiatrists routinely used standardized measures to assess outcome when treating depression and anxiety disorders. More than half of the clinicians indicated that they never used standardized measures to evaluate outcome. The authors did not ask the respondents why they were disinclined to use scales to measure outcome; however, they noted that several respondents included comments on the questionnaires indicating that they thought such scales were simplistic, not useful in clinical practice, of questionable reliability and validity, or overly burdensome and costly to implement routinely.

 conducted a similar survey of 314 psychiatrists in the US. They, too, found that the vast majority of psychiatrists did not routinely use clinical scales to monitor outcome of treating depression. More than half of the psychiatrists indicated that they never or rarely used scales to monitor outcome, and fewer than 10% almost always used scales to monitor outcome of depression treatment. They compared the characteristics of psychiatrists who reported using scales frequently or almost always with the rest of the group and found no differences between the two groups in sex, age, years of practice, or practice setting.

Psychiatrists who reported never, rarely, or only sometimes using scales to monitor outcome were asked the reasons for not routinely using scales in their clinical practice. More than one-quarter of them indicated that they did not believe using scales would be clinically helpful, that they take too much time to use, or that they were not trained in their use (

The results of these two surveys found that psychiatrists typically do not use standardized scales of established reliability and validity when treating depression. One issue identified as an obstacle in their use is the perceived burden of scale completion. If the payers of the delivery of mental health treatment increasingly encourage, or require, the measurement of outcome, then the user-friendliness of measurement tools, as well as their reliability and validity, will be critical to their widespread adoption. Clinicians are already overburdened with paperwork, and adding to this load by requiring repeated detailed evaluations with such instruments as the Hamilton Rating Scale for Depression

Self-report questionnaires are a cost-effective option because they are inexpensive in terms of professional time needed for administration, and they correlate highly with clinician ratings. To be sure, there are also limitations with self-report questionnaires such as response set biases, and their use may be limited by the readability of the scale and literacy of the respondent. However, self-report scales are free of clinician bias and are therefore free of clinician overestimation of patient improvement (which might occur when there are incentives to document treatment success).

This article was originally posted on 9/4/2014 and has since been updated.

Dr Zimmerman is Director of Outpatient Psychiatry and the Partial Hospital Program, Rhode Island Hospital, and Professor of Psychiatry and Human Behavior at Brown University in Providence, Rhode Island. The author reports no conflicts of interest concerning the subject matter of this article.

Psychiatrists in the UK do not use outcomes measures

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Why don’t psychiatrists use scales to measure outcome when treating depressed patients?

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3. Hamilton M. A rating scale for depression. 

Standardized, quantifiable outcome measures exist for most major psychiatric disorders, yet they are rarely used in routine clinical practice. This article identifies the rationale for using psychiatric scales.

The Importance of Measuring Outcomes in Clinical Practice

Recent research has raised concerns about the adequacy of psychiatric diagnostic evaluations conducted in routine clinical practice, particularly the detection of disorders that are comorbid to the principal diagnosis. Four independent research groups have found that comorbidity is diagnosed more frequently when semistructured interviews are used compared with unstructured diagnostic interviews.

 When patients’ desire for treatment of comorbid Axis I disorders that were not the primary reason for seeking treatment was examined, it was found that patients often wanted treatment for their comorbid conditions.

 Thus, detecting comorbidity was important from a consumer/patient perspective.

It is perhaps not surprising that the underrecognition of comorbidity has received greater attention in the current health care reform zeitgeist. Clinicians are struggling to conduct diagnostic evaluations more efficiently in the face of declining reimbursement rates. Anecdotal conversations with practicing psychiatrists indicate that they often complete their evaluations, including the write-up, in 30 to 45 minutes. It is to be expected that the frequency of missed diagnoses, and maybe even misdiagnoses, will increase when insufficient time is allotted for the diagnostic examination.

During the past 2 decades, semistructured diagnostic interviews have served as the diagnostic gold standard, albeit an imperfect one. In most of the studies summarized in the following reports, diagnoses were based on these interview schedules. Judged against this standard, the studies that compare clinical diagnoses to diagnoses based on semistructured interviews suggest that clinicians are not doing a very good job at picking up comorbidities.

Are these findings cause for alarm? That is hard to say, because little research has shown the clinical significance of the gap between researchers’ and clinicians’ diagnostic practices. Specifically, we are not aware of any studies that have examined the important question of whether the more reliable and comprehensive research diagnostic evaluations actually improve outcomes. In fact, one could argue that outcomes for patients are not more likely to be worse, even if diagnoses are missed.

Currently, pharmacological agents with broad-based efficacy are available; therefore, diagnostic error might not be important. The new generation of medications, such as SSRIs, have been found to be effective for depression, almost all anxiety disorders, eating disorders, impulse control disorders, and some somatoform disorders. In short, most of the disorders for which individuals seek outpatient care respond to at least 1 of the new generation of antidepressant medications. Thus, it is possible that accurate and comprehensive 

–oriented diagnostic evaluations are not critical after gross diagnostic class distinctions (eg, psychotic disorder vs mood disorder) are made.

On commonsense grounds, it seems logical that greater diagnostic accuracy will improve outcome. More complete and accurate diagnostic evaluations might influence whether a medication is prescribed, the choice of medication, the number of medications prescribed, and whether psychotherapy would be beneficial.

One can also hypothesize that more complete and accurate knowledge of a patient’s psychiatric disorder(s) might improve outcome independent of changes in treatment decisions. That is, better diagnostic practice may result in greater patient satisfaction with the diagnostic assessment, an improved alliance with the treating clinician and, consequently, better treatment adherence and better outcome.

It is important to recognize that diagnosis has more than 1 clinically relevant function. In addition to optimizing outcome, diagnosis is important for predicting treatment outcome. We would expect that a greater percentage of the variance in outcome would be predicted by comprehensive evaluations than by clinical diagnoses.

In reading the following articles, pay particular attention to whether controlled studies have been done that specifically examine efficacy of treatment in individuals with multiple diagnoses. Most often treatment recommendations are based on extrapolations from studies of single disorders. Thus, if a medication is effective in the treatment of disorder X and disorder Y then it is recommended for individuals who have both X and Y. 

The STAR*D study is the largest study to examine the influence of comorbidity on differential treatment response, and the investigators found little evidence that the type of comorbidity predicted differential response to sertraline, venlafaxine, or bupropion after depressed patients did not respond to an initial trial of citalopram.

 Based on studies of treatment efficacy for single disorders, one would expect that the depressed patients with comorbid anxiety disorders would have responded better to sertraline and venlafaxine than bupropion. However, there was no evidence of differential treatment response. Thus, there is little empirical support for the validity of the assumption that clinicians should preferentially choose a medication for patients with comorbid disorders because each of the disorders is effectively treated by the medication when it is not comorbid. 

The available evidence suggests that comorbidity is frequently overlooked. Should the standard of care move toward the adoption of semistructured diagnostic interviews in an effort to improve diagnostic practice? It has been nearly 30 years since 

 was published, and during this time pharmacotherapies and psychotherapies have been repeatedly shown to be effective for a wide range of 

 disorders. Consequently, it would seem more important now than 30 years ago that accurate diagnoses be made. It is hoped that the next generation of research on diagnosis (eg, changes in diagnostic criteria or practice) will attend to the most salient aspect of psychiatric treatment-the outcome of care.


1. Ramirez Basco M, Bostic JQ, Davies D, et al. Methods to improve diagnostic accuracy in a community mental health setting. Am J Psychiatry. 2000;157: 1599-1605.
2. Miller PR, Dasher R, Collins R, et al. Inpatient diagnostic assessments: 1. Accuracy of structured vs. unstructured interviews. Psychiatry Res. 2001;105:255-264.
3. Shear MK, Greeno C, Kang J, et al. Diagnosis of nonpsychotic patients in community clinics. Am J Psychiatry. 2000;157:581-587.
4. Zimmerman M, Mattia JI. Principal and additional DSM-IV disorders for which outpatients seek treatment. Psychiatr Serv. 2000;51:1299-1304.
5. Zimmerman M, Mattia JI. Psychiatric diagnosis in clinical practice: is comorbidity being missed? Compr Psychiatry. 1999;40:182-191.
6. Rush AJ, Wisniewski SR, Warden D, et al. Selecting among second-step antidepressant medication monotherapies: predictive value of clinical, demographic, or first-step treatment features. Arch Gen Psychiatry. 2008;65:870-880.



Recent research has raised concerns about the adequacy of psychiatric diagnostic evaluations conducted in routine clinical practice, particularly the detection of disorders that are comorbid to the principal diagnosis.

Is Diagnosis of Comorbidities Obsolete?

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Insights Into Depression and Anxiety:What Roles Do Anxiety Disorders Play in the Treatment of Depression?

Insights Into Depression and Anxiety: What Roles Do Anxiety Disorders Play in the Treatment of Depression?

During the past three decades, more research has been conducted on depression than on any other psychiatric disorder. The clinical and public health significance of depression was heightened by the results of the Medical Outcomes Study, which demonstrated that depression was more impairing than other chronic medical disorders such as arthritis and diabetes, and as impairing as cardiovascular disease (Wells et al., 1989). Recently, the replication of the National Comorbidity Survey confirmed previous findings regarding the high prevalence of major depressive disorder in the United States (Kessler et al., 2005).

Efforts to improve the treatment of patients with depression and understand the mechanisms underlying successful treatment have followed different paths. The current Special Report illustrates several different lines of investigation. Eero Castrén, M.D., Ph.D., reviews recent suggestions that neural plasticity and neurogenesis are central to effective treatment in his article "Neuronal Plasticity and Mood Disorders." Challenging the "chemical balance" theory of etiology and treatment, Castrén suggests that structural changes in neural networks underlie symptom amelioration.

Michael A. Posternak, M.D., likewise challenges traditional teaching--with regards to the onset of action of antidepressant medication in his article "How Quickly Do Antidepressants Begin to Work?" Traditional teaching says that medications generally take at least two to four weeks to work. Posternak summarizes a meta-analysis he recently conducted, which found that the greatest difference between active drug and placebo was in the first two weeks of treatment.

In their article "Impact of ECT on Health-Related Quality of Life and Function in Patients With Depression," W. Vaughn McCall, M.D., M.S., and Peter B. Rosenquist, M.D., highlight the importance of considering more than symptoms when evaluating treatment outcome.

Gabor I. Keitner, M.D., reinforces the notion that depression, like other illnesses, is a biopsychosocial disorder that has a reciprocal relationship with the interpersonal environment in which it occurs. In "Family Therapy in the Treatment of Depression," Keitner reviews studies demonstrating the beneficial effect of family therapy in treating depression and offers some general principles to consider when meeting with the families of patients with depression.

Depression may be a significant psychosocial risk factor in the development of coronary heart disease. In her article, "Depression, Stress and the Risk of Heart Disease," Chiara Rafanelli, M.D., Ph.D, reviews data from a recent study assessing the impact of depression, demoralization and stressful life events in predicting myocardial infarction and/or first-episode instable angina. The final two reports "Understanding the Role of Sigma-1 Receptors in Psychotic Depression" by Teruo Hayashi, M.D., Ph.D., and Tsung-Ping Su, Ph.D., and "The Light-er Side of Treating Seasonal Affective Disorder" by Daniel M. Blumberger, M.D., and Anthony J. Levitt, M.D., MBBS, FRCP, touch on issues related to the heterogeneity of depression. The 

 offers three options to reduce heterogeneity: division into separate disorders, subtyping within disorders and specifiers within disorders. Each of these approaches represents an attempt to identify more homogeneous groups of patients with presumptively different pathophysiologies, course and treatment response. Hayashi and Su discuss the role of the s receptor and subtyping depression based on the presence of psychotic features and the potential importance this has on selecting an antidepressant in treating psychotic depression. Blumberger and Levitt discuss the use of light therapy and pharmacotherapy in the treatment of seasonal depression.

extends a warm thank you to Dr. Zimmerman for his assistance with this Special Report.

Dr. Zimmerman is director of outpatient psychiatry at Rhode Island Hospital and associate professor of psychiatry and human behavior at Brown University Medical School.

Kessler RC, Chiu WT, Demler O et al. (2005), Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. [Published erratum Arch Gen Psychiatry 62(7):709.] Arch Gen Psychiatry 62(6):617-627 [see comment].

Wells KB, Stewart A, Hayes RD et al. (1989), The functioning and well-being of depressed patients. Results from the Medical Outcomes Study. JAMA 262(7):914-919 [see comment].

By 2020, depression will be the second leading cause of death and disability worldwide. As the importance of depression as a public health problem has been reinforced, research efforts have followed different paths. Read about some of the latest developments.

Author | Mark Zimmerman, MD