Psychogenic erectile dysfunction (ED) has been defined as the persistent inability to attain and maintain an erection sufficient to permit sexual performance. It shows a high incidence and prevalence among men, with a significant impact on the quality of life. Few neuroimaging studies have investigated the cerebral basis of erectile dysfunctions observing the role played by prefrontal, cingulate, and parietal cortices during erotic stimulation. In spite of the well-known involvement of subcortical regions such as hypothalamus and caudate nucleus in male sexual response, and the key role of nucleus accumbens in pleasure and reward, poor attention was paid to their role in male sexual dysfunction. In this study, we determined the presence of grey matter (GM) atrophy patterns in subcortical structures such as amygdala, hippocampus, nucleus accumbens, caudate nucleus, putamen, pallidum, thalamus, and hypothalamus in patients with psychogenic ED and healthy men. After Rigiscan evaluation, urological, general medical, metabolic and hormonal, psychological and psychiatric assessment, 17 outpatients with psychogenic ED and 25 healthy controls were recruited for structural MRI session. Significant GM atrophy of nucleus accumbens was observed bilaterally in patients with respect to controls. Shape analysis showed that this atrophy was located in the left medial-anterior and posterior portion of accumbens. Left nucleus accumbens volumes in patients correlated with low erectile functioning as measured by IIEF-5 (International Index of Erectile Function). In addition, a GM atrophy of left hypothalamus was also observed. Our results suggest that atrophy of nucleus accumbens plays an important role in psychogenic erectile dysfunction. We believe that this change can influence the motivation-related component of sexual behavior. Our findings help to elucidate a neural basis of psychogenic erectile dysfunction.

A day treatment program was developed for patients suffering with severe work-related complaints who were unable to function at work because of this. The program consisted of a number of treatment modalities, including Cognitive Behavioural Therapy, protocolized nonverbal therapies, and activation. The main objective of all these therapies was to analyze participants' personal qualities and vulnerabilities when functioning at work and to teach them new coping strategies and social skills to reduce their vulnerability in stressful situations. The results of the program were assessed in terms of scores on a number of self-rating questionnaires and hours spent at work. In a follow-up assessment one year after the original program had finished, we found a significant reduction in complaints and an increase in the number of hours spent on the job. At the start of the program, patients worked 25.2% of their contracted hours; a year later, this had increased to 77.3%. Even though this natural field study has its limitations, the results of the day treatment program seem very promising.

ABSTRACT: BACKGROUND: Suicidality in HIV/AIDS is not only a predictor of future attempted suicide and completed suicide, it is also associated with poor quality of life and poor adherence with antiretroviral therapy. This paper examines the prevalence and correlates of suicidality in HIV/AIDS in the African nation of Uganda. METHODS: A cross-sectional study was undertaken among 618 respondents attending two HIV clinics in semi-urban Uganda. A structured questionnaire was used to collect data on demographic, social, psychological and clinical factors. Correlates of suicidality were assessed using mulitvariable logistic regression. RESULTS: Prevalence of 'moderate to high risk for suicidality'(MHS) was 7.8% and that of life-time attempted suicide was 3.9%. Factors associated with MHS at univariate analysis were: female gender, food insecurity, increasing negative life events, high stress score, negative coping style, past psychiatric history, psychosocial impairment, diagnoses of post-traumatic stress disorder, generalised anxiety disorder and major depressive disorder. Factors independently associated with MHS in multivariate models were female gender, increasing negative life events, a previous psychiatric history, and major depressive disorder. CONCLUSIONS: These results are in agreement with the stress-vulnerability model where social and psychological stressors acting on an underlying diathesis (including previous and current psychiatric morbidities) leads to suicidality. These results identify potential targets to mitigate risk through treatment of psychiatric disorders and promoting greater adaptation to living with HIV/AIDS.

BACKGROUND Depression is a serious mental health problem, whose first onset is usually in adolescence. Online treatment may offer a solution for the current undertreatment of depression in youth. For adults with depressive symptoms, the effectiveness of Internet-based cognitive behavioral therapy has been demonstrated. This study is one of the first randomized controlled trials to investigate the effectiveness online depression treatment for young people with depressive complaints and the first to focus on an online group course. OBJECTIVE To evaluate and discuss the effectiveness of a guided Web-based group course called Grip op Je Dip (Master Your Mood [MYM]), designed for young people aged 16 to 25 years with depressive symptoms, in comparison with a wait-listed control group. METHODS We randomly assigned 244 young people with depressive symptoms to the online MYM course or to a waiting-list control condition. The primary outcome measure was treatment outcome after 3 months on the Center for Epidemiologic Studies Depression Scale. Secondary outcomes were anxiety (measured by the Hospital Anxiety and Depression Scale) and mastery (Mastery Scale). We studied the maintenance of effects in the MYM group 6 months after baseline. Missing data were imputed. RESULTS The MYM group (n = 121) showed significantly greater improvement in depressive symptoms at 3 months than the control group (n = 123)(t(187 )= 6.62, P <.001), with a large between-group effect size of d = 0.94 (95% confidence interval [CI] 0.64-1.23). The MYM group also showed greater improvement in anxiety (t(187 )= 3.80, P <.001, d = 0.49, 95% CI 0.24-0.75) and mastery (t(187 )= 3.36, P =.001, d = 0.44, 95% CI 0.19-0.70). At 12 weeks, 56%(68/121) of the participants in the MYM group and 20%(24/123) in the control group showed reliable and clinically significant change. This between-group difference was significant (χ(2)(1 )= 35.0, P <.001) and yielded a number needed to treat of 2.7. Improvements in the MYM group were maintained at 6 months. A limitation is the infeasibility of comparing the 6-month outcomes of the MYM and control groups, as the controls had access to MYM after 3 months. CONCLUSIONS The online group course MYM was effective in reducing depressive symptoms and anxiety and in increasing mastery in young people. These effects persisted in the MYM group at 6 months.

AIM To investigate the prevalence and physicians' detection rate of depressive and anxiety disorders in gastrointestinal (GI) outpatients across China. METHODS A hospital-based cross-sectional survey was conducted in the GI outpatient departments of 13 general hospitals. A total of 1995 GI outpatients were recruited and screened with the Hospital Anxiety and Depression Scale (HADS). The physicians of the GI departments performed routine clinical diagnosis and management without knowing the HADS score results. Subjects with HADS scores ≥ 8 were subsequently interviewed by psychiatrists using the Mini International Neuropsychiatric Interview (MINI) to make further diagnoses. RESULTS There were 1059 patients with HADS score ≥ 8 and 674 (63.64%) of them undertook the MINI interview by psychiatrists. Based on the criteria of Diagnostic and Statistical Manual of Mental Disorders (4th edition), the adjusted current prevalence for depressive disorders, anxiety disorders, and comorbidity of both disorders in the GI outpatients was 14.39%, 9.42% and 4.66%, respectively. Prevalence of depressive disorders with suicidal problems [suicide attempt or suicide-related ideation prior or current; module C (suicide) of MINI score ≥ 1] was 5.84% in women and 1.64% in men. The GI physicians' detection rate of depressive and anxiety disorders accounted for 4.14%. CONCLUSION While the prevalence of depressive and anxiety disorders is high in Chinese GI outpatients, the detection rate of depressive and anxiety disorders by physicians is low.

UNLABELLED ABSTRACT: BACKGROUND The need for cost-effective interventions for people suffering from major depressive disorders is essential. Behavioral activation is an intervention that can largely benefit from the use of new mobile technologies (for example smartphones). Therefore, developing smartphone-based behavioral activation interventions might be a way to develop cost-effective treatments for people suffering from major depressive disorders. The aim of this study will be to test the effects of a smartphone-delivered behavioral activation treatment. METHODS The study will be a randomized controlled trial with a sample size of 120 participants, with 60 patients in each group. The treatment group includes an 8-week smartphone-based behavioral activation intervention, with minimal therapist contact. The smartphone-based intervention consists of a web-based psychoeducation, and a smartphone application. There is also a back-end system where the therapist can see reports from the patients or activities being reported. In the attention control group, we will include brief online education and then recommend use of a smartphone application that is not directly aimed at depression (for example,'Effective meditation'). The duration of the control condition will also be 8 weeks. For ethical reasons we will give the participants in the control group access to the behavioral activation treatment following the 8-week treatment period. DISCUSSIONS We believe that this trial has at least three important implications. First, we believe that smartphones can be integrated even further into society and therefore may serve an important role in health care. Second, while behavioral activation is a psychological treatment approach for which there is empirical support, the use of a smartphone application could serve as the therapist's prolonged arm into the daily life of the patient. Third, as we have been doing trials on guided Internet treatment for more than 10 years it is now time to move to the next generation of information technology - smartphones - which are not only relevant for Swedish conditions but also for developing countries in the world which are increasingly empowered by mobile phones with Internet connection. TRIAL REGISTRATION ClinicalTrials.gov NCT01463020.

Maladaptive impulsivity is a core symptom in various psychiatric disorders. However, there is only limited evidence available on whether different measures of impulsivity represent largely unrelated aspects or a unitary construct. In a cross-species translational study, thirty rats were trained in impulsive choice (delayed reward task) and impulsive action (five-choice serial reaction time task) paradigms. The correlation between those measures was assessed during baseline performance and after pharmacological manipulations with the psychostimulant amphetamine and the norepinephrine reuptake inhibitor atomoxetine. In parallel, to validate the animal data, 101 human subjects performed analogous measures of impulsive choice (delay discounting task, DDT) and impulsive action (immediate and delayed memory task, IMT/DMT). Moreover, all subjects completed the Stop Signal Task (SST, as an additional measure of impulsive action) and filled out the Barratt impulsiveness scale (BIS-11). Correlations between DDT and IMT/DMT were determined and a principal component analysis was performed on all human measures of impulsivity. In both rats and humans measures of impulsive choice and impulsive action did not correlate. In rats the within-subject pharmacological effects of amphetamine and atomoxetine did not correlate between tasks, suggesting distinct underlying neural correlates. Furthermore, in humans, principal component analysis identified three independent factors:(1) self-reported impulsivity (BIS-11);(2) impulsive action (IMT/DMT and SST);(3) impulsive choice (DDT). This is the first study directly comparing aspects of impulsivity using a cross-species translational approach. The present data reveal the non-unitary nature of impulsivity on a behavioral and pharmacological level. Collectively, this warrants a stronger focus on the relative contribution of distinct forms of impulsivity in psychopathology.

BACKGROUND HIV treatment programs are in need of brief, valid instruments to identify common mental disorders such as depression. AIM To translate and culturally adapt the Self-Reporting Questionnaire (SRQ-20) for use in Uganda and to investigate its psychometric properties in this setting. METHODS Following an initial translation of the SRQ-20 from English to Luganda, key informant interviews and focus-group discussions were used to produce a culturally adapted version of the instrument. The adapted SRQ-20 was administered to 200 HIV-positive individuals in a rural antiretroviral therapy program in southern Uganda. All study participants were also evaluated by a psychiatric clinical officer with the Mini International Neuropsychiatric Interview (MINI). Receiver-operating-characteristic analysis was used to examine the sensitivity and specificity of the SRQ-20 compared to the clinical diagnosis generated by the MINI. RESULTS The prevalence estimates of any depressive disorder and current depression were 24%(n = 48) and 12%(n = 24), respectively. The SRQ-20 scores discriminated well between subjects with and without current depression based on the MINI, with an area under the curve of 0.92, as well as between subjects with and without any current or past depressive disorder, with an area under the curve of 0.75. A score of 6 or more had 84% sensitivity and 93% specificity for current depression, and 75% sensitivity and 90% specificity for any depressive disorder. CONCLUSION The SRQ-20 appears to be a reliable and valid screening measure for depression among rural HIV-positive individuals in southern Uganda. The use of this screening instrument can potentially improve detection and management of depression in this setting.

OBJECTIVES The present study aimed to validate screening tools that could be used to identify depression among workers. DESIGN Diagnostic test study. SETTINGS Workers from three Japanese companies agreed to participate. PARTICIPANTS Recruitment for the group 1 occurred between January 2001 and February 2004, and 89 participants (81 men and 8 women with a mean age of 38.4±6.6 years)(98.8%) took part in the study. Recruitment for the group 2 occurred between July 2000 and February 2004, and 1500 participants (1408 men and 92 women with a mean age of 40.9±7.2 years)(94.2%) took part in the study. Demographic data are shown in supplementary table 1. INTERVENTIONS Primary and secondary outcome measures: the Beck Depression Inventory (BDI) and a two-question case-finding instrument (TQI) were administered to 89 workers and Mini-International Neuropsychiatric Interview was conducted to verify the diagnosis of depression. A second group of 1500 workers completed the BDI and TQI to detect possible sample bias for the distribution of depression. Specificity, sensitivity and positive predictive value were calculated in order to obtain the optimal cut-off scores for BDI and TQI and receiver operating characteristic curves, and Youden Index were applied to further refine the optimal cut-off scores. RESULTS When paired together, BDI score ≥10 and TQI score of 2 adequately identified workers who had major depressive disorder and those who had other psychiatric disorders that are frequently comorbid with major depressive disorder. CONCLUSIONS The combination of BDI score ≥10 and TQI score of 2 can adequately screen for current and potential cases of depression among workers. Furthermore, BDI and TQI offer the advantage of being relatively easy to administer to a large number of workers. Early detection of depression could improve treatment outcomes and decrease economic burden. TRAIL REGISTRATION:

UNLABELLED ABSTRACT: BACKGROUND Substance use disorders seem to be an under considered health problem amongst the elderly. The Alcohol, Smoking and Substance Involvement Screening Test (ASSIST), was developed by the World Health Organization to detect substance use disorders. The present study evaluates the psychometric properties of the French version of ASSIST in a sample of elderly people attending geriatric outpatient facilities (primary care or psychiatric facilities). METHODS One hundred persons older than 65 years were recruited from clients attending a geriatric policlinic day care centre and from geriatric psychiatric facilities. Measures included ASSIST, Addiction Severity Index (ASI), Mini-International Neuropsychiatric Interview (MINI-Plus), Alcohol Use Disorders Identification Test (AUDIT), Revised Fagerstrom Tolerance Questionnaire-Smoking (RTQ) and MiniMental State(MMS). RESULTS Concurrent validity was established with significant correlations between ASSIST scores, scores from ASI, AUDIT, RTQ, and significantly higher ASSIST scores for patients with a MINI-Plus diagnosis of abuse or dependence. The ASSIST questionnaire was found to have high internal consistency for the total substance involvement along with specific substance involvement as assessed by Cronbach's α, ranging from 0.66, to 0.89 . CONCLUSIONS The findings demonstrate that ASSIST is a valid screening test for identifying substance use disorders in elderly.

OBJECTIVES: the Mini International Neuropsychiatric Interview (MINI) is a short diagnostic structured interview (DSI) designed to generate positive diagnosis for the main Diagnostic and Statistical Manual (DSM)-III-R/IV Axis I disorders and to explore the symptoms of Criterion A for Schizophrenia (Sc) to rule out the presence of Psychotic Disorders. The procedural validity of the MINI was investigated in psychiatric patients using the Composite International Diagnostic Interview (CIDI) as a gold standard in Europe and the Structured Clinical Interview for DSM-III-R (SCID-P)in the US. This paper presents the concordance and the reasons for discordance between the MINI and the CIDI for DSM-III-R Psychotic and Mood Disorders. No study had systematically analysed the sources of disagreement between DSI based on the same operational criteria in psychotic patients. METHODS: 256 consecutively recruited psychiatric patients and 50 non-psychiatric subjects passed the MINI and the CIDI. RESULTS: concordance was good for the presence of Major Depressive Episode (MDE), Manic Episode, Psychotic Disorders, syndromes or symptoms (0.65 to 0.82). Inconsistencies in evaluation of the disorder recency accounted for 25 to 40% of discordance for current diagnoses. Fifty-three percent of discordance for lifetime Manic Episode resulted from inconsistencies in the severity of the index episode. Fifty percent of discordance for the diagnosis of Psychotic Disorders was due to algorithmic differences between the two DSI. CONCLUSION: the MINI yields reliable DSM-III-R diagnoses within a short time frame (22 minutes). Depending on the quantitative and the qualitative analyses of discrepancies between the MINI and the CIDI for Psychotic Disorders and Mood Episodes, we proposed and tested modifications leading to improvements in both interviews. The procedural validity of the modified MINI according to the modified CIDI was found to be very good.

As part of the WHO-PPGHC study aimed to better understand the form, frequency and burden of psychiatric conditions in primary care throughout the world, the clinical characteristics of dysthymic patients consulting in primary care were examined. A total of 25,916 general health care attenders at 15 sites in 14 countries were screened using the 12-item General Health Questionaire (GHQ-12). Of those screened, 5,438 were assessed in detail using a Primary Health Care version of the Composite International Diagnostic Interview (CIDI-PHC) in conjunction with among others the Brief Disability Questionnaire (BDQ) and the 28-item General Health Questionnaire (GHQ-28). General practitioners (GPs) gave their opinion on the existence of a psychological problem and indicated what therapeutic intervention was proposed to patients they recognised as psychological cases. The estimated current prevalence of dysthymia as defined by the ICD-10 was 2.1%. The social disability was found to be substantial in patients with dysthymia (52.2% of patients moderately or severely disabled) similar to that observed in patients with Depressive Episode (DE)(57.4%). When both conditions were present, the level of disability was even higher (63.6%). The symptoms presented by dysthymic patients without DE were mostly those specific for the diagnosis of dysthymia (ie, tearful, hopeless, inability to cope, pessimism) while these symptoms were less frequent when dysthymia was complicated by a DE. On the contrary, fatigue and loss of interest were more rarely observed in "pure" dysthymics. In spite of a lower symptomatic severity about half of the patients with dysthymia were recognised as cases by their GPs, a proportion similar to those with DE. However, dysthymics without DE were not, in contrast to patients with DE or with dysthymia and DE, more treated with drugs than non-depressed patients.

BACKGROUND: Studies devoted to the detection and treatment of anxiety and depression in adult populations show that at least 10% meet ICD10 criteria for an anxiety or a depressive disorder, but only half are diagnosed as such and only one third of those receive appropriate treatment. The goal of the APRAND program was to explore the possibility of improving management strategies via health education during doctors' visits. METHODS: In 2001, EDF-GDF conducted an experimental program in which 21 physicians from its in-house health insurance program used the MINI mental state examination to screen for ICD10 criteria for anxiety and depressive disorders in 9743 employees on sick leave. A "here-elsewhere" epidemiologic study evaluated the program, recording the initial diagnoses and studying a year later the outcome of the persons identified with these disorders in 8 active centers (with prevention activities) and in 13 control centers (without prevention activities). The activities consisted of explanations of the disorders identified, delivery of the test results, delivery of leaflets based on the WHO guidelines, and strong recommendations to see a general practitioner, or a psychiatrist, or the occupational physician, if necessary. Logistic regressions compared the two groups, taking into account sex, age, geographic region, comorbidity, and medical care at screening. RESULTS: Preventive activities were significantly associated with the disappearance at 1 year of depressive episodes (OR=1.93; CI 95%; 1.3-2.84) and of phobic or panic disorders (OR=1.98; CI 95%; 1.14-3.44). The only other variables affecting prognosis were age and sex. The probability of recovery or remission increased by 10 to 20% at active centers, according to age, sex and disorder. Moreover, the physicians reported that they learned a great deal from the program, which thus also improved their practices. CONCLUSION: Diagnosis and prognosis of depressive episodes and phobic and panic disorders in adult populations can be improved by a preventive diagnostic and educational approach of the type used by APRAND during doctor's visits.

Structured diagnostic interviews, which evolved along the development of classification's systems, are now widely used in adult psychiatry, in the fields of clinical trials, epidemiological studies, academic research as well as, more recently, clinical practice. These instruments improved the reliability of the data collection and interrater reliability allowing greater homogenisation of the subjects taking part in clinical research, essential factor to ensure the reproducibility of the results. The diagnostic instruments, conversely to the clinical traditional diagnostic processes allow a systematic and exhaustive exploration of disorders, diagnostic criteria but also severity levels, and duration. The format of the data collection, including the order of exploration of the symptoms, is fixed. The formulation of the questions is tested to be univocal, in order to avoid confusions. In child and adolescent, researches in pharmacology and epidemiology increased a lot in the last decade and the standardisation of diagnostic procedures is becoming a key feature. This Article aims to make an assessment, a selection, and a description of the standardized instruments helping psychiatric diagnosis currently available in the field of child and adolescent's psychiatry. Medline and PsycINFO databases were exhaustively checked and the selection of the instruments was based on the review of four main criteria: i) compatibility with international diagnostic systems (DSM IV and/or ICD-10); ii) number of disorders explored; iii) peer reviewed Journals and iv) richness of psychometric data. After the analysis of the instruments described or mentioned in the literature, 2 structured interviews [the Diagnostic Interview Schedule for Children (DISC) and the Children's Interview for Psychiatric Syndromes (ChIPS)] and 4 diagnostic semi-structured interviews [the Schedule for Affective Disorders and Schizophrenia for School-Age Children (Kiddie-SADS), the Diagnostic Interview for Children and Adolescent (DICA), the Child and Adolescent Psychiatric Assessment (CAPA) and the Interview Schedule for Children and Adolescents ISCA)] were retained according to the 3 first criteria. All can be administered by clinicians, and x out of 6 can also be administered by lay-interviewers. All include a child/adolescent version and a parent version. Two instruments evaluate the presence of DSM IV axe II disorders: The ISCA explores the criteria of the Antisocial Personality Disorder. The CAPA evaluates Borderline, Obsessional-compulsive, Histrionic and Schizotypic Personality Disorders. Regarding the psychometric quality criterion, the selection was much more difficult because of the lack of data and the weakness of the samples studied in reliability studies. Interrater reliability appeared to be good for the 6 instruments, with kappas ranging from 0.5 to 1. This is usual in such instruments. The test-retest reliability was found to vary from bad to excellent depending on the instruments, the "informant" status (child/adolescent or parent), and the disorder explored, kappas ranging from 0.32 to 1. The worst results concerned face-to-face reliability studies which showed weak concordances for the diagnoses, whatever the procedure implemented: Diagnostic interview vs. i) Another diagnostic interview, vs. ii) An expert diagnosis or vs. iii) Scales and questionnaires. Overall, the K-SADS-PL appeared to be the instrument that has the best test-retest reliability for Anxious Disorders and Affective Disorders (the value kappa showing good to excellent reliabilities). Several important methodological observations emerged from this review. Firstly, the metrological data corresponding to the diagnoses according to DSM IV or ICD-10 criteria's were lacking. The face validity was globally satisfactory, but the data concerning their face-to-face validities and their test-retest reliability, although better than in the former versions, were limited because they were tested on small sample. In fact, it appeared that the agreements depend on the informant, the sample studied, the various diagnostic categories and the instrument used. Since the studies carried out by Cohen et al., with now obsolete versions of the DISC and K-SADS, no other study establishing a comparison between two EDS have been conducted. Consequently, the clinicians must be very careful before comparing DSM or ICD diagnoses generated by different instruments. The second point was the length of the interviews that appeared sometimes longer than instruments used in adults, considering the fact that diagnostic procedure implies two independent interviews, one with the child/adolescent and one with the adult referent. The minimum duration was found to be 1 h 30 for the Chips in clinical setting, while it could reach 4 h or more for the DISC IV or the ISCA. The interviews had to be often carried out in several sessions, so the assessment became very difficult in easily tired and/or distractible subjects. The third point referred to the necessity to consider multiple data sources in young patients during the diagnostic procedure, and the weakness of the levels of agreement generally reported between sources. Empirically, it was observed that the investigator granted more weight to the report of the children than to the parent's one, when the clinical judgement was necessary to synthesize the data. On another level, studies showed a high agreement on the factual contents or on the specific events (ex: hospitalization), like on the obvious symptoms (ex: enuresis). The parents report more problems of behaviour, school and relational difficulties, whereas the children report more fear, anxiety, obsessions and compulsions, or delusional ideas. In other words, it appeared that children were better informants in describing their mental states (internalised disorders), and that adults would bring more reliable information in describing externalised disorders. Like McClellan and Werry, we think that further researches are needed to clarify if and when this is the case. The last major point concerned the problem of language. These instruments must be used in the maternal language of the interviewees and they were developed for most of them into English only. For example, there is only one instrument available into French (the Kiddie SADS). Nowadays, it remains difficult to conduct international studies in child and adolescent psychiatry and/or to compare data is this domain. To conclude, the use of the EDS and EDSS brings many benefits, in academic researches as well as in clinical practice, but a more systematic use is limited by a certain number of parameters. The instruments currently available in child and adolescent are far from being optimal in terms of quality and quantity. It seems necessary and useful to contribute to their development and their improvement. In particular, the following points should be considered: drastic reduction of the length of the interviews; simplification in the use of these instruments, during the interviews, but also in the treatment of the data collected during the final phase of diagnosis generation, the clinician having to carry out ceaseless returns to check the presence or not of each diagnostic criterion; reduction of the duration of the highly necessary training, which can be easily solved by the global simplification of the instruments; quantitative and qualitative improvements of psychometric properties, in particular in terms of sensitivity, specificity and face-to-face validity. Finally, it is highly necessary to continue to develop structured diagnostic interviews adapted to the assessment of child and adolescent psychiatric diagnoses keeping in mind simplicity, feasibility and reliability. Developing this kind of instruments is hard, expensive, and sometimes tiresome but it remains the inescapable stage to produce high quality data in the future.

OBJECTIVE The safety and efficacy of mecamylamine as a monotherapy in children and adolescents with Tourette's disorder (TD) was investigated in an 8-week multicenter, double-blind, placebo-controlled study. METHOD Eligible subjects included subjects with TD (DSM-IV), with a naturalistic mix of comorbid diagnoses, nonsmokers, aged 8 to 17 years, whose behavioral and emotional symptoms (according to parents) were more disturbing than tics. After a washout period of all psychotropic medication, subjects were randomly assigned to either mecamylamine (n = 29) or placebo (n = 32). Mecamylamine doses ranged from 2.5 to 7.5 mg/day. Primary efficacy measures included the Tourette's Disorder Scale-Clinician Rated (TODS-CR) and 21-point Clinical Global Improvement scale; secondary efficacy measures included the Yale Global Tic Severity Scale and a rage-attack scale (RAScal). RESULTS Of the 61 subjects who were randomized, 50 (82%) completed at least 3 weeks on medication and 38 (62%) completed the full 8-week trial. Study withdrawals included 12/29 on mecamylamine and 11/32 on placebo. For the total sample, mecamylamine was no more effective than placebo on any of the outcome measures. However, an item analysis of the TODS-CR suggested that mecamylamine may have reduced sudden mood changes and depression in moderately to severely affected subjects. Except for a slight increase in heart rate during the 1st week in both the mecamylamine and the placebo groups, there where no significant mecamylamine-related changes in vital signs, electrocardiogram, complete blood cell count, or blood chemistry values. CONCLUSIONS Mecamylamine, in doses up to 7.5 mg/day, is well tolerated in children and adolescents, but as a monotherapy it does not appear to be an effective treatment for tics or for the total spectrum of symptoms associated with TD. However, further studies should be conducted to investigate its possible therapeutic effects in subjects with comorbid mood disorders and as an adjunct to neuroleptic medication.

BACKGROUND: During these last years, many structured and standardized diagnostic interviews have been developed in order to identify psychiatric disorders in a standardized way. These tools enable a systematic investigation of these disorders according to international classifications. Their main drawback is to be long. To assess the care of depression, we used a shorter and more simple tool: the Mini International Neuropsychiatric Interview (MINI) to identify depressive subjects. METHOD: The study was conducted in the Gazel cohort from the French National Electricity and Gas Company. A stratified sample of 2394 civil servants selected in order to over-represent depressive subjects was asked to answer to the MINI interview through a phone interview. An epidemiological and statistical analysis was performed to test the MINI internal validity: prevalence of depressive disorders using different threshold of diagnosis (number of symptoms required to identify someone as depressive), frequency of different symptoms, variability between investigators and potential biases. RESULTS: Respondents to the phone interview (1108 civil servants) had more often presented depression markers for the last 5 years. Prevalence of depressive episodes changed little when we varied the threshold of diagnosis and did not stress any threshold problem. The variability between investigators was important, but the estimation of prevalence remained stable when we excluded extreme rates of prevalence. The choice of a classification system affected the prevalence estimation. Using the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) from the American Psychiatric Association, the prevalence of depressive episodes was lower and closer to the estimations shown in the literature than using the International Classification of Disease (ICD 10). Moreover, the stratification assigned very unbalanced weights to the stratification strata. By excluding depressive episodes observed in the stratum "control"(no depression "marker" from 1989 to 1994 in the database), the prevalence was very lower, whatever the classification was. Finally, factors which appeared linked to care of depression with the ICD definition remained the same when the DSM diagnosis definition was used, and relative risks were quite similar. CONCLUSION: The MINI appears to be a short and simple tool, suited to the epidemiological studies. This analysis does not highlight any failure in the internal consistency of the MINI. The remaining question is what the MINI really measures, particularly comparing to a psychiatrist's diagnosis.

BACKGROUND: This study explored the prevalence, socio-demographic characteristics and severity of different anxiety syndromes in five European primary care settings, as well as medical help-seeking, recognition by general practitioners (GPs) and treatment prescribed. METHOD: The data were collected as part of the WHO study on Psychological Problems in General Health Care. Among 9714 consecutive primary care patients, 1973 were interviewed using the Composite International Diagnostic Interview. Reason for contact, ICD-10 diagnoses, severity and disability were assessed. Recognition rates and treatment prescribed were obtained from the GPs. RESULTS: Anxiety syndromes, whether corresponding to well-defined disorders or to subthreshold conditions, are frequent in primary care and are associated with a clinically significant degree of severity and substantial psychosocial disability. Their recognition by GPs as well as the proportion treated are low. CONCLUSIONS: Since people with subthreshold anxiety show a substantial degree of disability and suffering, GPs may consider diagnostic criteria to be insufficient. However, their awareness of specific definitions and treatment patterns for anxiety disorders still needs a lot of improvement both for patients' well-being and for the cost resulting from non-treatment.

The rate of detection of depressed patients by general practitioners (GPs) is generally reported to be lower than 50%, with some studies giving a value as low as 14%. In addition, GPs tend to overdiagnose anxiety and underdiagnose depression. Patients are not necessarily aware of the psychological nature of the disorder and only one-fifth list psychological complaints as the reason for contact. We collected information on the prescription and consumption of drugs in order to assess the influence of recognition of depression by GPs and of other factors on the treatment received by patients. Our results, which are particularly important in the context of current discussions on the cost of mental healthcare treatments, indicate not only a need for GPs to improve their identification rates but also a need to make patients more aware of the nature of their psychological diagnoses. When spontaneous psychological complaints are presented, the identification rate increases very substantially, and when patients are well aware of their conditions, compliance increases. It is clear from our results that greater specific recognition of psychiatric patients accompanied by the prescription of a specific treatment would not substantially alter the direct costs of drug prescription. On the contrary, it would very probably lower many costs, since the proportion of specific treatment given to properly identified patients is very low at present.

In a sample of 2096 consecutive primary care patients recruited in the Paris region, social phobia was a highly prevalent disorder (5.1%). The most frequent comorbid condition was depressive episode, which affected 70% of patients with social phobia of early onset (at less than 15 years of age), while the highest association was with agoraphobia (odds ratio 10.4). No association was observed with generalized anxiety disorder. Alcohol abuse and suicidal ideation and attempts are also commonly associated with social phobia. However, when patients presented to a general practitioner with comorbid depression present, 76% were recognized as cases (though only 11% were identified as having an anxiety disorder), but in the absence of depression, only 46% were identified as cases. Given the degree of disability caused by social phobia, there is an obvious need for improved education of both doctors and patients regarding its status as a disorder, and its treatability.

OBJECTIVE: To develop a Spanish version of the WHO-Composite International Diagnostic Interview (WHO-CIDI) applicable to Spain, through cultural adaptation of its most recent Latin American (LA v 20.0) version. METHODS: A 1-week training course on the WHO-CIDI was provided by certified trainers. An expert panel reviewed the LA version, identified words or expressions that needed to be adapted to the cultural or linguistic norms for Spain, and proposed alternative expressions that were agreed on through consensus. The entire process was supervised and approved by a member of the WHO-CIDI Editorial Committee. The changes were incorporated into a Computer Assisted Personal Interview (CAPI) format and the feasibility and administration time were pilot tested in a convenience sample of 32 volunteers. RESULTS: A total of 372 questions were slightly modified (almost 7% of approximately 5000 questions in the survey) and incorporated into the CAPI version of the WHO-CIDI. Most of the changes were minor - but important - linguistic adaptations, and others were related to specific Spanish institutions and currency. In the pilot study, the instrument's mean completion administration time was 2h and 10min, with an interquartile range from 1.5 to nearly 3h. All the changes made were tested and officially approved. CONCLUSIONS: The Latin American version of the WHO-CIDI was successfully adapted and pilot-tested in its computerized format and is now ready for use in Spain.

The objective was to study the accuracy of the post-traumatic stress disorder (PTSD) section of the Composite International Diagnostic Interview (CIDI 2.1) DSM-IV diagnosis, using the Structured Clinical Interview (SCID) as gold standard, and compare the ICD-10 and DSM IV classifications for PTSD. The CIDI was applied by trained lay interviewers and the SCID by a psychologist. The subjects were selected from a community and an outpatient program. A total of 67 subjects completed both assessments. Kappa coefficients for the ICD-10 and the DSM IV compared to the SCID diagnosis were 0.67 and 0.46 respectively. Validity for the DSM IV diagnosis was: sensitivity (51.5%), specificity (94.1%), positive predictive value (9.5%), negative predictive value (66.7%), misclassification rate (26.9%). The CIDI 2.1 demonstrated low validity coefficients for the diagnosis of PTSD using DSM IV criteria when compared to the SCID. The main source of discordance in this study was found to be the high probability of false-negative cases with regards to distress and impairment as well as to avoidance symptoms.

The development and well-being assessment (DAWBA) has been used in various epidemiological studies, whereas the clinical value of the instrument needs support from further studies. In particular, it is important to document how the use of the DAWBA influences clinical decision-making. The present study employed the DAWBA in a consecutive series of 270 new referrals to a large public child and adolescent psychiatric service in Zurich, Switzerland. ICD-10 based diagnoses were obtained from clinicians for all patients and reliability of DAWBA expert raters was calculated. The DAWBA diagnoses were randomly disclosed (n = 144) or not disclosed (n = 126) before clinical decision-making. The reliability of DAWBA expert diagnoses was very satisfactory and the agreement under the disclosed versus the non-disclosed condition amounted to 77 versus 68% for internalizing disorders and to 63 versus 71% for externalizing disorders. The increment in agreement due to disclosure of the DAWBA diagnosis was significant for internalizing disorders. Access to DAWBA information was more likely to prompt clinicians to add an extra diagnosis. Professional background and degree of clinical experience did not affect diagnostic agreement. Overall, diagnostic agreements between DAWBA expert diagnoses and clinical diagnoses were in the fair to moderate range and comparable to previous studies with other structured diagnostic interviews. The inclusion of the DAWBA into the clinical assessment process had an impact on diagnostic decision-making regarding internalizing disorders but not regarding externalizing disorders.

PURPOSE This study estimates the prevalence of common mental disorders and the proportion and potential determinants of detection among adolescents attending prenatal care. METHODS We recruited 930 consecutive adolescents admitted for obstetric care, of which 457 participants had attended the hospital's prenatal care unit. Common mental disorders were assessed using the Composite International Diagnostic Interview (version 2.1). A detailed review of prenatal care records was used to identify detection of psychiatric disorders by prenatal healthcare professionals. RESULTS A total of 103 adolescents (22.5%) had some mental disorder but only one-fifth of them had had their psychiatric disorder detected during prenatal care. The most frequent diagnosis using the Composite International Diagnostic Interview (version 2.1) was depression (13.5% or 62), but only 21% had been detected. Alcohol and drug dependence were the least common mental disorders (2.4%), but they were the most commonly detected (45.5%). Physical chronic condition increased the likelihood of detecting psychiatric disorder. CONCLUSION Mental health is not yet recognized as an integral component of practice in prenatal care. Given the potential effect of antenatal psychiatric morbidity on maternal and child outcomes, especially among adolescents, practice needs to be changed and prenatal care professionals trained in the recognition and basic treatment of common mental disorders.

OBJECTIVES: the Mini International Neuropsychiatric Interview (MINI) is a short diagnostic structured interview (DSI) designed to generate positive diagnosis for the main Diagnostic and Statistical Manual (DSM)-III-R/IV Axis I disorders and to explore the symptoms of Criterion A for Schizophrenia (Sc) to rule out the presence of Psychotic Disorders. The procedural validity of the MINI was investigated in psychiatric patients using the Composite International Diagnostic Interview (CIDI) as a gold standard in Europe and the Structured Clinical Interview for DSM-III-R (SCID-P)in the US. This paper presents the concordance and the reasons for discordance between the MINI and the CIDI for DSM-III-R Psychotic and Mood Disorders. No study had systematically analysed the sources of disagreement between DSI based on the same operational criteria in psychotic patients. METHODS: 256 consecutively recruited psychiatric patients and 50 non-psychiatric subjects passed the MINI and the CIDI. RESULTS: concordance was good for the presence of Major Depressive Episode (MDE), Manic Episode, Psychotic Disorders, syndromes or symptoms (0.65 to 0.82). Inconsistencies in evaluation of the disorder recency accounted for 25 to 40% of discordance for current diagnoses. Fifty-three percent of discordance for lifetime Manic Episode resulted from inconsistencies in the severity of the index episode. Fifty percent of discordance for the diagnosis of Psychotic Disorders was due to algorithmic differences between the two DSI. CONCLUSION: the MINI yields reliable DSM-III-R diagnoses within a short time frame (22 minutes). Depending on the quantitative and the qualitative analyses of discrepancies between the MINI and the CIDI for Psychotic Disorders and Mood Episodes, we proposed and tested modifications leading to improvements in both interviews. The procedural validity of the modified MINI according to the modified CIDI was found to be very good.

Background: The diagnostic ability of general practitioners (GPs) concerning mental disorders is not optimal, and could be improved by structured diagnostic interviews. Various aspects of the Structured Psychiatric Interview for General Practice (SPIFA) are examined. Aims: The inter-rater reliability of the SPIFA, the time used by GPs and specialists and the GPs satisfaction are examined. The properties of the SPIFA are compared with those of the Prime-MD and the MINI schedules. Methods: Inter-rater reliability of the SPIFA was tested in 336 patients in general practice. The patients were randomized to two interview strategies. Either both GPs and psychiatrists used the SPIFA, or GPs used the SPIFA and psychiatrists a modified version of the SCID for Axis I disorders. The satisfaction was investigated by a questionnaire sent to 1000 GPs who had SPIFA training. Results: The SPIFA showed adequate inter-rater reliability for depression, anxiety disorders and increased suicidal risk for both interview strategies. In patients with more than two co-morbid disorders, the inter-rater reliability was poor. The mean duration of SPIFA was 21 min for SPIFA screening and 22 min for SPIFA manual. The 192 GPs responding to the questionnaire were mostly satisfied with the SPIFA. Conclusions: The SPIFA seems to be a reliable, valid and helpful instrument for GPs making diagnoses of mental disorders in their patients. Compared with the Prime MD and the MINI, the SPIFA seemed to have comparable psychometric properties but better feasibility in primary care.

WORK INTEREST: To assess vulnerability factors of outpatients with fibromyalgia, by the evaluating prevalence of DSM-IV axis I disorders (mental disorders) and axis II disorders (personality disorders). METHODS: 30 outpatients with fibromyalgia were examined consecutively, and were administered the Mini International Neuropsychiatric Interview and the Structured Clinical Interview for DSM-IV. RESULTS: The patients were found to have a high prevalence of DSM-IV axis I disorders (63,3% received a diagnosis of depressive and/or anxious disorder), and axis II disorders (46,7% received at least one diagnosis of personality disorder, including obsessive-compulsive personality disorder: 30%, borderline personality disorder: 16,7%, and depressive personality disorder: 16,7%). PERSPECTIVES: Our results show the importance of psychiatric comorbidities, including personality disorders from outpatients with fibromyalgia. Personality disorders have to be taken into account in the treatment by their impact on doctor-patient relation. Our results suggest the importance of liaison psychiatry in the treatment of those patients.

In the last few decades, there has been a long debate on the existence of agoraphobia (AG) without a history of panic attacks (PAs). In the present study, the problem of the relationships between AG and PAs is addressed trough a reevaluation of the cases who had been diagnosed with AG in the community survey of Sesto Fiorentino. Forty-one of the 75 subjects who met the criterion of AG in the Sesto Fiorentino Study were reinterviewed by experienced clinical psychiatrists. The Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) and the Composite International Diagnostic Interview were used to make the diagnoses. The Mobility Inventory for Agoraphobia (MIA) and a specific adjunctive question,"why do/did you avoid?", were used to compare AG subjects with or without PD. Of the 41 subjects with a lifetime history of AG, 12 cases had original diagnosis of AG without PAs and the remaining 29 had PD with AG. After the reassessment, in 10 cases, the criteria for the diagnosis of AG without PAs were confirmed, totaling a lifetime prevalence of 0.4%(confidence interval, 0.2-0.8). Agoraphobia subjects with and without PAs were comparable as regard to sex, age, age of onset, duration of illness, family history for anxiety or mood disorders, MIA scores, number, and type of situations avoided. Thus, AG seems to exist also in absence of a history of PAs, and the one-way relationship between the occurrence of PAs and a following development of AG, postulated by DSM-IV, should be reconsidered for the future classifications.

The author examined the course of somatoform disorders in non-referred adolescents. Somatoform disorders were coded from DSM-IV criteria, using the computerized Munich (Germany) version of the Composite International Diagnostic Interview. About 35.9% of the adolescents with somatoform disorders at the index investigation continued to have the same disorders at the follow-up investigation: 26.7% had anxiety, 17.1% had depression, 22% had substance-use disorders, and 53.7% had no psychiatric disorders. Factors related to the chronicity of somatoform disorders included gender, comorbid depressive disorders, parental psychiatric disorders, and negative life events. Somatoform disorders showed a heterogeneous pattern of course.

Refugees and asylum seekers have a high risk of developing mental health problems and appropriate screening in people from diverse origins remains a challenge. The aim of this study was to validate a structured diagnostic interview, adapted from the Major Depressive Episode (MDE) and Posttraumatic Stress Disorder (PTSD) sections of the Mini International Neuropsychiatric Interview, to detect these disorders among newly arrived asylum seekers. The adapted questionnaire was administered by nurses in a primary care context and its performance was judged against the expert opinion of a mental health specialist. One hundred one subjects were included in the study (mean age: 30; origin: Africa 58%, Europe: 37%, Asia: 5%). MDE and PTSD were diagnosed among 33% and 30% of them respectively. The questionnaire demonstrated moderate sensitivity (MDE: 79%; PTSD: 69%), but high specificity (MDE: 95%; PTSD: 94%). These characteristics remained stable despite cultural differences and use of interpreters. This instrument could be used for systematic screening of MDE and PTSD in refugees from various origins.