1 Boring Old Man

The mission of the MacArthur Initiative on Depression and Primary Care is to enhance the ability of primary care clinicians to recognize and manage depression… The goals that serve the Initiative’s mission are:
1. To develop practice systems that facilitate recognition and care of depression;
2. To develop educational programs and tools for primary care that enhance patient care;
3. To evaluate the impact of these programs, tools and models; and
4. To disseminate these ideas and materials to primary care clinicians, medical groups, specialty societies, health plans, and other organizations committed to high quality depression care.

Dimensional Aspects of Psychiatric Diagnosis [July 26-28, 2006]

^{Prepared by Michael B. First, M.D., DSM Consultant to the American Psychiatric Institute for Research and Education [APIRE], a subsidiary of the American Psychiatric Association.}

^{A diagnosis-related research planning conference focusing on dimensional approaches in diagnostic classification was held at the Natcher Conference Center on the NIH campus in Bethesda, Maryland on July 27th and 28th, 2006. The conference was the seventh in a series of 12 conferences on "The Future of Psychiatric Diagnosis: Refining the Research Agenda" convened by the American Psychiatric Institute for Research and Education [APIRE] in collaboration with the WHO and NIH, with funding from NIH…}

^{John Helzer, MD [Burlington, VT] opened the conference with a description of its rationale and goals These were:}

1. to review the advantages and drawbacks of offering a quantitative "dimensional" component in DSM-V and ICD-11;
2. to discuss various alternative dimensional approaches; and
3. to discuss a research agenda relevant to designing and testing dimensional alternatives.

^{He stressed that the six diagnostic areas scheduled for formal presentation – i.e., substance use disorders, mood disorders, psychotic disorders, anxiety disorders, childhood disorders, and personality disorders – were illustrative examples and that it was not the intention of the conference to confine discussion to these areas. Dr. Helzer noted that although DSM-III was a revolutionary paradigmatic shift, the diagnostic progress it fostered revealed the inadequacies of a strictly categorical diagnostic model. He then offered four recommendations for DSM-V:}

1. that the DSM-V criteria should include options for dimensional approaches;
2. that the categorical approach of DSM should be retained given the ongoing need for diagnostic categories for clinical work and research;
3. that the content of DSM-V dimensional components be determined by categorical definitions given the need to be able to relate the dimensional scales back to the categorical definitions; and
4. that DSM-V should be structured to ensure maximum utility for future taxonomic needs…

^{The mood disorders breakout group proposed adding dimensionality to major depressive disorder by exploring the implications of adopting the PHQ-9, a nine-item self-report scale with a 0-27 range of scores. Used as a severity measure, suggested cutpoints include 5-9 for mild, 10-14 for moderate, 15-19 for moderately severe, and 20 or greater for severe, with "significantly improved" defined as a 5-point drop after 6 weeks, "responded to treatment" as a 50% drop in score, and "remission of depression" as a score of less than 5. Such an approach has clinical utility in that it can identify probable cases, it identifies cases at risk who need referral, it confirmed current treatment in 60% of cases, it informed a change of treatment in 40% of cases, and in >90% of visits, clinicians rated it as useful. It has research utility in that it sets benchmarks for improvement, recovery, and remission and permits clinical audits of practice. The scale still needs validation in different settings and with different types of patients [e.g., high risk patients with comorbid conditions].}

^{Dr. Helzer noted that although DSM-III was a revolutionary paradigmatic shift, the diagnostic progress it fostered revealed the inadequacies of a strictly categorical diagnostic model.}

10. Concentration/Decision making:
0 There is no change in my usual capacity to concentrate or make decisions.
1 I occasionally feel indecisive or find that my attention wanders.
2 Most of the time, I struggle to focus my attention or to make decisions.
3 I cannot concentrate well enough to read or cannot make even minor decisions.
11. View of myself:
0 I see myself as equally worthwhile and deserving as other people.
1 I am more self-blaming than usual.
2 I largely believe that I cause problems for others.
3 I think almost constantly about major and minor defects in myself.