MINI- SCANPRESENTER- Dr. PAVITHRAC/P- Dr. P. JOHN MATHAI

INTRODUCTIONPsychiatric disorders contribute heavily to the

global burden of disease, but their detection and standardised treatment falls behind, compared with the major somatic disorders due to lack of reliable & standardised tools for their detection.

Structured & semi- structured diagnostic interviews are being used with increasing frequency in psychiatry currently.

Initially used to standardize data collection in psychiatric epidemiology studies, they are now also used in multicenter clinical/ drug trials for accurate diagnosis across sites.

Most recently, in demands for accountability in the delivery of clinical care, they are being adopted to ensure diagnostic precision for outcome tracking in non research settings.

In contrast to usual clinical interview, they also allow comparisons across clinical centers & have the capacity to reduce variability in diagnosis in the interest of improving quality of care.

HISTORY:The Present State Examination(PSE)

constructed by J. K. Wing & colleagues in 1959 and modified in at least nine subsequent editions ,was the first standardized structured clinical interview to be adopted on an international basis in psychiatry .

Its use grew from the concern that patients with similar ailments were given different diagnostic criteria.

There was a need to get different groups to agree to get the same diagnostic criteria

The PSE operationalised these diagnostic criteria for the clinical interview.

Their evolution & level of sophistication paralleled the evolution of internationally acceptable diagnostic criteria & the increase in the predictive power of these criteria.

Reduced interviewer/ rater bias

Time duration of structured interview listed in order of creation

DIS- diagnostic interview schedule. SADS- schedule for affective disorders. SCID- structured clinical interview for DSM. CIDI- comprehensive international diagnostic interview. SCAN- schedules for clinical assessment in neuropsychiatry. MINI- mini international neuropsychiatric interview. SDDS- symptom driven diagnostic interview. PRIME- MD- primary care evaluation of mental disorder.

Long (=/> 45mins)

Medium( 15- 45 mins)

Short (5-10mins)

older PSE

DIS

SADS

SCID SDDS

CIDI PRIME-MD

SCAN

Newer MINI MINI SCREEN

MINI- Plus

interview

Rater qualifications

format Designed for

Duration in mins

Time frame

Diagnostic output

PSE Trained mental health professional

Close ended: optional rater inquires

Med & psych patients, epidemiology

15-60 Last month

Descriptive syndromes

DIS Lay interviewer with 1 wk intensive training

Close ended only

Community respondents, also patients

45-75 Lifetime, pst month, past 6 mon, past yr

DSM IIIR diagnosis

SADS TMHP Open & close ended

Med & psy patients, community

90-120 Previous weeks

RDC categories

SCID TMHP Open followed by close ended: optional rater

Med & psy pat, epidemiology

45-60 Current episode

DSM III R diagnosis

CIDI TMHP Close ended optional rater inquires

Med & psy pat epidem

120-180

Current & lifetime

ICD 10 & DSM III R

interview

Rater qualifications

format Designed for

Duration in mins

Time frame

Diagnostic output

MINI Limited Training

Close ended: optional rater inquires

Clinical settings & research

15 Current & few lifetime

DSM IV & ICD 10

MINI PLUS

Limited Training

Close ended optional rater inquires

Research <45 Current & Lifetime

DSM IV & ICD 10

MINI SCREEN

Patient rated

closed ended

Primary care

5 Current DSM IV & ICD 10 SCREEN

SDDS Patient rated screen, clinician rated interview

Closed ended

Medical patients, primary care

3-10 Current episode

DSM III R diagnosis

PRIME- MD

PQ- pat rated screenCEQ- clinician administered interview

Closed ended

Medical patients, primary care

8 Current DSM III R diagnosis

OBSTACLES:Since they were first developed in academic

centers, they reflected the academician’s interest in detail, accuracy & precision.

Enormous data collection-Frequently they collected data on a large number of disorders & its subtypes, reflecting unique interest of individual developers rather than data driven plan.

Longer duration of administration-Early interviews were long & often difficult & cumbersome to use.

Not user friendlyThey required extensive training & also

experience & technical expertise in psychiatry or psychology.

These interviews were costly to administer.

There was a increased need for a very short psychiatric screening instrument.

Hence, SDDS, PRIME- MD & MINI- screen evolved. These are all on one page, paper & pencil, largely patient rated screening instruments but are not standardised diagnostic interviews & need clinicians evaluations to follow up on the positive patient responses.

NEED FOR DEVELOPMENT OF MINI:Hence there was a need for a

structured interview that would bridge the gap between the detailed, academic, research oriented interview & the ultra short screening tests designed for primary care.

Shorter than the clinical interview but more comprehensive & standardised than the screening test, & should provide a less costly alternative in international clinical trails & can be used in clinical settings in psychiatry.

GOALS IN THE DESIGN OF MINI:Short & inexpensiveSimple, clear & easy to administerHighly sensitive ie high proportion of

patients with a disorder should be detected by the instrument

Specific ie have the ability to screen out patients without disorders

Compatible with international diagnostic criteria, including ICD 10, DSM III R & IV

Able to capture important subsyndromal variants

Useful in clinical psychiatry as well as research settings

Balance between brevity & simplicity on one hand & accuracy on the other

Instrument must have the ability to detect a substantial proportion of patients without incorrectly labeling a disproportionate number of patients with out disorders.

The MINI was not intended to replace psychiatrists. Rather, like a laboratory test in medicine, it permitted the trained interviewers (health information technicians) to capture routine & repetitive information maximizing the medical encounter & leaving the specialists time for other critical tasks

MINI FAMILY1. MINI2. MINI PLUS3. MINI SCREEN4. MINI KID

MINI- MINI Plus Major depressive episode Dysthymia, suicidality Mania / hypomania episode Panic disorder Agoraphobia, Social phobia, Specific phobia, Obsessive-compulsive

disorder Posttraumatic stress

disorder Alcohol dependence/abuse, substance

dependence/abuse, Psychotic disorders, Anorexia nervosa,

Bulimia nervosa, Generalised anxiety

disorder Antisocial personality

disorder, Somatization disorder Hypochondriasis, Body dysmorphic disorder Pain disorder Conduct disoder Attention deficit

hyperactivity disorder, Adjustment disorder Premenstrual dysphoric

disorder Mixed anxiety depressive

disorder

SCAN:Is a set of instruments aimed at assessing,

measuring & classifying the psychopathology & behaviour associated with the major psychiatric disorders of adult life.

Is the successor of PSE 9Is a semi structured clinical interview.Are interviewer based and involve clinical

judgement. Here interviewer has to make sure that sufficient information is gathered through cross-examination before the rating is given and should probe further using his or her own questions

when needed. 4 components:1. Tenth edition of present state examination PSE102. Glossary of differential definitions3. Item group checklist IGC4. Clinical history schedule CHS

1,872 items spread out over 28 sections PSE10 has 2 parts:Part 1- covers somatoform, dissociative, anxiety,

depressive & bipolar disorders & problems associated with appetite alcohol & other substance use.

Part 2- has a screen. Covers psychotic & cognitive disorders, observed abnormalities of speech, affect & behaviour.

The SCAN does not assess or classify personality disorders.

2 versions- paper & pencil & computer assisted version of SCAN 2.1 (I- shell 1.0.4.6)

Data from schedules can be entered in variety of ways: on SCAN schedules themselves, on SCAN coding sheets, in the free entry SCAN record book, into laptop computer file.

In its complete form, SCAN is intended for use only by clinicians with an adequate knowledge of psychopathology who have taken a training course.

Central principal is that the interview, although substantially structured, retains the features of clinical examination.

Aim of the interviewer is to discover which of the comprehensive list of phenomena have been present during a designated period of time & with what degree of severity.

The items listed are differentially defined in a glosssary.

The examination is therefore based on a process of matching the respondent’s behaviour & description of subjective experiences against the clinical definitions provided.

A rich data base of differentially defined clinical phenomenon forms the core of SCAN.

Numerous classifying algorithms can be applied to generate diagnoses according to criteria of ICD 10, DSM IIIR, IV.

A virtue of SCAN is that its clinical database has not been constructed solely in accordance with any one nosology.

Overall intraclass correlation coefficient is 0.67 & reliability of lifetime diagnosis is 0.60

ADVANTAGES:psychometric properties retained its roots in Anglo-Saxon psychiatry

and the phenomenological tradition, which emphasises the personal experience described by the individual

Flexibility, the incorporation of detailed cross examination, which allows changes in the order & wording of questions according to the way the interview is going,

the freedom of the clinician to pursue some lines of enquiry while cutting off others,

the fact that examiner & not the patient makes the judgment as to whether a symptom is present

USES:Used as a standard against which to contrast the

validity of other instrumentsThe technique of cross-examination has become a

standard in clinical practice and the SCAN’s definitions of symptoms are quoted in many textbooks of psychiatry.

The cross-examination technique entails in-depth exploration of the symptoms in terms of severity, frequency and interference (often with the use of free-form questions), until the interviewer is satisfied that the criteria for the symptom are met (or not).

Thus, unlike in interviews such as the Mini International Neuropsychiatric Interview (MINI) or CIDI, a yes or no answer given by the individual is only the beginning of further probing for severity, persistence and interference.

Draw back-In spite of its strengths, the SCAN is not routinely used in clinical practice, because of its detail, length and relatively extensive training requirements.

Thus, an abbreviated version of the SCAN, mini-SCAN was developed as a more practical and shorter version of the SCAN, retaining its principle of cross-examination.

MINI- SCANIt was developed under the auspices of the

World Health Organization Advisory Committee.

The first version (called ‘Present State Examination for clinical use’) was developed by Dr Aksel Bertelsen of the Danish Training and Reference Center (TRC) in Aarhus.

Was published in a pocket-sized booklet, containing an abridged version of the symptom questions on the right-hand page and the definitions of symptoms on the left-hand page.

Its aim was to provide a training tool for registrars and interns and it only contained the queries and definitions of symptoms.

It offered no classification items such as questionsabout the duration of symptoms, interference with functioning or information about the course. Danish, English and Dutch versions available. Danish version has been introduced

extensively and clinically used.This first version was expanded and

computerised by Fokko. J. Nienhuis (who heads the Dutch TRC in Groningen) mini-SCAN.

Aims:1. symptom and classification items were

made compatible with current classification systems.

2. items included screening questions, questions about duration of symptoms and interference with functioning.

3. sophisticated algorithms (diagnostic rules) were developed,

The overall idea behind the computer-assisted version was to make a user-friendly clinical interview based on the SCAN, producing a diagnosis and a clinically useful report after administration.

There is no paper and pencil version of the mini-SCAN.

The mini-SCAN covers a wide range of Axis I disorders1. Depressive disorders, including subtypes2. Bipolar disorders, including subtypes3. Dysthymic disorder4. Abuse and dependence, any substance (At a time

only one can be investigated)5. Social phobia6. Cognitive disorder (Mini-Mental State Examination)7. Agoraphobia8. Specific phobia9. Obsessive–compulsive disorder10. Generalised anxiety disorder11. Post-traumatic stress disorder12. Schizophrenia and related disorders13. Anorexia nervosa14. Bulimia nervosa15. Attention-deficit hyperactivity disorder

Software and algorithmsThe mini-SCAN software (computerised

interview) is the next stage of I-shell, the software written by WHO.

It is an interview shell, containing the whole SCAN text & has a passive database.

The interviewer must administer it as if it were the paper version, meaning that the choice of sections and items to be administered is completely left to the user & Items or sections can be skipped at the user’s discretion.

The user is not prompted for missing information.

At the end of the interview diagnostic algorithms can be run, resulting in a diagnosis (if any).

The mini-SCAN is entirely web-based and can therefore be used on any computer that has access to the internet.

It has ‘active’ software.Positively rated screening questions (one for

each section) activate the corresponding sections (e.g. depressive symptoms), where the individual symptom questions follow.

One symptom screen will show the question and the definition of the symptom below it.

The rating options for symptoms are: ‘0’ (absent or subsymptom level), ‘1’ (symptom level) and ? (cannot rate/rating deferred).

Sections have dynamic skips, thus avoiding superfluous questions.

The program does not allow the user to leave a section without completing it.

If all core symptoms (which are the first in the section) are rated absent, the user has the choice either to move to the next section or to complete the present one.

The reason to change the ‘passive’ approach was that while using the SCAN sometimes a diagnosis was not given because of missing information, often just one or a few items. This is no longer possible in the mini-SCAN.

After the symptoms are rated, the program enters a decision phase, comparable to making a differential diagnosis.

In this phase ‘prompts’ are presented to the user, usually history questions, clinical judgement or questions about interference with functioning.

The prompts are dependent on the combination of positively rated symptoms and are decisive for the final diagnosis (criteria for a depressive episode are met prior episodes of depression, mania or mixed episodes). It then produces the diagnosis {major depression (single episode or recurrent) or bipolar disorder}.

In this prompt phase, symptoms of all sections are considered, much as happens in the clinical diagnostic process.

This prompt mechanism makes it possible to handle complex clinical cases with a wide variety of symptoms

The algorithms produce the DSM–IV / ICD 10 diagnoses.

The results are shown on the screen in a report, showing the personal data of the individual and interviewer, diagnosis, prompts and the rated items of the administered sections.

Also the observed behaviour is presented in the report.

This report makes the diagnostic process more transparent

The raw data can be exported to statistical programs for further analyses.

MINI plus vs mini SCANThe questions of the MINI-Plus are more checklist-

like. It lacks the definitions of symptoms and the cross-examination technique. These differences in principles and method are not trivial and can lead to different results.

The duration of administration MINI-Plus: 15–60 min; mini-SCAN 15–90 min. MINI Plus covers more symptoms (e.g. psychotic symptoms) that are not necessarily required for classification but may have clinical significance, & also has cross-examination.

The MINI-Plus has lifetime and current diagnoses, the mini-SCAN only current diagnoses (although a representative episode can also be investigated).

The mini-SCAN offers a full report of all data after administration.

SCAN vs mini SCAN:Both intended for clinicians.SCAN allows assessment of lifetime, representative

episode and present state symptoms. Mini SCAN- current diagnosis

SCAN allows for four severity ratings: absent (0), subclinical level (1), symptom level moderate (2), symptom level severe (3); the mini-SCAN only has two ratings: absent or subclinical level (0) or symptom level (1).

SCAN has far more elaborate definitions of symptoms, more questions per symptom and a wider coverage of symptoms.

SCAN has modules such as the clinical history schedule, making it possible to record earlier episodes and diagnoses. This may be particularly important in epidemiological studies.

SCAN requires extensive training.

For the SCAN, the mean duration is 73 min (minimum 30, maximum 140). For the mini-SCAN, the mean duration is about a third shorter, namely 48 min (minimum 15, maximum 90).

For research purposes the SCAN is the first choice, particularly if earlier or lifetime pathology is assessed or if comparison with other studies using the SCAN is pursued. For clinical purposes, if an assessment of the present episode is required & for clinical studies where the present episode is the only focus of the interview, the mini-SCAN could be considered.

CONCLUSION:The standard application of (structured and

semi-structured) psychiatric interviews help to improve the quality of psychiatric diagnosis in clinical practice and consequently improve allocation to effective treatment .

But despite the possible benefit of interviews, their application in patient care is, however, the exception rather than the rule, partly due to their design, user interface and length.

So development of shorter versions like mini scan’s will help in effective diagnosis & standardised treatment of psychiatric disorders.

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