Pergamon J pwhror. Ra., Vol 28. No. I., pp. 57-84, 15194 Copyright , 1994 Elsev,cr Sc~encr Ltd Printed in Great Brimin All rights rcserved 0022-3956194 $7.00 + .OO RELIABILITY AND VALIDITY STUDIES OF THE WHO- COMPOSITE INTERNATIONAL DIAGNOSTIC INTERVIEW (CIDI): A CRITICAL REVIEW HANS-ULRIC’H WITTCHEN Max-Planck-lnstitutc of Psychiatry, Clinical Institute, Clinical Psychology, Kraepelinstrasse 2- IO. D-80804 Miinchen. Germany Summary-This paper reviews rehahility and validity studies of the WHO Composite International Diagnostic Interview (CIDI). The CID1 is a comprehensive and fully standardized diagnostic interview designed for assessing mental disorders according to the definitions of the Diagnostic Criteria for Research of ICD-10 and DSM-III-R. The inslrument contains 276 symptom questions many of which are coupled with probe questions to evaluate symptom severity, as well as questions for assessing help-seeking behavior, psychosocial impairments. and other episode-related questions. Although primarily intended for use in epidemiological studies of mental disorders. it is also being used extensively for clinical and other research purposes. The review documents the wide spread use of the instrument and discusses several test-pretest and interrater reliability studies of the CIDI. Both types of studies have confirmed good to excellent Kappa cocffXents for most diagnostic sections. In international multicenter studies as well as several smaller center studies the CID1 was judged to be acceptable for most subjects and was found to bc appropriate for use in difiercnt kinds of settings and countries. There is however still a need for reliability studies in general population samples. the area the CID1 was primary intended for. Only a few selected aspects of validity have been examined so far, mostly in smaller selected clinical samples. The need for further procedural validity studies of the CID1 with clinical instruments such as the SCAN as well as cognitive validation studies is emphasized. The latter should focus on specific aspects, such as the use of standardized questions in the elderly. cognitive probes to improve recall of episodes and their timing. as well as the role of order effects in the presentation of diagnostic sections. Introduction THE C~MPOSITF. International Diagnostic Interview (CIDI, WHO, 1990) is a comprehensive, fully standardized diagnostic interview for the assessment of mental disorders according to the definitions and criteria of the ICD- 10 Diagnostic Criteria for Research (WHO, 199 1 a,b). and the third edition of the Diagnostic and Statistical Manual of Mental Disorders--revised (DSM-III-R; APA, 1987). The development of the CID1 was made possible by the World Health Organization’s (WHO) and the former Alcohol. Drug Abuse, and Mental Health Administration’s (ADAMHA) Joint Project on Diagnosis and Classification of Mental Disorders in Alcohol and Drug-Related Problems. Having been designed for use in a variety of cultures and settings, the core version is available in 16 languages (Wittchen et al., 1991). Although it was primarily intended for use in epidemiological studies of mental disorders, the CID1 is also being used extensively for clinical and research purposes. The history and development of an early draft of the CID1 has already been described comprehensively by Robins et al. (1988). Details of its structure, application (Essau & Wittchen, 1993). its diagnostic coverage and analysis (Wittchen, 1993) have also been presented elsewhere and
Transcript
Pergamon J pwhror. Ra., Vol 28. No. I., pp. 57-84, 15194
Copyright , 1994 Elsev,cr Sc~encr Ltd Printed in Great Brimin All rights rcserved
0022-3956194 $7.00 + .OO
RELIABILITY AND VALIDITY STUDIES OF THE WHO- COMPOSITE INTERNATIONAL DIAGNOSTIC INTERVIEW
(CIDI): A CRITICAL REVIEW
HANS-ULRIC’H WITTCHEN
Max-Planck-lnstitutc of Psychiatry, Clinical Institute, Clinical Psychology, Kraepelinstrasse 2- IO. D-80804 Miinchen. Germany
Summary-This paper reviews rehahility and validity studies of the WHO Composite International Diagnostic Interview (CIDI). The CID1 is a comprehensive and fully standardized diagnostic interview designed for assessing mental disorders according to the definitions of the Diagnostic Criteria for Research of ICD-10 and DSM-III-R. The inslrument contains 276 symptom questions many of which are coupled with probe questions to evaluate symptom severity, as well as questions for assessing help-seeking behavior, psychosocial impairments. and other episode-related questions. Although primarily intended for use in epidemiological studies of mental disorders. it is also being used extensively for clinical and other research purposes. The review documents the wide spread use of the instrument and discusses several test-pretest and interrater reliability studies of the CIDI. Both types of studies have confirmed good to excellent Kappa cocffXents for most diagnostic sections. In international multicenter studies as well as several smaller center studies the CID1 was judged to be acceptable for most subjects and was found to bc appropriate for use in difiercnt kinds of settings and countries. There is however still a need for reliability studies in general population samples. the area the CID1 was primary intended for. Only a few selected aspects of validity have been examined so far, mostly in smaller selected clinical samples. The need for further procedural validity studies of the CID1 with clinical instruments such as the SCAN as well as cognitive validation studies is emphasized. The latter should focus on specific aspects, such as the use of standardized questions in the elderly. cognitive probes to improve recall of episodes and their timing. as well as the role of order effects in the presentation of diagnostic sections.
Introduction
THE C~MPOSITF. International Diagnostic Interview (CIDI, WHO, 1990) is a comprehensive, fully standardized diagnostic interview for the assessment of mental disorders according to the definitions and criteria of the ICD- 10 Diagnostic Criteria for Research (WHO, 199 1 a,b). and the third edition of the Diagnostic and Statistical Manual of Mental Disorders--revised (DSM-III-R; APA, 1987). The development of the CID1 was made possible by the World Health Organization’s (WHO) and the former Alcohol. Drug Abuse, and Mental Health Administration’s (ADAMHA) Joint Project on Diagnosis and Classification of Mental Disorders in Alcohol and Drug-Related Problems. Having been designed for use in a variety of cultures and settings, the core version is available in 16 languages (Wittchen et al., 1991). Although it was primarily intended for use in epidemiological studies of mental disorders, the CID1 is also being used extensively for clinical and research purposes. The history and development of an early draft of the CID1 has already been described comprehensively by Robins et al. (1988). Details of its structure, application (Essau & Wittchen, 1993). its diagnostic coverage and analysis (Wittchen, 1993) have also been presented elsewhere and
will only be briefly summarized below. The purpose of this paper is to review currently avail- able data on its reliability and validity in an attempt to identify critical areas for further improk ement.
Rationale, Format and Structure of the CID1
Similar to its predecessor- -the NIMH-Diagnostic Interview Schedule (DIS. Robins. Helzer, Croughan & RatclifE 1981) -the two main characteristics of the CID1 are the almost exclusive reliance on the respondent’s self-report and the .\.trrtl~lrrr.c/ilcilio,r of symptom questions, clinical probe questions, time related questions for the evaluation of the first and lost occurrence of a syndrome or diagnosis and the fully computerized diagnostic analysis. This unusually high degree of standardization has several advantages. Most importantly it improves the consistency of symptom assessment and the reliability of diagnostic decisions. A number of authors (Climent ct al.. 1Y7S: Grossman ct al.. 1971; Helzcr, 198.1; Kendell. 1975: Robins. 1Y89, Spitzer & Fleiss, 1974; Wclner. Liss, & Robins. 1975; Wittchen, IYYI) have identified six major sources of reduced reliability in a clinician’s diagnostic process: Namely variance in: (I) questions asked to assess psychopathological symptoms. (3) the symptom information that the respondent provides, (3) the time criteria used to evaluate the clinical relevance, (4) the interpretation of the information provided, (5) the interpretation of the diagnostic criteria underlying the respective diagnostic system. and (6) random errors caused. for example, by a failure to listen or perform the coding accurately. The CIDI’s high degree of standardization aims to reduce the first five sources of variance with the hope of increasing reliability as one essential prerequisite for a better validity. This also allows discrepancies between two independent assessors of the same subject to bc traced back to the respective CID1 questions and its codings. This offers the option for an empirical identification of critical symptom questions and their subsequent improvement. A third advantage is that the administration of the CID1 does not require extensive clinical knowl- edge and experience. Bccawx of its detailed instructions and fully specified questions and probes, the CID1 can bc uaeci reliably by non-clinicians after a relatively brief training period. The ability of the ClDI to be administered by non-clinician is important. cspccially in studies of mental disorders in a general population, because clinicians are usually expcns- ive and are in short supply in many counties and settings. Furthcrmorc standardized interviews also improve the completeness and comprehensiveness of the data obtained (Climcnt et at.. 1975) and http to safeguard against examiner bias in the collection and interpretation of information (Grossman et al. 1971; Kendell 1975; Wclner et a1. 1975). In the case of the CIDI. the diagnostic decisions are made tnore objective by using the computerized diagnostic programs. Another advantage which stems from using the stan- dardized interview is the consistency and comparability of data across studies.
The (‘ID1 consists of 276 .s~mptrw qw.vtiom. not all, because of the skip rules. being asked of all respondents. In comparison with the DIS. main difierences are: deletion of all
questions that are not needed for DSM-III-R (i.e., deletion of Feighner and RDC criteria). inclusion of additional questions to assess ICD-IO criteria. an expansion of somatoform and anxiety sections to cover a broader spectrum of specific diagnoses. ;I reduction of- symptom questions that require further probing (especially in the anxiety section). changes
RELIAHILTY ANU VALILHTY OF THF CID1 59
in the wording of many of the symptom questions that have been either found to be problematic in previous research or not applicable cross-nationally and cross-culturally. Nevertheless about 72% ofall questions remained almost the same and for the somatoform, affective and psychotic sections the standard DIS “probe flow chart questions” (PRB) system was retained. These probe questions follow each positive response to selected symptom questions to assess psychosocial severity and psychiatric relevance. This chart instructs the interviewer on the proper question to ask next, what to record, and when there is sufficient information to code the symptom. A code of PRB 1 indicates that the symptom is absent; PRB 2 indicates that the symptom, although present, was not severe enough to cause any impairment or help seeking. A PRB 3 indicates that the symptom was always caused by taking medication, drugs or alcohol; PRB 4 indicates that the symptom was always caused by a physical illness and injury; PRB 5 indicates a positive psychiatric symptom. Another technical change is the numbering system. The CID1 interview guide is structured in I5 sections, each with a distinctive letter, organized loosely along the categories of ICD-IO. i.e., section C (somatization, pain, dissociative and hypochondriacal disorder), Section D (depressive disorders), etc.
The administration of the CIDI requires a comprehensive 1 -week training in one of the officially designated WHO training centers in which the use of the interview, the probe system, coding, the computerized data entry and diagnostic analysis and its interpretation are taught. This is facilitated by a standard training manual with video segments and scripts, the CID1 user manual and the CID1 diagnostic programs manual. An essential part of this training is that of supervised practice interviews.
By using the CID1 computer programs for standard data entry and diagnostic analysis. 76 ICD-10 and 56 DSM-III-R diagnoses can be computed (Table I). The diagnoses are printed with several options, including the optional use of diagnostic hierarchies and exclusions, degrees of severity and subtypes, as well as the age that the criteria are first and last met. For diagnoses in the substance use section, two different sets of criteria can be chosen to arrive at a diagnostic decision (clustered = criteria met within the same period of time. and, unclustered = criteria met at least partially consecutively over the lifetime).
CID1 modules and modifications of the CID1
Given the short period of time after its official publication there are surprisingly many diagnostic modules that can be used to assess disorders not covered by the core version of the instrument as well as technical and procedural modifications of the CIDI. At this point additional modules have been developed and tested for the following disorders and purposes: a more detailed assessment of substance abuse phenomena, called substance abuse module (SAM, Cottler, 1991) post-traumatic stress disorders (PTSD, Andrews, Peters, Guzman, & Bird, submitted), antisocial (Robins et al., 1981) and conduct disorder (Kessler, in press), pathological gambling, psychosexual dysfunctions, neurasthenia, per- sistent pain disorder (all modules available at WHO on request). A comorbidity and severity module is also currently being pilot-tested allowing for an evaluation of the sequence of disorders, the type of their overlap, and their severity (Wittchen & Gnutzmann, in preparation).
ICI>-IO (DC-R)
Disorders resulting l’rom the USC of tobacco Dependence syndrolnc (r: I 7.2)
Agoraphobia without pamc disorder (1‘40.00) Apornphohia with pamc disorder (1‘40.01 ) Social phobia (F40. I ) Specilic (isolated) phobias (F40.2)
Dcpressivc episode mild severity (F32.00. F72.01. suhtypcb) modcrate (I:i2. IO. k-32. I I. subtypes) 3evcrc wthout psychotic 5yniptoma (F32.2) >c’\~crc with psycholic symptom\ (F32 3)
Rccurrcnt Dcprchsive disordu c‘u~wcnt mild (F33.00, F32.01, aub~qpcs) current modcrate (F33. IO. F33. I I. subtypes) current SCCL‘I-c withoul psychotic symptoms (Fi3.2) current LICCC~C with psychotic symptoms (I:ii.3)
Dwrders resulting from the LISC of alchohol llarmful UC (FIO. I)
-Dcpcndcncc sy ndromc (F IO.?)
Obs~sslvc-compLIlsive disorder (F’31) Disorders resulting from the L~C of:
Hnrmful LISC of.
Depcndencc syndrome (II‘. Opiods (I- I I, I. I- I I .7) Cannahinoids (F 12. I. F 12.2) Scdatwcs or hypnotics (Fl3.l. FL.?)
--C‘ocalne (F14.1. 1‘14.2) ~Othcr stimuklnts (l;I I. Fl5.2)
Ilallu5nogens (Fl6.1. Flh.2) volatile solvents (F 18. I. F I X.2) other psychoacri\c substances (b ICJ. I I- IV)
Mania without and with psychotic symptoma (F?O. I. ICV).?) or?nnw brain s)ndromu (ICOO) Bipolar AlTcctive diwrdcr\
i‘ut-rcnl epkodc 11) pomanic (I:3 I .O) current manic without psychotic symptoms (I‘? I. I ) airrent manic with p5)chotic symptoms (k-31.2) ~currcnt episode mild or modcratc depression (Fi 1.3) current episode scwrc dcprcssion (I-‘3 I .4. F3 I .5. subtypes) current episode m~xcd (F3 I .6) bipolar diwrdcr, un~pccilied (F3 I .O)
Othu Bipolar dlwrdcr (I;3 I .X)
RELIARIL~Y ANII VALIIHTY OF THE CID1 61
Table I--continued
DSM-III-R
--Agoraphobia without history of panic disorder -Social phobia -Simple phobia -Generalized anxiety disorders
--Inhalants 4pioids --Amphetamine or similar acting symp. -Sedatives -Stimulants -PCP
Organic, including symptomatic mental disorders -organic brain syndrome
In addition to these optional modules for the standard CIDI, there are at least three major modifications of this instrument, namely the computerized CID1 (CIDI-AUTO, Andrews, 1992), the University of Michigan version of the CID1 (UM-CTDI, Wittchen & Kessler, in preparation) and the Primary Care version (CIDI-PMC, WHO, 1992), developed within an international multicenter study called “psychological disorders in primary care” (Sartorius et al., in press). Table 2 summarizes the similarities and differences of these modified versions of the standard CIDI. Because the CIDI-AUTO is almost identical, except for the fact that verbatim entries within the probe flow chart system have to be typed in by the interviewer or respondent, it is not included in this table.
The CIDI-AUTO is the fully computerized version of the standard CIDI, to be coded either by an interviewer, reading the questions from the screen directly to the respondent with subsequent coding or by the respondent himself. This computerization makes the CID1 training in the probe flow chart unnecessary and increases tremendously the ease of CID1 administrations.
The UM-CIDI, modified for use in the US-National Comorbidity Survey (NCS, Kessler et al., in press), includes only the anxiety, affective, psychotic, substance abuse sections, but adds questions for conduct and antisocial personality disorder as well as PTSD. Fur- thermore it uses a number of special features, aiming at a specification of certain aspects, such as a more detailed assessment of age of onset for single criteria, help seeking and medication, syndrome instead of symptom probes for the evaluation of substance use and
Diagnostic coverage
Additional modules and diagnoses
Diagnostic analysis
Order of diagnostic sections Special features
UM-CID1
The following sections arc omitted: somatoform, obsessive compulsive. catin! disorders and cognitive impalrmcnt omitted. psychotic section modilicd (2.stage examination)
Post-traumatic stress disorder, antisocial personality and conduct. options for categorical subthreshold diagnoses. brief recurrent depression
Standurd Cl DI diagnostic programs with a conversion program
Some as standard CIDI. starts with anxiety disorders Stem questions from anxiety and depressive diwrders precede the anxiety section, the probe flow chart is hpclled out, for afTectivc disorders syndrome exclusion instead of symptom cxclusionh (substance and illness), memory probes prcccdc onset qucst~ons. additional onset questions for single criteria. help seeking. and medication use. Finer resolution fol course r&ted items. scaled versions of interference questions.
PMC-CID1
The following sections are omitted: simple and social phobias. bipolar. psychotic. obsessive compulsive, eating, most substance disorders (except alcohol, modified version). and cognitive impairment Neurasthenia, mixed-anxiety depression, several options for categorical and dimensional (cross- sectional) subthreshold diagnoses
Two options: standard CID1 program applicable with conversion program or special SAS diagnostic program Same starts with somatoform disorders
Separate coding options fol- current symptoms, no probe flow chart is used. instead clinical ratings are used. emphasis on somatic exclusions. require clinical experience, allows derivation of categorical and dimensional measures for moht disorders
illness exclusions, as well as additional questions for time-related phenomena. It is also noteworthy that the UM-CID1 also incorporates a number of cognitive strategies, aiming at an improvement of lifetime recall. Rationale. as well as data on the UM-CID1 reliability and validity, are currently prepared for publication.
The PMC-CID1 offers several additional options for computing diagnoses with various threshold models as well as pure cross-sectional symptom and severity ratings. It assesses several somatoform disorders, anxiety disorders (without simple and social phobia), depressive disorders and alcohol abuse. It also offers several new diagnostic categories such as ICD-IO diagnoses of neurasthenia, mixed-anxiety depression as well as subthreshold categories. Findings on feasibility and reliability of this modified CID1 are currently being prepared for publication.
Findings of the Prc-CID1 Era: Reliability and Validity Studies with the DIS
Due to the fact that the CID1 is built on the DIS and uses its probe flow chart system. it seems to be informative to start the review with findings from the DIS. This will also allow an examination of how well problems identified with the DIS approach have been solved in the CIDI.
RELIABILTY ANI) VALIVITY OF THE CID1 63
Table 3 demonstrates that the DIS reliability and selected aspects of its validity have been studied in quite a number of studies. Unlike other instruments these studies were also conducted in many other languages (e.g.. Spanish. Chinese, German). The majority of investigators chose test-retest (T-RT) reliability designs in inpatients and outpatients. In addition to major studies that included sample sizes of N > 100, several small-scale studies were conducted that focused on specific diagnostic groups, such as alcoholics and psychotic subjects. Some studies not only indicated diagnostic reliability, but also the reliability information for symptom information. Almost all studies reported their diag- nostic findings in terms of lifetime occurrence. Frequently this design was combined with some sort of validity checks, by either using diagnoses by a psychiatrist (clinical validity), using diagnostic checklists or by applying another structured interview, such as the SADS, the PAI, the PSE, or the AMDP checklist interview (abbreviations are explained in the fbotnotes of the table). These studies might best be described as “concurrent or procedural validity” studies. Almost all studies measured T-RT reliability in terms of the kappa value (that ranges from negative values = less than chance agreement) to values of zero (indicating chance agreement) to perfect agreement (kappa equals 1). Since the kappa value is difficult to interpret if the base rate of the condition is low, some authors also indicated other measures, such as percentage agreement or Yule’s Y. In the following sections, kappa values will generally be reported. However, if the base rate of the condition is lower than 10% we will indicate Yule’s Y coefficients, because they seem to be more adequate. These coefficients can be interpreted the same way as kappa.
Studies in the early 1980s were particularly focused on establishing the technical equiv-
alence of DTS findings obtained by trained lay intrrvicw~ers as compared to cliniciuns. The congruence between clinicians and lay interviewers using the DIS was found to be good to excellent (kappa .5--.7) in all studies across most diagnostic groups, with kappa values between lay interviewer pairs being higher than between psychiatrist pairs. In general there was a tendency for clinicians using the DTS to be slightly more sensitive, whereas lay interviewers were more specific. Test-retest jndings across all diagnoses, obtained in designs with short time intervals of several days, were found almost consistently to be high (kappa of above .6), although considerable variations exists between studies with regard to kappa values for specific DSM-III disorders. Some of these lower kappa values (defined here as below .4) might be due to the above mentioned base rate problem, but nevertheless authors rather consistently report problems with panic disorder, generalized anxiety disorder, dysthymia and somatization. Good agreement (> .6) was usually found for sub- stance use disorder, OCD, depressive and manic episodes (not taking into account subtypes).
Validit), ,findings show more variation. Comparisons with diagnoses assigned by psy- chiatrists show almost identical findings as the test-retest studies. High chance corrected agreement coefficients were obtained, except for panic disorder, somatization and psychotic disorders. The comparison of DIS diagnoses with other clinical diagnostic instruments, such as the SADS, the PDI or AMPD showed problems with the assessment of psychotic symptoms and panic symptoms. The table also reveals that some of the diminished kappa values, such as in the SADS study by McLeod, Turnball, Kessler and Abelson, (1990) are obviously due to low base rates, because the Y-coefficient was found to be high in the same study. The only study reporting poor agreement coefficients for most diagnostic categories
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e D
IS
I I y
ears
af
ter
incl
usio
n.
Con
c~rr
rri~
t d
idif
j,.
Spen
gler
&
D
IS
and
CID
1 ite
ms
are
Witt
chen
. 19
88:
com
pare
d in
lar
ge
sam
ple
of
Miin
chen
fo
rmer
ps
ychi
atri
c in
patie
nts
to a
Hen
dric
ks
et a
l. 19
83:
Was
hing
ton
Witt
chen
. 19
84:
Miin
chen
Bre
slau
. 19
84:
Cle
vela
nd
. st
ruct
ured
cl
inic
al
inte
rvie
w
(AM
DP,
‘DIA
SIK
A)
and
the
IMPS
. P
roce
duru
l rt
rlid
ii~.
Tw
o in
depe
nden
t as
sess
men
ts
by
non-
cl
inic
ians
(D
ISX
IDI)
an
d cl
inic
ians
fo
r cu
rren
t an
d lif
etim
e ps
ycho
tic
sym
ptom
s.
Tim
e in
terv
al
I 7
days
. D
IS
in b
lack
ad
ults
. D
IS
find
ings
in
pat
ient
sa
mpl
es
arc
com
pare
d w
ith
char
t di
agno
ses.
C
orzc
urre
n/
ruli
dii
I’
.
DIS
.2’i
n ps
ychi
atri
c pa
tient
s.
2 in
depe
nden
t ad
min
istr
atio
ns
of
the
DIS
by
4 c
linic
ians
. T
R
T
w/iu
hi/i/
y.
Vid
eo
anal
ysis
of
rea
sons
fo
r di
scre
panc
ies.
DIS
.3
in a
stu
dy
of w
omen
w
ith
hand
icap
ped
child
ren.
Sa
me
sess
ion,
co
mpa
riso
n w
ith
CE
S-D
fo
r de
pres
sion
an
d G
AD
. C
‘onr
cr,y
~nr
ruli
clit
~~
. m
etho
d no
t fu
rthe
r sp
ecif
ied.
43 f
orm
er
patie
nts
with
ps
ycho
tic
synd
rom
es
218
form
er
inpa
tient
s
12 d
eprc
sscd
. I I
sc
hizo
phre
nic
and
23
alco
holic
pa
tient
s
20 p
sych
iatr
ic
inpa
tient
s w
ith
mor
e th
an
one
diag
nosi
s
3 IO
mot
hers
of
ha
ndic
appe
d ch
ildre
n
Onl
y ps
ycho
tic
DIS
sy
mpt
oms
Psyc
hotic
ite
ms
only
Dep
ress
ion,
al
coho
lism
. sc
hizo
phre
nia.
id
entif
icat
ion
AI1
DIS
di
agno
ses
and
sym
ptom
s
Dep
ress
ion
and
GA
D
diag
nose
s (c
urre
nt
and
lifet
ime)
C‘o
ncor
rlun
ce:
sens
itivi
ty
(lif
etim
e)
for
hallu
cina
tions
64
%,
for
delu
sion
s 85
.7%
. C
oncl
usio
n:
DIS
un
dere
stim
ates
th
e lif
etim
e oc
curr
ence
of
psy
chot
ic
sym
ptom
.
Con
corh
7ce
(Ilf
erir
t7c)
w
ith
the
diag
nost
ic
inte
rvie
w
(AM
DP)
w
as
.77
for
any
delu
sion
s.
.32
(Yul
es
Y:
63)
for
visu
al
and
.54
for
audi
tory
P
hallu
cina
tions
. C
onco
rdan
ce
with
th
e IM
PS
c
was
sl
ight
ly
low
er
ns.
Con
cord
ance
pr
esen
t w
as
.4l
for
delu
sion
s (s
ensi
tivity
33
%
and
.67
for
$
hallu
cina
tions
(s
ensi
tivity
67
%).
2 5 Z
=:
g
Dia
gnos
tic
conc
orda
nce:
ka
ppa:
de
pres
sion
1.
0, a
lcoh
olis
m
.50,
sch
izop
hren
ia
.24.
Goo
d ag
reem
ent
with
ka
ppa
rang
ing
from
.9
to
3 .5
(ph
obia
s).
Onl
v I6
ite
ms
had
a 2
. co
ncor
danc
e lo
wer
th
an
.75%
, m
ost
of t
hem
fr
om
som
atiz
atio
n an
d pa
nic
sect
ion.
M
ajor
re
ason
fo
r di
scre
panc
y w
as
the
deri
vatio
n fr
om
stri
ct
inte
rvie
w
and
prob
e ru
les.
A
gree
men
t of
CE
S-D
cu
toff
w
ith
both
di
agno
ses
arou
nd
80%
fo
r sp
ecili
city
an
d se
nsiti
vity
. go
od
conc
orda
nce
with
C
ES-
ca
sene
ss
cut-
off.
Witt
che
n.
rt
al..
D
IS.?
in
l‘o
rmc
r p
syc
hia
tric
19
X5.
Miin
ch
cn
in
pa
tient
s a
nd
sub
jec
ts
from
a
e
cn
era
l po
pu
latio
n
sam
ple
. A
ll ~c
rc e
xam
ine
d b
y th
e D
IS
an
d
ind
ep
en
de
ntly
b
y a
LEA
D
(~vv
wtlu
~rr
l L t
rlrtli
c~~)
st
and
ard
ta
king
In
to
ac
co
unt
all
clin
icia
ns
ratin
y fro
m
dift
‘ere
nt a
sac
ssm
cnt
in
slrum
cnt
s (D
IASI
KA.
AM
DP)
us
ed
in t
his
pro
spe
cti\
e
lon
gitu
din
al
stud
y of
seve
n b
ea
l-5.
Eig
ht
psy
ch
iatr
ists
an
d I
2 p
syc
holo
gist
s d
id t
he i
nte
r\ i
tw s
a
nd
re
ap
pra
isal,
(alw
ays
se
co
nd)
Ant
hony
c
t a
l..
DlS
.3
cro
wsc
ctio
na
l I
mo
nth
19x5
: H
alt1
mo
re
dia
gno
ses
co
mp
are
d t
o a
noth
er
ind
ep
end
ent
clin
ica
l in
terb
ieti
in
the
ge
ne
ral
po
pu
lau
on
(r
and
om
. w
eig
hin
g).
fr
ow
tlwtr
i ~
,il(ir
/if~
,. St
udy
of
sour
ce
< o
f d
isag
ree
me
nt.
Sc\c
nty
-sc
\en
Ia
> in
terv
icw
rs
did
the
DIS
. 4
psy
ch
iatr
ists
the
re
ap
pra
isals.
66
”/0
of
the
rc
np
pra
iaa
ls tic
rc
do
ne u
ithin
3
we
eks
. 75
uith
in
1
17 I
I’orm
el
All
DIS
-LIS
M-II
I D
ue t
o b
a,c
ra
te p
rob
lem
s h
ap
pa
s in
the
ge
ne
ral
psy
ch
iatr
ic
dia
en
osc
s a
nd
ICD
In
pa
tient
s.
1% fr
om
Y.
po
pu
latio
n
\am
plc
Mc
rc s
light
I>
Iov,
cr
as
Cl~
LSS
lllC
~liO
l~
co
mp
are
d t
o t
he c
linic
al
sam
ple
. Ka
pp
a
we
re
the
pc
nc
ral
go
od
to
exc
elle
nt (
< 8
) fo
r: m
ajo
r d
ep
ress
ion,
p
op
ula
tion
. b
ipo
lar,
ph
ob
ias.
O
CD
a
nd
sub
sta
nce
. Lo
we
r st
ratif
ied
sa
mp
le
kap
pa
s ( <
.5)
an
d lo
we
r se
nsit
ivity
( <
.60)
we
re
lou
nd
fo
r p
syc
ho
tic d
isord
ers
. p
an
ic p
ers
on
alit
! d
Iso
rde
ra.
Mo
at
DIS
.3
The
c
on
co
rda
nc
e f
’or o
ne-m
ont
h d
iag
nost
ic
\+
a’;
d
iag
nose
s.
111)
\c
r> I
BM w
ith
kap
pa
s t’
l-om
-
.02
for
pa
nic
to
>>
mp
tom
<lg
l-cc
nlc
nt
the
hyh
cst
of
alco
hol
\\ith
.15.
we
eks
. an
d 9
0+0
with
in
90d
a)
\. Th
e
clin
ica
l in
tcrv
ie\Q
(SPE
) ,1
85 a
m
od
ifie
d a
nd
Ia
r&
exp
and
ed
\c
rsio
n
of
the
PST
.. H
elte
r e
t a
l..
DIS
..?
teb
t of
ag
rcc
mrn
t o
f la
> D
IS
391
\tth
jec
t\ (
70”
“)
19x5
: St
. Lo
t&
dia
gno
ses
an
d D
IS
h)
\uh
lcc
t< f
rom
th
e
psq
ch
iatr
ics
an
d t
heir
clin
ica
l ze
nera
po
pulat
ion
diagn
oses
. Pw
c~rt
lwrr
l m
rl
c~li
t~i~
~rrl
rr
~lid
crti
o~r.
56
0 D
IS
resp
ond
ent
s fro
m
LCA
\s
ith a
d
iag
no
si\ a
nd
a s
am
ple
of
tho
se
\\ith
no
dia
gn
osis
w
crc
sc
lel‘l
ec
i tb
r th
e r
cc
\alu
atio
n.
The
,rc
c\a
lua
tlon
to
oh
pla
ce
We
ller
et a
l..
1985
: G
alve
ston
Hw
u et
al..
19
86
ab;
1988
: T
aiw
an
Erd
man
n et
al.,
19
87:
Wis
cons
in
Can
ino
et a
l.,
1987
: Sa
n Ju
an
Puer
to
Ric
o
MD
=
6 w
eeks
af
ter
the
firs
t D
IS.
85%
w
ere
Inte
rvie
wed
w
ithin
3
mon
ths.
T
he
reev
alua
tion
used
th
e D
IS
plus
a
chec
klis
t af
ter
each
D
IS
sect
ion
(Hel
zers
ch
eckl
ist)
. N
ine
phys
icia
n in
terv
iew
ers.
In
inp
atie
nts
agre
emen
t be
twee
n D
IS
and
anot
her
crite
rion
-bas
ed
inte
rvie
w
the
Psyc
hiat
ric
Dia
gnos
tic
Inte
rvie
w
was
st
udie
d.
Con
c.w
ret7
f ur
lidi
~y.
Tw
o in
depe
nden
t co
unte
rbal
ance
d ex
amin
atio
ns
by
med
ical
st
uden
ts.
time
inte
rval
IO
day
s (3
to
21 d
ays)
. D
IS.3
co
mpa
red
to i
ndep
ende
nt
asse
ssm
ent
with
th
e P
DI
and
a di
agno
stic
ch
eckl
ist
in t
wo
sam
ples
of
pat
ient
s an
d pa
rt
of
the
Tai
wan
ge
nera
l po
pula
tion
sam
ple
(sub
sam
ple)
. C
oncu
rren
t ra
lidi
!,~:
DIS
by
la
y,
PD
I by
7
clin
icia
ns
with
go
od
inte
rrat
er
rel.
No
time
inte
rval
in
dica
ted.
D
IS.3
in
inp
atie
nt
sam
ples
as
co
mpa
red
to u
nstr
uctu
red
rout
ine
clin
ical
di
agno
ses.
C
rirr
rion
rc
rlid
ity.
D
IS
by
I I l
ay i
nter
view
ers,
in
depe
nden
t cl
inic
al
diag
nose
s by
ch
arts
. Po
or
met
hodo
logi
c se
ctio
n.
No
info
rmat
ion
abou
t re
liabi
lity
of c
linic
al
diag
nose
s an
d tim
e in
terv
al.
DIS
.3
adm
inis
tere
d tw
ice
to
sele
cted
ou
tpat
ient
an
d co
mm
unity
re
spon
dent
s.
Mi.~
er/
T
RT
rd
iahi
litv
an
d va
liditv
: D
IS
bv l
av
and
clin
icia
n in
terv
iew
pl
us
ratin
g of
clin
icia
n fo
r cl
inic
al
diag
nosi
s.
Ord
er
was
ra
ndom
. in
terv
iew
s m
ostly
on
th
e sa
me
day.
X6
psyc
hiat
rist
s in
patie
nts
86 c
linic
al
patie
nts
96 c
omm
unity
no
n-
rand
om
case
s
220
in-
and
outp
atie
nts
129
outp
atie
nts.
60
co
mm
unity
re
spon
dent
s
Sele
cted
an
d Pr
inci
pal
diag
nosi
s ag
reem
ent
.72.
Fo
r m
ost
corr
espo
ndin
g D
IS
diag
nose
s go
od
agre
emen
t w
as
foun
d.
PD
I is
an
d P
DI
diag
nose
s si
mpl
er
and
less
com
preh
cnsi
vc.
CM
-DIS
di
agno
stic
cl
asse
s
DIS
-DSM
-III
di
agno
ses
All
DIS
di
agno
ses
In t
he c
linic
al
sam
ple
high
ka
ppa
from
.5
4 to
.9
6 (d
epre
ssiv
e E
piso
de).
In
the
com
mun
ity
sam
ple
low
er
kapp
as:
high
co
ncor
danc
e (<
.55)
fo
r m
anic
an
d af
fect
ive
epis
ode,
ps
ycho
sexu
al
dysf
unct
ion
low
ka
ppas
fo
r an
xiet
y st
ate.
ph
obic
di
sord
er.
and
alco
hol.
toba
cco.
Sl
ight
ov
erdi
agno
sing
of
man
ic,
phob
ic.
OC
D
and
alco
hol.
Kap
pas
for
conc
orda
nce
of c
urre
nt
and
lifet
ime
diag
nose
s w
as
poor
w
ith
kapp
as
rang
ing
from
-
.03
for
schi
zoph
reni
c di
s.
to
.39
for
OC
D.
DIS
m
ade
stri
king
ly
mor
e ph
obia
di
agno
ses,
ov
erdi
agno
sing
of
dep
ress
ive
diso
rder
w
as
less
frc
qucn
t.
Rel
iahi
litj
, (l
ay
vs c
linic
ian)
w
as
good
to
ex
celle
nt
(>
.6)
exce
pt
for
dyst
hym
ia,
man
ia,
Schi
zoph
reni
a (.
45)
and
som
atiz
atio
n.
Con
corc
lunc
r w
it17
clin
icd
dia,
ynos
es
(lay
vs
C
D):
go
od
spec
ific
ity
( > 7
7%),
bu
t lo
w
sens
itivi
ty.
Kap
pa
valu
es
good
fo
r ag
orap
hobi
a,
alco
hol
and
cogn
itive
im
pair
men
t an
d lo
w
(.2X
-.35
) fo
r al
l ot
hers
. T
he
conc
orda
nce
betw
een
clin
icia
ns
DIS
an
d C
D
was
m
arke
dly
high
er!
Tab
le
-3 C
o,~r
//~w
l
.Aut
hr)l
D
wgn
an
d in
ter\
ic
ucl-
%
mpl
e D
iagn
osx
Fmdi
ngs
and
com
men
ts
Blo
um
et a
l..
The
co
mpu
tcrw
d D
IS.3
ua
\ X
0 pa
tient
s D
IS-d
iayn
oscs
V
ery
sim
ilar
resu
lts
to
Hcl
rer
rtud
y w
ith
a m
ean
1947
: O
tta\\
adm
inis
tere
d tw
ice
in :
I 7.
RT
ka
ppa
of .
.i7.
No
drop
-elf
of
num
ber
of
relia
biht
) de
sign
. 7.
da!s
tm
lr
diag
nose
s re
port
ed.
intc
rlal
.
~!cL
cod
et ;
1l..
DlS
.3
depr
essl
on
hter
n Ph
ases
I:
236
cas
es.
Lkprc5sion
onl!
A
gree
men
t \+
:Ic
.i’J
for
any
depr
cssi
\e
diso
rder
. I’l
90:
com
pari
son
with
th
e SA
DS
for
‘I6
pote
ntia
l ca
st‘\
.2
X f
or
MD
E.
Yul
es
Y \
+a\
high
w
ith
.76
and
Mln
ncap
olls
st
udyi
ng
disc
repa
ncw
. (C
liuiu
~i
Phas
e I I
: al
l ca
ses
.X3.
rcs
pccl
l\cly
. ru
/i&ri
ou.)
A
s pa
rt
of a
larg
er
stud
) an
d th
eir
spou
rs
353
a fe
\c o
f DIS
dep
ress
ion
item
s \+
erc
used
. A
sub
sam
ple
of
Phas
e I
DIS
re
spon
dent
s M
ere
then
rc
intc
rbic
wed
ab
out
I1 M
ccks
la
ter
with
th
e SA
DS.
A
sses
smen
t \\a
lim
itcd
to B
h-m
onth
tim
e fr
anc.
SA
DS
inte
rcie
hs
uere
co
mpl
eted
by
psy
chin
trlc
so
cial
w
orke
rs.
\~JT
~J 4
’cl
III’
:
Man
ual
for
the
Res
earc
h D
la:r
noht
lc
CI-
~~~I
-I:I
: (‘D
=
C‘l
~n~c
al D
~ay~
oaes
. C
ES-
D
~ C
ente
r fo
r E
pldc
mio
logi
c St
udie
s D
epre
ssio
n Sc
ale:
C
ID1
CID
I-A
=
Com
poG
te
Inte
rnat
iona
l D
iagn
ostic
In
tel-
\iew
: C
M-D
IS
= C
hinc
sc
Mod
iticd
V
ersi
on
of
the
Dia
gnos
tic
Inte
rvic
u Sc
hedu
le:
1)1.
4SIK
A
= D
iayl
ostis
chc
Sich
tloch
kart
el:
DIS
~~
Dla
gnot
lc
Intc
r\ic
u Sc
hcdu
lc:
DIS
-RD
C
~ D
iagn
ostic
In
tel-
\icw
Sc
hedu
le-R
csca
rcll
Din
gnos
tic
Crl
twa.
di
\. =
diw
l-dc
t-(5
):
LX
M-I
II
III-
R
IV =
L
Xag
nobt
ic
and
Stat
lrtlc
al
Man
u;~l
of
M
enta
l D
isor
der%
: E
C.4
:
Epi
dem
iolo
gic
C.a
tchm
ent
Are
a Pr
oyam
: G
AD
=
Gcn
cral
A
nxie
ty
Dis
orde
r:
GA
S =
Glo
bal
.4dl
ustm
ent
Scal
e:
GP
= G
ener
al
Prac
titio
ner:
IC
‘D-9
IO
=
Inte
rnat
iona
l C
lass
ific
atio
n 01
D
~sw
se:
IMP
S
= In
patw
~t
illul
tldlm
cns~
onal
Pa
!chl
atrl
c Sc
ale:
IP
SS
~ In
trrn
atw
nal
PIlo
t St
udy
of S
chlro
phre
nia:
K :
Kap
pa:
LE
AD
=
Lon
~itu
dina
I E
xper
t A
ll D
ata.
M
D
= Il
~!io
r D
cprr
ssio
n:
MD
E
= M
aJor
D
epre
ssio
n E
plso
dc:
11.5
. =
not
sigm
liant
: O
CD
=
Ohs
cssI
vc
Com
puls
lvc
Dis
orde
r:
PA1
= Ps
?chi
all-
lc
.4sa
cssm
cnt
Intc
rwu:
I’
D1
: Ps
ychi
atri
c D
layn
ostic
In
terL
ie\+
: PS
E
= Pr
cscn
t St
ate
Exa
min
atio
n:
r =
real
lahi
lit);
R
cl.
= R
elia
bilit
):
RD
I =
Rcn
ard
Dia
gnos
tx
Inte
rvitw
: . SA
DS-
I.
= Sc
hedu
le
for
Aff
ectiv
e D
isor
ders
an
d Sc
hiro
phre
nia
Lif
etim
e:
SAM
=
Subs
tanc
e A
buse
M
odul
e:
SCA
N
7 Sc
hedu
le>
for
Chn
ical
.4
sscs
smcn
t in
N
euro
psyc
hiat
ry:
SPE
=
The
St
anda
rd
Psyc
hiat
ric
Exa
min
atio
n:
T
RT
=
Tes
t-re
test
R
elia
bilit
y:
\’
= Y
ules
-Y.
RELIAHILTY AND VALIDITY OF THE CID1 69
(Anthony et al., 1985) used a specifically developed clinical instrument administered by a psychiatrists at lengthy time intervals of up to years after the initial DIS administration. The reasons for this unfavorable finding have not been clarified but might be related to the validity of the clinical instrument (the SPE), and to base rate problems as well as design characteristics.
To summarize, the DIS, was found to be an instrument with acceptable to good reliability and validity indices for DSM-III diagnoses. Problems, however, were apparent in the panic. somatoform and psychotic sections, that have repeatedly been shown to produce diminished kappa and Y values. It is noteworthy that although the DIS was developed as an instrument for epidemiological and general population studies, only 4 of the 16 reliability or validity studies are based on random samples of the population.
Reliability studies with the CID1
The development of the CID1 dates back to 1981, when the WHO/ADAMHA Task Force on diagnostic instruments decided to explore the feasibility of combining the two most widely used instruments in psychiatric epidemiologic research, the DIS and the PSE. Three phases of work went into the development of the CID1 from this beginning. and almost all the studies and publications cited in Table 4 reflect this concerted international effort. Phase I began in 1981, when a small group of consultants met with the authors of the DIS and present state examination (PSE) to develop further the existing DIS items and incorporate additional questions from the PSE to allow the derivation of ICD-9 compatible classes. Stimulated by the success of these meetings, a series of studies were carried out in 1982 through 1985 to test the feasibility, diagnostic coverage, and adequacy of this new instrument to assess ICD-8 diagnoses (Robins et al., 1988). These studies came to be known as the CID1 field trials-phase I.
All the studies in the Phase I were conducted in clinical settings (in- and outpatients, primary care). The plan at that time was to go into more representative community samples in subsequent phases. As documented below, this was never done because of budget constraints. Phase I included a test-retest reliability study (Semler et al., 1987b, see Table 5 for details) and two procedural validity studies against the PSE administered by clinicians (Farmer, Katz, McGriffin, & Bebbington, 1987; Semler, 1989). These studies documented a good test-retest reliability over a short recall period of IL3 days, particularly in those sections that were found in the DIS as being problematic (such as panic and generalized anxiety disorder), but only moderate concordance between the CID1 and PSE in clinical samples. Because of the latter finding and the fact that the draft version of ICD-10 criteria became available and was better suited for translation into questions and diagnostic algo- rithms. the PSE approach was abandoned. Several questions from the PSE were retained, however, because of their usefulness for the derivation of ICD-IO diagnoses.
This revised version of the instrument, now covering DSM-III-R and ICD-IO. was then used in a Phase II international WHO field trial to explore the cross-cultural acceptability, feasibility and reliability of the CID1 in different countries and settings. The Phase II studies interviewed 575 patients in 19 centers around the world, the vast majority of them selected from psychiatric inpatient or outpatient settings. Each setting contributed between 25 and 32 patients.
Witt
chcn
. I9
83 (\
-I a\
c 1)
Scm
ler
er a
l..
19x7
21
(\\il
\c‘I
)
Scn
ll~l-
rl al
,. I9
X7h
(\
\a\e
I)
Des
ign
and
~nte
r\ie
~cr
CID
1 in
psy
chia
tric
pa
tient
s.
all
patie
nts
wer
e in
ter\
iew
cd
twic
e In
depe
nden
tI>.
3-
&y
time
inte
rbal
. pl
us
a cl
inic
ian
reev
alua
tion.
(a
) T
-RT
rc
habi
lit!:
tv
.o
psyc
hiat
rist
s.
tao
psyc
holo
gist
s.
cont
rolle
d fo
l-
o&r
as w
ell
as s
ex o
f m
terv
iene
r an
d pa
tient
s.
(h)
Proc
edur
al
\alld
lt)
as
com
pare
d to
the
PS
E
and
clin
ical
tii
agno
scs.
CrD
I.
kst
of i
mpr
o\cm
ents
m
ade
subs
eque
ntly
to
the
Witt
chcn
st
ud>.
t\\
0 i
ndep
cndc
nt
intw
ic
u 5.
sam
e in
terv
iew
era.
Pr
oced
ural
\a
liditL
w
ith
PSE
. C
hang
es
vcrc
m
ade
in
item
fo
rmul
atio
n an
d al
gorj
thm
s C
I/)/
IC
.\I r
<‘l<
‘\r w
/irrl
li/i/~
~ i,r
1~
5j~l
rttr
lric
~ pat
ient
s.
TN
0
psyc
hiat
rist
s an
d t&
o ps
qcho
lo$s
t~
1~0
inde
pcnd
cnt
m\c
stig
atlo
ns.
\am
c ro
om.
sam
e tlm
c.
I 4
iln!s
apa
rt
CID
1 co
ncur
l-cn
t \s
lidit>
ai
th
the
[‘SE
on
item
. sv
ndro
me
clas
h an
d In
dex
of d
cfin
ltion
. T
wo
mdc
pcnd
ent
exam
inat
ion>
w
ith
the
PSE
(t
wo
Intc
rvic
wer
s)
and
the
ClD
l (o
ne
intr
r\kw
er)
in
outp
atic
ntb.
O
rder
ra
ndom
. ?~
omt‘
w
ithin
on
e 5e
Liio
n.
som
e w
ith
a tm
le
inte
r\al
of
scv
rral
da
ys
Sam
ple
D~n
gnos
cs
60 I
npat
ient
s fo
r A
ll C
IDI
diac
pnos
rs
relia
bilit
y an
d 19
2 al
l sy
mpt
oms.
In
patie
nts
fat
addi
tiona
l PS
E
valid
ity
part
ite
ms
All
CID
1 di
agno
ses
hO I
npal
icnt
\. 10
,4
11 C
ID1
diag
nose
\ m
alts
an
d 30
fem
ales
an
d hy
mpt
oms
30 o
u- ;Inil
~npa
ticnt
s al
l PS
E
and
CID
1
corr
capo
ndln
s ca
tego
rk
Find
ings
an
d co
mm
ents
G00
d T
K
7 ~e
/iclh
r/if
~f7r
z~/i~
~,~.
s for
all
diag
nose
s.
exce
pts
for
dyst
hym
ia
(.47
) an
d G
AD
(.
46).
V
ery
few
IO
U r
elia
bilit
y ite
ms
wer
e id
entif
ied
(cha
ncgc
d in
sub
sequ
ent
vers
ion\
of
CID
I).
sccu
nd
inte
rwe\
+ ha
d si
gnif
ican
t sh
orte
r du
ratio
n fe
wer
sy
mpt
oms.
an
d fe
wer
di
agno
ses
for
phob
ias
only
. PI
.OM
/UI.
OI r
~/i&
f!.
as c
ompa
red
to P
SE:
Goo
d co
ncor
danc
e on
ite
m
leve
l (c
onco
rdan
ce
62
(for
m
ania
)-88
(p
hobi
a)
and
the
time
rela
ted
ques
tions
. O
n th
e sy
ndro
me
lcvc
l (P
SE
cl
asse
s)
poor
co
ncor
danc
e w
as
foun
d fo
r m
ost
diag
nost
ic
sect
ions
. po
ssib
ly
due
to d
iffe
rent
ite
m
cont
ent
in P
SE
(IC
D-9
) an
d C
ID1
(DIS
- II
I).
and
scor
ing
algo
rith
ms.
C
onco
rdan
ce
with
cl
inic
al
prin
cipa
l dl
apno
sia
was
go
od
(all
abov
e 3)
. C
ID1
mad
e tu
icc
as m
an!
xcon
darq
di
agno
ses.
T
he
impl
cmcn
tatio
n of
add
ition
al
item
s.
rew
ordi
ng.
as w
ell
as o
ther
ch
ange
s re
sulte
d in
an
nnpr
o\,e
d co
ncor
danc
e \\i
th
the
PSE
sy
ndro
me
scor
e\.
Exc
ept
for
dyst
hym
ia
and
GA
S.
good
to
ex
celle
nt
diag
nost
ic
agre
emen
t ( >
.6)
for
crow
se
ctio
nal
as w
ell
as l
ifet
ime
diag
nose
s.
Subt
ypes
of
diso
rder
wcrc
sl
ight
ly
low
er
(sim
ple
phob
ia
and
rccu
rrcn
t de
pres
sion
).
Ord
er
elT
cct:
ns
Con
cord
ance
fo
r in
divi
dual
sy
mpt
oms
low
. br
oade
r ca
tepo
rvx
and
diag
mos
tic
clas
ses
bette
r.
with
K
ran
g?in
p be
twee
n .9
4 (d
elus
iona
l an
d ha
lluci
nato
ry
synd
rom
es)
and
spec
ific
In
curo
tlc
aqnd
rom
e~
.39.
Cot
tler,
I9
9 I
(wav
e II
)
Lei
tmey
er,
1990
(w
ave
I)
Wac
ker
et
al.,
1990
(w
ave
11)
Witt
chen
et
al
., 19
91
(wav
e II
)
Cot
tler
et a
l..
1990
(w
ave
II)
Wac
ker,
1991
(w
ave
III)
CID
I-SA
M
was
te
sted
fo
r re
liabi
lity
in s
ubst
ance
ab
user
s.
A
disc
repa
ncy
inte
rvie
w
was
us
ed
to
unde
rsta
nd
reas
ons
for
diff
eren
ces
CID
I+zl
inic
al
valid
atio
n of
C
ID1
sym
ptom
qu
estio
ns
for
pres
ence
an
d ac
cura
cy
of
expl
anat
ions
an
d tim
ing.
Fo
llow
ing
the
CID
1 in
a r
egis
tere
d pr
imar
y ca
re
unit
each
sy
mpt
om
was
re
eval
uate
d by
the
GP
on
the
basi
s of
sec
ond
inde
pend
ent
clin
ical
in
terv
iew
an
d th
e re
view
of
his
ch
arts
. C
IDZ
T-R
T
relia
bilit
y st
udy
in a
ra
ndom
po
pula
tion
sam
ple
of B
ase1
re
side
nts.
L
ay
and
clin
icia
n in
terv
iew
ers,
tw
o in
depe
nden
t in
vest
igat
ions
, l-
6 da
ys
time
inte
rval
. C
IDI-
inte
rrat
er
relia
bilit
y st
udy
108
inte
rvie
wer
s,
53 c
linic
al,
55
non-
clin
ical
in
terv
iew
ers.
R
ando
m
assi
gnm
ent.
One
in
terv
iew
ad
min
iste
rs
and
scor
es,
the
obse
rver
sc
ores
an
d is
allo
wed
to
ris
k pr
oble
mat
ic
sect
ions
. Sa
me
desi
gn
as a
bove
bu
t fo
cuse
d on
su
bsta
nce
diso
rder
T A
RT
exa
min
atio
n of
ran
dom
sa
mpl
e of
the
B
ase1
pop
ulat
ion
with
a
20-m
onth
s tim
e in
terv
al
39 s
ubst
ance
ab
user
s
32 p
rim
ary
care
at
tend
ers
100
subj
ects
fr
om
the
city
of
Bas
e1
575
subj
ects
an
d pa
tient
s fr
om
out
and
inpa
tient
se
tting
s,
19 c
ente
rs
Cri
teri
a as
abo
ve
85 s
ubje
cts
from
ge
nera
l po
pula
tion
sam
ple
DS
M-I
II
and
DSM
-III
-R
all
non-
psyc
hotic
C
ID1
sym
ptom
s
non-
psyc
hotic
di
sord
ers
from
th
e C
ID1
all
CID
1 di
agno
ses
and
sym
ptom
s
subs
tanc
e di
sord
er
DSM
-III
-R
ICD
-IO
Kap
pa
and
Yul
es
Y f
or
diag
nost
ic
conc
orda
nce
wer
e ca
lcul
ated
. A
vera
ge
kapp
a w
as
.84
for
DSM
an
d .8
2 fo
r D
SM-I
II-R
. It
em
by i
tem
re
liabi
lity
was
go
od
to e
xcel
lent
. M
ost
pers
ons
stat
ed
as a
rea
son
for
disc
repa
nt
answ
ers
that
th
ey
did
not
unde
rsta
nd
the
ques
tion.
C
onco
rdan
ce
of C
ID1
ques
tions
fo
r so
mat
ofor
m
diso
rder
s an
d ra
nged
fr
om
.32
to
X9,
for
an
xiet
y di
sord
ers
betw
een
.27
and
.8,
for
depr
essi
on
.4 t
o .7
9.
Goo
d to
exc
elle
nt
relia
bilit
y fi
ndin
gs
for
all
but
5 t tw
o di
agno
ses:
G
AD
(.
46)
and
pani
c (.
51).
c
Rea
son
for
disc
repa
ncie
s:
inco
rrec
t pr
obin
g,
$
and
wro
ng
skip
s.
Ord
er
effe
ct:
ns.
a 3 2
Exc
elle
nt
kapp
a fo
r al
l se
ctio
ns
rang
ing
from
.6
7 to
.9
7. N
o di
ffer
ence
s be
twee
n cl
inic
ian
and
2
non-
clin
icia
n pa
irs.
A
gree
men
t on
sy
mpt
oms
f:
slig
htly
lo
wer
(X
4).
Ei
As
abov
e,
bu
t al
coho
l cr
iteri
a qu
estio
ns
indi
cate
d lo
wer
ac
cept
abili
ty
and
slig
htly
lo
wer
co
ncor
danc
e (n
s)
Agr
eem
ent
(Yul
es
Y)
was
go
od
for
depr
essi
ve
epis
odes
(.
67),
dys
thym
ia
(.77
),
agor
apho
bia
(.77
),
soci
al
phob
ia
(.68
),
pani
c (.
71),
G
AD
(.
64),
bu
t po
or
for
spec
ific
ph
obia
s (.
22)
and
subt
ypes
of
de
pres
sion
. A
t tim
e 2
mor
e si
mpl
e ph
obia
s an
d m
ore
pani
c di
sord
er
wer
e di
agno
sed.
Tab
le
4 C
ontin
ued
Aut
hor
And
rew
s,
subm
itted
Witt
chcn
et
al
.. 19
93
(wav
e II
I)
Pete
rs
&
And
rew
s.
1993
Cot
tlrr.
19
93
Janc
a et
al..
19
92 a
,b
(wav
e 11
1)
Des
ign
and
inte
rvie
wer
Sa
mpl
e
CID
1 co
ncur
rent
va
lidity
w
ith
the
SCA
N.
Clin
ical
in
terv
iew
ers,
tw
o in
depe
nden
t in
terv
iew
s,
rand
om
orde
r of
adm
inis
trat
ion.
on
e se
ssio
n (p
art
of t
he e
xten
ded
CID
1 an
d SC
AN
fi
eld
tria
ls).
38
pat
ient
s of
psy
chos
omat
ic
clin
ic
wer
e st
udie
d in
T-R
T
desi
gn
(3.d
ays
time
inte
rval
) by
ra
ndom
ly
assi
gned
tw
o cl
inic
al
and
non-
clin
ical
in
terv
iew
s to
eva
luat
e cl
inic
al
mlid
ity
CID
1 di
agno
ses
wer
e co
mpa
red
to c
linic
al
cons
ensu
s di
agno
ses
(IC
D-1
0).
101
outp
atie
nts
from
an
an
xiet
y di
sord
er
clin
ic
38 i
npat
ient
s of
a
psyc
hoso
mat
ic
hosp
ital
CID
I-A
se
lf a
dmin
iste
red
by
patie
nts.
Pr
oced
ural
va
lidity
ag
ains
t st
anda
rd
LE
AD
cl
inic
al
diag
nose
s (t
wo
clin
icia
ns
mad
e co
nsen
sus
diag
nose
s us
ing
clin
ical
in
terv
iew
, se
lf-r
epor
t m
easu
res,
tr
eatm
ent
outc
ome
info
rmat
ion.
94 o
utpa
tient
s fr
om
an
anxi
ety
diso
rder
s cl
inic
Subj
ects
fr
om
the
gene
ral
popu
latio
n as
wel
l as
tre
ated
sa
mpl
es
wer
e in
terv
iew
ed
with
th
e SA
M
for
the
DSM
-IV
fi
eld
tria
ls.
Com
pari
sons
of
rat
es
of
diag
nost
ic
syst
ems
wer
e m
ade.
20
sub
ject
s fr
om
St.
Lou
is
cent
er.
two
clin
icia
ns
scor
ed
ICD
- IO
(a)
an
d D
SM-I
II-R
(b
) ch
eckl
ist
whi
le
obse
rvin
g or
af
ter
adm
inis
teri
ng
the
CID
1 (I
2
inte
rvie
wer
s).
887
subj
ects
fr
om
trea
ted
sam
ples
an
d th
e ge
nera
l po
pula
tion
20 s
ubje
cts
from
pr
imar
y ca
re,
psyc
hiat
ric
outp
atie
nts.
em
ploy
ees
of
hosp
ital
Dia
gnos
es
DSM
-III
-R
diag
nose
s,
anxi
ety
and
depr
essi
ve
diso
rder
s
sele
cted
IC
D-
IO
DSM
-III
-R
diag
nose
s,
anxi
ety
and
depr
essi
ve
diso
rder
s
Find
ings
an
d co
mm
ents
Con
cord
ance
: in
trac
lass
ka
ppa
rang
ed
from
.3
9 (M
D)
to
.62
(OC
D)
from
cu
rren
t an
d fr
om
.34
(MD
) to
.6
1 (=
CD
) fo
r lif
etim
e di
agno
ses.
C
anon
ical
co
rrel
atio
n an
alys
es
show
ed
that
th
e tw
o in
stru
men
ts
mad
e si
mila
r di
agno
stic
di
scri
min
atio
ns.
Kap
pa
(CID
1 vs
clin
ical
di
agno
ses)
w
as
foun
d to
be
exce
llent
fo
r de
pres
sion
(,
7)
som
atiz
atio
n (.
9) p
ain
(.6)
and
di
ssoc
iativ
e di
sord
ers.
lo
w
for
pani
c,
agor
apho
bia
and
GA
D
(.3
to
.5).
The
re
ason
fo
r po
or
clin
ical
co
ncor
danc
e w
as
not
disa
gree
men
t on
th
e pr
esen
ce
of t
he
sym
ptom
s,
but
rath
er
that
cl
inic
ians
re
gard
ed
othe
r di
agno
ses
as
dom
inan
t an
d sa
w
no
need
to
giv
e se
para
te
anxi
ety
diag
nose
s as
wel
l. T
c
CID
I-A
ge
nera
ted
2.53
di
agno
ses
per
patie
nt.
clin
icia
ns
1.27
. Se
nsiti
vitie
s ra
nged
fr
om
.29
$
(pan
ic,
GA
D)
to
.86
pani
c di
sord
er
with
i r
agor
apho
bia.
Sp
eciti
citie
s ra
nged
fr
om
.52
(sim
ple
phob
ia)
to
.94
(OC
D).
C
anon
ical
$
corr
elat
ion
anal
ysis
su
gges
ts
that
C
IDI-
A
mad
e si
mila
r di
agno
stic
di
scri
min
atio
ns
than
cl
inic
ians
. D
SM-I
II.
DSM
-III
- I I
D
epen
denc
e w
as
foun
d to
be
mor
e st
ame
acro
ss
R.
DSM
-IV
. IC
D-
IO
syst
ems
than
ab
use
and
harm
ful
use.
DSM
-III
-R
ICD
-IO
O
vera
ll di
agno
stic
co
ncor
danc
e w
as
foun
d to
di
agno
ses
be g
ood
(K =
.7
7),
anxi
ety/
phob
ic
diso
rder
s (.
73).
de
pres
sive
di
sord
ers
(.78
),
subs
tanc
e us
e di
sord
ers
(.X
3).
.V/~
tr. S
et
Tab
le
3 fo
r ab
brev
iatio
ns.
RELIA~ILTY AND VALIUITY OF THE CID1 73
The Phase II field trial findings documented a few ambiguities and cross-cultural differ- ences in meanings of questions, some of which were subsequently changed. A general criticism from many sites in this study was the length of the CIDI, with about 65% of the interviewers rating the CID1 as too long. The average duration of interview of a patient who had at least one diagnosis was about 103 minutes per interview in newly trained interviewers, but only 78 minutes in experienced interviewers. Sections with a particularly long administration time were those for somatoform, depression and substance use disorders (Wittchen et al., 1991). Nevertheless the CID1 was judged as being acceptable (49.3% as good, 41.5% moderate, 9.2% poor) and appropriate for most settings especially for out- patient and primary care settings (Wittchen et al., 1991).
Table 5 summarizes the combined findings from all test - retest data available, including the 60 psychiatric inpatients from the wave I field trials (Semler et al., 1987b), the 60 subjects from a random population sample studied by Wacker (1991) in wave II, as well as to 38 inpatients from a psychosomatic clinic (Wittchen, Essau, Rief, & Fichter, 1993) jointly with findings from the interrater reliability (Wittchen et al., 1991) study from the wave II field
Table 5 Summary of test-retest and interrater reliability findings (N = 575) of the CIDI in the WHO Field Trials: Joint analysis of three independent studies with a comparable design
*Findings for ICD-10 diagnoses available on request (T-Rt studies included are Semler at al., 1987 (N = 60), Wittchen et al., 1993 (N = 38).
Wacker, 1991, N = 60). **Interrater findings are based on N = 575 subjects.
14 H.-U. WITTCHN
trials. The test-retest studies of the CID1 all had a comparable design. They involved two in- dependent clinical and non-clinical interviewers, who reinterviewed a patient within 3 days of the first interview. The kappa coefficients were found to be good for all diagnoses, except for bipolar II (59) dysthymia (52) and simple phobia (59). It is particularly important to point to the fact, that previous difficulties with panic disorder as well as dysthymia, both being problematic in several DE studies, were obviously solved. Panic now shows a kappa of .84 and dysthymic disorder of 52. Results according to ICD-10 were quite similar.
Reliability of time-related questions in the CID1 was of special importance, because the CID1 is specifically designed to assess the occurrence of disorders over the life span (Wittchen et al., 1989a). Questions related to the duration of the longest depressive or manic episode, and to the number of depressive or manic episodes had high to perfect intraclass correlation coefficients, although percentage agreement rates were found to be considerably lower. This indicates that almost one-third of the respondents obviously had difficulties to recall the precise duration or number of episodes at both occasions. The age of onset information from the CID1 proved to be reliable.
The wave II interrater study indicated an excellent reliability of the CID1 in almost all sections, except for somatization which had a kappa value of 0.68. But it also provided insight as to the most frequent reasons for discrepancies between two interviews. Most discrepancies could be traced back to idiosyncratic changes of questions by one interviewer, as well as mistakes in the probe flow chart. Other potential sources of variance, such as that the respondent changed his mind, or random errors (lack of interviewer’s attention, miscodings etc) were found to be of minor importance (Wittchen et al., 1991). Similar findings were obtained for the substance-related portions of the interview, that were inde- pendently evaluated with an extended module the CIDI-substance abuse module (Cottler et al., 1990, 1991).
Phase III of the field trials included a series of work group meetings to finalize minor revisions of the CIDI, due to changes in the Diagnostic Criteria for Research of the ICD- 10, that occurred about this time. The resulting final version of the instrument was than pilot-tested in a third multicenter study. Data from this final Phase III, that include reli- ability as well as validity components, are only partially published up to now (Cottler, 1993; Janca et al., 1992a,b; Wacker, Miillejans, Klein, & Battegay, 1992; Wittchen et al, 1993). Of special importance are the data from the participating center in Base1 that replicated the test-retest design by Semler in a sample of 60 randomly chosen subjects of the general population. This study confirmed the good symptom and diagnostic reliability that was found in the earlier study by Semler et al., (1987). Wacker (1991) also conducted a separate long term test-retest reliability study, in which 85 subjects from a general population sample (Wacker et al., 1992) were reexamined blindly about 20 months after the initial examination. DSM-III-R and ICD-10 lifetime diagnostic reliability was found to be acceptable to good with kappa/Yule Y coefficients, well above .5. (major depression: .57, dysthymic disorder: .52, panic with agoraphobia: .SO, without: .73, agoraphobia: .65, GAD .86 and social phobia .65). In a careful examination of discrepancies he identified, in depressive and anxiety disorders, cases that slipped just below the diagnostic threshold, because they tended to report slightly lower numbers of symptoms in the second interview. This order effect has also been noted in earlier studies (e.g., Helzer et al.. 1985).
RELIAHILTY AND VALIDITY OFTHE CID1 75
Validity Studies with the CID1
There have been several procedural and clinical validity studies with the DIS supporting the conclusion that the DIS (and therefore the CIDI) fully structured approach could be a useful strategy for epidemiological and clinical studies. Initially, however, there was little emphasis on further clinical validation studies with the CID1 itself. The exceptions were the procedural validity studies against the PSE by Farmer et al. (1987, 1991) and Semler (1989), the clinical validation study by Leitmeyer (1990), who examined the concordance of CID1 symptoms against clinical consensus ratings by clinicians. Reports from the wave III field trials by Janca et al. (1992a) for DSM-III-R diagnoses found good overall diagnostic concordance between a clinical checklist and CID1 diagnoses (depressive disorders K = .84, anxiety and phobic disorders K = .76, substance use disorders K = .83). In the same small sample of 20 primary care attenders and outpatients he also confirmed good concordance for ICD-10 diagnoses with kappa values ranging from .73 to .83. Wittchen et al. (1993) found similarly high clinical confirmation rates for ICD-10 diagnoses in 38 patients from a specialized clinic for psychosomatic disorders. These studies support the good agreement coefficients of CID1 diagnoses with routine clinical diagnoses, checklist diagnoses as well as with other scales. But none of these studies can be judged as providing sufficient evidence for the different constructs of validity that are needed for more persuasive evidence.
The lack of large-scale validation efforts for the CID1 can at least be partially explained by the feeling that basic design problems with adequate validation strategies have not been sufficiently clarified. Controversies still cluster about the basic concerns of what can be regarded as the best available clinical standard and to what degree other strategies, such as cognitive validation strategies should be used. This discussion was further complicated by the fact that the CID1 is the first diagnostic instrument for the assessment of ICD-10 diagnoses. Until very recently no other instrument with a proven reliability was available against which the performance of the CID1 could be measured. Due to the advent of ICD- 10 and the associated diagnostic criteria for research a year ago, routine or research diagnoses by experienced psychiatrists do not seem to offer attractive alternatives.
With the availability of the new Structured Clinical Assessment for Neuropsychiatry (SCAN, WHO 1992), the SCAN system now offers such a strategy. Although the WHO CID1 field trials have ended with Phase III, several validity studies comparing the CID1 to the SCAN and a clinical reevaluation using the LEAD method (this abbreviation means that the clinical diagnosis is based on Longitudinal data, Expert ratings as well as the inclusion of All Data available about the patient) are now under way. The Australian center has been the first that has recently presented preliminary findings (see Table 4) with this approach (Andrews et al., submitted; Peters & Andrews, 1993).
Conclusion
Feasibility and reliability
To conclude, the CID1 is a highly standardized diagnostic interview for the assessment of mental disorders according to the definitions and criteria of ICD-10 and DSM-III-R. Revisions to meet DSM-IV criteria are already in progress. Given the wide range of
76 H.-U. WITICHEN
diagnoses covered, it can be regarded as a time efficient, objective and, in terms of its consistency as being used by two independent interviewers, a reliable strategy to assess a wide range of psychopathology and diagnoses. It is also remarkable that obviously many of the reliability problems of the DIS have been successfully solved in the CIDI. Reliability coefficients for GAD, panic and dysthymia are now all well above a kappa value of .5. Thus the CID1 offers clinicians and non-clinicians a reliable tool to determine the frequency of symptoms and the distribution of specific mental disorders in various settings cross-cultur- ally, given appropriate CID1 training. Another advantage of this instrument is its coverage of two diagnostic systems, the ICD-IO and the DSM-III-R. It also offers flexibility with respect to several aspects: it can be supplemented by modules to study other diagnoses and psychopathological features in more detail, and it can be used for comorbidity analysis due to the option to derive diagnoses by using or ignoring diagnostic hierarchies. The CID1 flexibility is also underlined by the fact that it offers several modifications that might be better suited for specific research questions, examples for this include the computerized administration by using the CIDI-AUTO, the UM-CIDI, or the primary care version (CIDI-PMC). Since these versions, despite of their modifications, all offer the option of using the standard CID1 data file and thus the use of the standardized computerized diagnostic programs, data can be directly compared between centers following different research perspectives. This specific advantage has stimulated WHO to build up a common CID1 data bank for use by researchers around the world.
Is there u needjkw further reliability studies?
The review has clearly identified one major gap in our knowledge about the CIDI, namely that there are only very few test-retest reliability studies in general population samples, the field for which the CID1 has been primarily developed. Except for the small samples in two settings in the field trials as well as Wacker’s study in Basel, there is no evidence, that the promising figures in clinical samples hold true in randomly selected population samples.
Problem areus
Despite the many advantages there are also quite a number of critical issues that can be identified on the basis of the above mentioned studies. These critical issues also signal the further research that is needed.
(1) Phrasing of some symptom questions. This group of problems deals with technical inconsistencies, for example, sometimes the same diagnostic criterion is translated in slightly different words or series of questions (such as in the phobia section), the fact that important additional information for coding the responses is in the separate user manual and not in the interview, and finally the fact that many questions are too long and should be broken in several questions. All three aspects might create confusion and inconsistencies and thus might contribute significantly to a diminished reliability and validity (Kessler, 1991). The long questions have been found to be particularly difficult for the elderly (Knauper 1993), countries with lesser literacy (field trials II) and in specific cultures (Isaac, 1990, Miranda. Mari, Ricciardi. & Arruda, 1990, Lyketsos, Gerontas. & Aritizi, 1990). A related issue is
RELIABILTY AND VALIDITY OF THE CID1 II
also the identification of synonyms for key symptoms and concepts, such as depressed mood (blue, low, etc.), that play a critical role particularly in examinations that use subjects with varying cultural backgrounds. Here research has been initiated (Kessler, 1991) to identify the relevance and the effect of other terms as well as by examining whether respondent cards that list complex phenomena might be useful tools to cope with this problem.
(2) Probeflow chart. As useful as this innovative probing technique might be, there are still several concerns: first, mistakes in the probe flow chart are a significant source of unreliability (see above); and second, this probe system relies heavily on the medical doctor’s decisions being communicated to the respondent. In countries with almost no medical infrastructure the validity of this approach has been questioned (Rubio-Stipec, et al. 1993). In addition the use of the probe questions for single items might be inadequate, particularly in the depression and mania section. Because the cognitive complexity involved in respond- ing to the probing, together with the effort of understanding some of the long and complex symptom questions, some subjects should obviously get bored and learn to say “no” (Rubio- Stipec et al., 1993). In the elderly, the probe complexity in the depression section might even be responsible for a lack of sensitivity (Knauper & Wittchen, in press), the UM-CID1 offers the option of syndrome based, spelled out probes, that obviously takes care of the problem in many cases (Blazer, Kessler, McGonagle, & Swatz, in press).
(3) Lack of specificity of clinical information. The categorical nature of many severity oriented questions as well as questions for time related phenomena has been criticized. Here suggestions have been made to include dimensional ratings rather than categorical to assess the degree of avoidance and psychosocial interference. The accuracy of rating past episodes and time of onset might be improved by cognitive memory search methods (Cannel, Miller, & Oksenberg, 1981; Kessler et al., in press). The PMC version of the CID1 (WHO, 1992) goes someway towards these goals by using flexible dimensional criteria that allow the derivation of current syndromes and the determination of severity.
(4) Sequence and position eficts. Some concerns have been expressed that due to the length of the interview, early sections have a greater probability of “yes” responses than sections asked later. Indirect support for this comes from epidemiological studies that report higher rates of depression if the long (18 minutes) somatoform section with many probe questions is omitted (Kessler, 1993; Wacker et al., 1992). The UM-CID1 suggests that this problem can be fixed by putting the important stem questions for all diagnoses at the front of the interview (Kessler et al., in press).
(5) Diagnostic problems. A number of more clinically oriented researchers (Anthony et al., 1985; Ganguli & Saul, 1982; Pulver & Carpenter, 1983; Spengler & Wittchen, 1988) have demonstrated diminished validity coefficients for items in the psychotic section. They object to the current CID1 approach because it does not allow for clinical judgements, and thus may not be “valid” for the assessment of more severe mental disorders such as acute or residual schizophrenic disorder. This seems to be a high priority area for further
78 H.-U. WITTCHI:N
improvement of the CID1 as well. Furthermore. from a clinical perspective concern still exists about the fact that clinical judgements cannot be coded in the CID1 at all, except for a few observation items in the end of the interview.
This overview of problem areas stresses the need for further studies to improve the instrument. Most of these concerns probably fall into what has been called “cognitive validation” studies (Cannel et al., I98 1). These studies examine whether there is an adequate match between the intent of question and what the respondent actually understands and responds to.
Vulidution strutegies Aside from this fruitful area of “cognitive validation” studies that might bring research on diagnostic instruments closer to basic research in cognitive and social psychology as well as to the area of survey research, highest priority should be laid upon clinical procedural validity studies. The current situation calls for comparisons of the
CID1 approach with clinical instruments such as the SCAN, covering ICD-IO diagnoses and DSM-III-R) or other instruments, such as the SCID (Spitzer, Williams, Gibbons, & First, 1990). These studies will be needed for both patient as well as random population samples and will be complex due to the many confounding factors that could be active (sequence effects, learning effects, etc.). If possible these studies should include other validity standards, for example. longitudinal information, information by other sources (significant others) such as proposed by the LEAD standard (longitudinal, experts, all data. Spitzer & Williams, 1980). These types of studies are currently being initiated by the WHO. Data might provide an adequate first validation of the DSM-III-R and ICD-IO version of the CID1 and will bring to a close the methodological investigations of the instrument. If previous phases of the field trials can be used as a guide, we can predict from the reliability findings, that the validity will be good.
The CID1 in comparison to other instrunwnts
There are a number of different structured diagnostic interviews currently available for assessing mental disorders (Hasin & Skodol, 1989; Helzer, 1983; Page, I99 1; Pull & Wittchen, 1991; Ustiin & Wittchen, 1992; Wittchen & Unland, 1991). Thus, many clinicians are confronted with the question: “which is the best interview of all‘?“. There is no simple
answer to this question, because all instruments have been developed with specific research interests they all have their strengths and weaknesses. A good example is provided by the comparative studies of the CID1 and the Structured Clinical Interview for DSM-III-R (SCID; Wittchen et al., 1989b) as well as Page’s (1991) excellent review and comparative analysis of several instruments for the assessment of anxiety disorders. The kappa values of the CID1 and the SCID were similar for some diagnoses such as major depression, bipolar disorders and psychotic disorders or substance-related disorders, however, marked differences were found for others. For example, the kappa values of the panic disorder and agoraphobia as measured by the SCTD were relatively low, which was surprising because the SCID has been used extensively to assess these two disorders, for example, in the context of the Upjohn Collaborative Study; these discrepancies were probably due to different phrasing and intonation of questions by different interviewers, depending on their concept
RELIABILTY ANDVALIDITY OFTHE CID1 19
of panic disorder. By contrast, the reliability for both disorders as assessed by the CID1 was extremely high (Wittchen et al., 1989b). Similar findings were summarized by Page (1991) in his comparison with the ADIS, the SCID and the SADS. Based on these studies we could suspect that the choice of interview is not random. Each of the available interviews has been developed for particular purposes. Some are more suited for psychopathological research (CIDI, SCAN, SADS), other ones more for clinical practice (SCID). Some provide brief assessments of a larger number of disorders, others provide a more detailed assessment of limited numbers of disorders. Some follow the structure of the available diagnostic systems more than others. Page suggests, in his overview (1991), 10 questions which might be found useful to the clinician when he has to select a structured diagnostic interview to use.
(1) Does the interview cover the relevant disorders? (Can irrelevant disorders be omitted?) (2) Does the interview cover the relevant diagnostic system (i.e., ICD-10, RDC, or DSM-
III-R)? (3) How long does the interview take? (4) Does the interview provide a sufficiently detailed assessment? (5) Is the interview sufficiently reliable? (6) Who can administer the interview? (Clinicians, non-clinicians? Are they available?) (7) Are scoring procedures available and applicable? (i.e., if computer facilities are avail-
able, are they compatible?) (8) How widely is the interview used (and is comparison data available?) (9) Is support readily available?
(10) Is the interview applicable to the target population? The choice of the appropriate instrument therefore obviously depends on the specific
research questions under study and the acceptability of the respective interview for the researcher. Acceptability might be a critical aspect with regard to the CIDI, because many clinicians find it boring and sometimes difficult to follow the strict rules of this standardized instrument, as opposed to less rigid checklists and structured clinical approaches.
Andrews (1992) and Andrews et al. (in press) recently pointed to the fact that clinical diagnoses not supported by other assessment tools may no longer be good mental health practice. By going back to Meehl’s (1954) landmark study that concluded that statistical predictions were at least as accurate and often more accurate than the judgment of trained clinicians, he stressed the importance of reliability in symptom assessment. Structured diagnostic instruments with standardized analytic procedures do not vary as do clinical judgments about the same diagnostic data; the latter usually vary from occasion to occasion and between any two sets of clinicians. Since standardized diagnostic procedures and statistical compilations do not vary in this matter and since reliability is important because it is a prerequisite for validity, the use of comprehensive diagnostic instruments for mental disorders becomes essential. Structured diagnostic instruments such as the CID1 were developed to improve the reliability of the clinical judgment as to how well a patient’s complaint satisfies diagnostic criteria. The CID1 achieves this goal by modellingan interview on the basis of clinical expertise and the gains in validity come from standardizing the content of the questions as well as from the form of the interview and the scoring process. No matter how perfect the structured diagnostic interview might be, validity will always be limited to the validity inherent in the diagnostic criteria on which that instrument is based
80 fI.-U. WITI(.HI.N
and the exactness with which the interview elicits the behaviors, thoughts and feelings described by those diagnostic criteria. This points to the intimate interrelationship of clear and explicit diagnostic criteria and diagnostic algorithms of our classification systems for mental disorders and the continuous process of building and improving on these criteria adequate diagnostic instruments.
A c~litlolc~lcc~y~~r?ll~tl/.\ -The author would like to thank Drs Lee Robins, Gavin Andrews, Linda Cottlcr, Alcxandcr Janca. Ron Kessler as well as the members of the CID1 Editorial Committee for their helpful comments to earlier drafts of this paper.
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