bipolar disorder

218 Pages·2007·1.67 MB·English

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CONTENTS
Preface vii
Part I.General Issues
1. Philosophical Underpinnings ofClinical Interviewing 2
Johan Rosqvist,Thröstur Björgvinsson,and Jill Davidson
2. Unstructured Interviewing 7
Sandra Jenkins
3. Structured and Semistructured Interviews 24
Julie N.Hook,Elise Hodges,Kriscinda Whitney,and Daniel L.Segal
4. Motivational Interviewing 38
Jennifer R.Antick and Kimberly R.Goodale
5. Mental Status Examination 49
Michael Daniel and Tracy Carothers
6. Multicultural Issues 64
Daniel S.McKitrick,Tiffany A.Edwards,and Ann B.Sola
7. Selecting Treatment Targets and Referral 79
Paula Truax and Sara Wright
8. Suicide Risk Assessment 95
Elizabeth T.Dexter-Mazza and Kathryn E.Korslund
9. Writing Up the Intake Interview 114
Daniel L.Segal and Philinda S.Hutchings
Part II.Specific Disorders
10. Major Depressive Disorder 134
Keith S.Dobson and Martin C.Scherrer
11. Bipolar Disorder 153
Sheri L. Johnson,Lori Eisner,and Randy Fingerhut
12. Schizophrenia 166
David Roe,Abraham Rudnick,and Kim T.Mueser
13. Panic and Agoraphobia 184
Norman B.Schmidt,Julia D.Buckner,and J.Anthony Richey
14. Specific Phobia 202
Laura L.Vernon
15. Social Phobia 223
Stefan M.Schulz,Alicia E.Meuret,Rebecca Loh,and Stefan G.Hofmann
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16. Posttraumatic Stress Disorder 238
Johan Rosqvist,Thröstur Björgvinsson,Darcy C.Norling,
and Berglind Gudmundsdottir
17. Generalized Anxiety Disorder 252
Jonathan D.Huppert and Michael R.Walther
18. Eating Disorders 266
Tiffany M.Stewart and Donald A.Williamson
19. Borderline Personality Disorder 282
Kathryn E.Korslund,Angela Murray,and Susan Bland
20. Alcohol and Other Drug Disorders 301
Jon Morgenstern and Thomas Irwin
21. Sexual Dysfunction and Deviation 317
Tamara Penix and Dahamsara R.Suraweera
Part III.Special Populations and Issues
22. Couples 340
Sarah Duman,Jed Grodin,Yolanda M.Céspedes,Emily Fine,
Poorni Otilingam,and Gayla Margolin
23. Intellectual Disability 358
Melissa L.Gonzáles and Johnny L.Matson
24. Neurologically Impaired Clients 378
Charles J.S.Golden and Zarabeth L.Golden
25. Older Adults 392
Lesley P.Koven,Andrea Shreve-Neiger,and Barry A.Edelstein
26. Sleep Disorders 407
Shawn R.Currie and Jessica M.McLachlan
27. Physical Abusers in the Family 427
Louise S.Éthier and Carl Lacharité
28. Behavioral Medicine Consultation 446
John G.Arena
Index 000
About the Editors 469
About the Contributors 470
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PA R T I I
S
PECIFIC
D
ISORDERS
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10
M D D
AJOR EPRESSIVE ISORDER
KEITH S. DOBSON AND MARTIN C. SCHERRER
DESCRIPTIONOFTHEDISORDER under “Mood Disorders”the conditions with the
defining feature ofa disturbance in mood.Three
Both depression and the often comorbid condi- categories are delineated: the depressive disor-
tion of anxiety, as Dozois and Dobson (2004) ders, the bipolar disorders, and two disorders
recently observed,“are frequently referred to as based on etiology,mood disorder due to a general
the common colds of mental disorders”(p. 1). medical condition and substance-induced mood
Though accurate in its reflection of the wide- disorder. The absence of past manic, mixed, or
spread nature of depression, such a view fails hypomanic episodes distinguishes the depressive
to reflect just how debilitating and costly this from the bipolar disorders.The focus ofthe pre-
condition is to those who experience it and to sent discussion is on the depressive disorders,
society in general (Dozois & Dobson,2004). including major depressive disorder, dysthymic
Accurate assessment ofclinical depression is a disorder, and depressive disorder not otherwise
critical step in the conceptualization and treat- specified, each of which is briefly discussed in
ment planning process,and a central element of turn. Before addressing these disorders, we will
such assessment is clinical interviewing. After a outline the diagnostic criteria for a major depres-
brief review of the depressive disorders, we will sive episode because these criteria are crucial in
examine interviewing strategies in general and in diagnosing the various depressive disorders.
the context ofmajor depressive disorder and then
Major Depressive Episode. A major depressive
consider behavioral assessment and differential
episode is defined as a period of at least 2 weeks
diagnosis.Finally,we will address the implications
involving a range of symptoms that represent
for assessment in terms of treatment planning,
a change from prior functioning and are present
with particular emphasis on cognitive-behavioral
for most ofthe day,nearly every day.At least five
models ofcase formulation as an avenue through
of nine specific symptoms are required, with at
which ideographic information is applied to a
least one ofthe symptoms involving either a pre-
general and empirically supported intervention.
dominantly depressed or irritable (i.e.,in children
or adolescents) mood or markedly diminished
interest or pleasure in all or almost all activities.
DSM-IV-TRDepressive Disorders
Additional symptoms include a significant change
The Diagnostic and Statistical Manual of in appetite or weight; change in sleep patterns
Mental Disorders (DSM-IV-TR; American (insomnia or hypersomnia);psychomotor distur-
Psychiatric Association [APA], 2000) includes bance (agitation or retardation);fatigue or loss of
134
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Major Depressive Disorder 135
energy; feelings of worthlessness or excessive pattern to the onset and remission of major
guilt; diminished ability to think or concentrate, depressive episodes.
or indecisiveness; and recurrent thoughts of
death, suicidal ideation, or a suicide attempt or Dysthymic Disorder. Dysthymic disorder has as
specific plan. Such symptoms must cause clini- its central feature a chronically depressed mood
cally significant distress or impairment in func- for most ofthe day,more days than not,that lasts
tioning and do not meet criteria for a mixed at least 2 years. In addition, at least two of the
episode, which involves symptoms of a manic following symptoms are present:appetite distur-
episode in addition to a major depressive episode. bance, sleep disturbance, low energy or fatigue,
Furthermore,the symptoms must not be caused a low self-esteem, poor concentration or indeci-
substance or general medical condition and are siveness, and hopelessness. During the 2-year
not better accounted for by bereavement,which is period,the person has never been without these
defined as a period of grief occasioned by the symptoms for more than 2 months at a time and
death ofa lost one,lasting less than 8 weeks. has never experienced MDD.However,the diag-
nosis may be made ifa person experienced MDD
Major Depressive Disorder. The defining feature with full remission before developing dysthymic
ofmajor depressive disorder (MDD) is the pres- disorder. Also, after the initial 2 years of dys-
ence of one or more major depressive episodes thymic disorder,a person may experience super-
in the absence ofa manic,mixed,or hypomanic imposed episodes of MDD, resulting in both
episode.The presence of a single major depres- diagnoses (also called double depression).
sive episode results in the diagnosis of MDD, Specifiers for dysthymic disorder include early
single episode, whereas two or more major onset(before age 21 years) and late onset(21 years
depressive episodes separated by at least 2 con- or older), and with atypical features, which fol-
secutive months result in the diagnosis ofMDD, lows the criteria as defined for MDD.
recurrent.A number ofspecifiers are available to
further elaborate the clinical status and features Depressive Disorder Not Otherwise Specified. The
ofthe current episode. DSM-IV-TR(APA,2000) includes the not other-
Current severity is indicated as mild,moder- wise specified (NOS) category for conditions
ate,or severe (with or without psychotic features, with depressive features that do not meet criteria
which may be mood-congruent or-incongruent). for other depressive disorders.Examples include
The chronic specifier is indicated if criteria for premenstrual dysphoric disorder,minor depres-
MDD have been met continuously for at least sive disorder,recurrent brief depressive disorder,
2 years. The catatonic features specifier is indi- and postpsychotic depressive disorder of schizo-
cated when the clinical picture is characterized phrenia (suggested research criteria for these
by marked psychomotor disturbance (including conditions are provided in the DSM-IV-TR’s
symptoms such as motoric immobility,excessive Appendix B:“Criteria Sets and Axes Provided for
and apparently pointless motor activity, and Further Study”).Also falling in the depressive dis-
peculiar or stereotyped movements). A loss of order NOS category are instances wherein MDD
pleasure or a lack ofreactivity to usually pleasur- is superimposed on another disorder, such as
able stimuli, in addition to symptoms such as delusional disorder, psychotic disorder NOS, or
early morning awakening and excessive or inap- the active phase of schizophrenia,as long as the
propriate guilt,indicates the melancholic features symptoms do not better meet the diagnosis of
specifier. The atypical features specifier is indi- schizoaffective disorder.The NOS category is also
cated by mood reactivity and at least two addi- used when it is unclear whether a depressive dis-
tional features,such as significant weight gain or order is primary or due to a substance or general
increased appetite,hypersomnia,and sensitivity medical condition.
to interpersonal rejection.The postpartum onset
specifier is used when the onset is within 4 weeks
The Impact and Cost ofMDD
postpartum. Finally, longitudinal course speci-
fiers include with and without full interepisode The depressive disorders take a substantial toll
recovery,determined by whether full remission is on both the individuals who experience them and
attained between major depressive episodes,and society at large.Depression has been rated by the
the seasonal patternspecifier indicates a seasonal World Health Organization as the number one
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136 SPECIFIC DISORDERS
cause of disability in the world (Muñoz, Le, 6 months (Kessler, 2002). Rates of DSM major
Clarke, & Jaycox, 2002) and has been found to depression,as identified by structured diagnos-
negatively affect physical health (e.g., increased tic interviews,are much lower,at less than 1% in
rates of cardiac problems) and interpersonal children,up to 6% in adolescents,and 2–4% in
relationships (e.g., troubled parent-child rela- adults (Kessler,2002).This discrepancy in find-
tionships, increased rates of divorce) (Dozois & ings between symptom screening measures and
Westra, 2004; Gotlib & Hammen, 2002). diagnostic interviews is worth consideration
Depression is also associated with significant role because it underlines the importance of attend-
impairment, comparable to that caused by seri- ing to subsyndromal symptoms, particularly
ously impairing chronic physical disorders (Kessler, given evidence that such symptoms may predict
2002). For example, a recent large-scale epi- later onset ofmajor depression (Kessler,2002).
demiological examination ofMDD,the National Large-scale epidemiological investigations of
Comorbidity Survey Replication (NCS-R),found the prevalence of depression have varied in their
that ofrespondents with MDD,96.9% reported at findings. For example, findings from the most
least some,87.4% at least moderate,59.3% severe recent epidemiological survey carried out in the
or very severe,and 19.1% very severe role impair- United States,the NCS-R,which was conducted
ment associated with their depression (Kessler et in 2001–2002 and used DSM-IV criteria, esti-
al.,2003).Given its early age ofonset (i.e.,median mated the prevalence of MDD to be 16.2% for
age ofonset is in the mid-20s),depression can also lifetime and 6.6% for the 12 months before
negatively affect critical life course role transitions, assessment (Kessler et al.,2003).These estimates
including educational attainment,entry into the are much higher than those from the Epidemio-
labor force,parenting,and marital timing and sta- logical Catchment Area study carried out approx-
bility (Kessler,2002). imately two decades earlier, which estimated
The social cost of depression is high as well. prevalence rates for MDD using DSM-IIIcriteria
Much of the role impairment caused by the dis- to be 3.0–5.9% for lifetime and 1.7–3.4% for
order is seen as reduced work performance,with 12 months (Weissman, Bruce, Leaf, Florio, &
some estimates placing the annual cost ofdepres- Holzer, 1991). A number of reasons for such
sion in terms of lost productivity in the United discrepancy have been proposed, including
States at more than $33 billion (Kessler, 2002). methodological differences across surveys, less
For example,the NCS-R found that respondents reluctance to admit depression in more recent
with 12-month MDD reported an average of cohorts,and a genuine increase in the prevalence
35.2 days in the past year when they were unable of depression in recent cohorts (Kessler, 2002),
to work or carry out normal activities, which particularly among young people (Gotlib &
is more than twice the less than 15 days recently Hammen,2002).
reported for most chronic conditions (Kessler
et al.,2003).Depression is not only one ofthe most
The Course ofMDD
common disorders faced by mental health profes-
sionals but also one ofthe most costly (Dozois & The typical onset of depression is in adoles-
Westra,2004). cence, and the disorder is increasingly being
understood as often involving a chronic or
recurring course (Gotlib & Hammen, 2002).
The Epidemiology ofMDD
Epidemiological data indicate that the risk ofini-
Given recent estimates, such as that almost tial onset ofdepression is fairly low until the early
20% ofthe U.S.population at one point in their teens,when it begins to rise in a linear fashion,
lives will experience a clinically significant and the slope ofthis increase has become increas-
episode ofdepression,the disorder is among the ingly steep in more recent age cohorts (Kessler,
most common psychiatric conditions (Gotlib & 2002; Kessler et al., 2003). The course of an
Hammen, 2002). In terms of point prevalence, untreated major depressive episode is variable but
community self-report surveys indicate that as typically lasts 4 months or longer (APA, 2000).
many as 20% ofadults and 50% ofchildren and Although they may change in severity,the specific
adolescents report experiencing depressive symptoms endorsed by people with major
symptoms for recall periods between 1 week and depressive disorders appear to remain stable over
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Major Depressive Disorder 137
the course of the disorder (Minor,Champion,& INTERVIEWINGSTRATEGIES
Gotlib,2005).
Even after recovery from an episode after treat- Structured Diagnostic Interviews
ment,many people continue to experience symp-
Structured diagnostic interviewing has been
toms and psychosocial impairment,and residual
called a necessary tool in assessing psychological
symptoms are associated with a more severe
disorders, given the complexity of current
relapsing and chronic course ofthe disorder (Judd
diagnostic systems such as the DSM-IV-TR
et al., 1998, 2000). More than 80% of people
(Barbour & Davison,2004).Structured diagnos-
with a history of major depression experience
tic interviews exhibit a number of advantages
recurrent episodes (Kessler, 2002), and rates of
over their unstructured or less structured coun-
recurrence increase and time between episodes
terparts. For example, they lessen the possible
decreases with each successive episode (Boland &
impact of interviewer bias, they are generally
Keller,2002).A number of risk factors for recur-
more comprehensive and ensure adequate cov-
rent depression have been identified,including a
erage of symptoms, and they have been shown
history of frequent or multiple episodes, double
to improve diagnostic reliability (Groth-Marnat,
depression, and long duration of individual
1999).Therefore,structured and semistructured
episodes (Boland & Keller,2002).
diagnostic interviews have become the standard
in research situations and are becoming the
Comorbidity and MDD “hallmark of empirically driven clinical prac-
tice”as well (Summerfeldt & Antony,2002,p.3).
It has been noted that “the existence of‘pure’
The selection ofa particular interview is based
depressive states may be quite rare”(Clark,Beck,
on a number ofpotential considerations,includ-
& Alford, 1999, p. 23) and that comorbidity
ing coverage and content. Coverage includes
among people with depression is the “norm”
whether the interview covers the disorders of
(Kessler,2002).Particularly high rates ofcomor-
interest and such factors as time period of inter-
bidity are observed between depressive disorders
est and course of the disorder.Content refers to
and anxiety disorders,schizophrenia,substance
such issues whether the interview was developed
abuse, and eating disorders, and depression
for and validated with (or is generally applicable
often is comorbid with a range of medical con-
to) the population of interest; psychometric
ditions (Belzer & Schneier, 2004; Dozois &
factors,involving consideration ofreliability and
Dobson,2002).For example,the NCS-R found
validity in terms ofthe diagnoses and population
that 72.1% of respondents with lifetime MDD
of interest; and practical issues, such as length
also met criteria for at least one of the other
of the interview and training requirements
DSM-IVdisorders assessed,with the highest rate
(Summerfeldt & Antony,2002).The Schedule for
of comorbidity observed with anxiety disorders
Affective Disorders and Schizophrenia (SADS)
(59.2%),followed by impulse control disorders
and the Structured Clinical Interview for DSM-
(30.0%; e.g., bulimia, conduct disorder, anti-
IV Axis I Disorders (SCID) are commonly used
social personality disorder) and substance use
examples ofstructured diagnostic interviews that
disorders (24.0%) (Kessler et al.,2003).
exhibit excellent psychometric properties and
In the event of comorbidity, depression
have been identified as the best methods for
generally is secondary,occurring after the onset
diagnosing mood disorders (Dozois & Dobson,
of the comorbid condition.This pattern occurs
2002).Each ofthese structured interviews will be
more often for some comorbid conditions,such
addressed in turn.
as anxiety disorders, than for others, such as
substance use disorders,and more often among
men than women (Kessler, 2002; Kessler et al., Schedule for Affective Disorders and Schizophrenia.
2003).Consideration ofcomorbid conditions in The SADS (Endicott & Spitzer, 1978) is one of
the assessment of depression is critical because the earliest attempts to address diagnostic error
comorbidity is generally associated with greater through structured interviewing. Developed
psychosocial impairment and poorer treatment before the DSM-III,which introduced the use of
response and outcome (Boland & Keller, 2002; explicit diagnostic criteria, the SADS relies on
Dozois & Dobson,2002). the research diagnostic criteria (RDC) ofSpitzer,
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138 SPECIFIC DISORDERS
Endicott,and Robins (1978).Since its introduc- Whereas Part I focuses on individual symp-
tion, the SADS has undergone a number of toms,Part II is organized by specific syndrome,
expansions,and several versions are available,each with questions for each section that assess
developed for a specific purpose (Summerfeldt & screening criteria,individual symptoms,degree
Antony, 2002). Some versions differ in terms of impairment or severity, and associated fea-
of the temporal focus of assessment;the regular tures.Specific symptoms are rated in a dichoto-
version (SADS) differentiates symptoms experi- mous fashion (“yes” or “no”), and clinically
enced over the past year from past history significant ratings are used to determine RDC
of mental disorders,the lifetime version (SADS- diagnosis. As a semistructured interview, the
L) considers all current and past symptoms,and SADS provides a number oflevels ofinquiry for
the change version (SADS-C) assesses change in each symptom, including standard questions,
symptoms over time. Other versions have been optional probes,and nonstandardized questions
developed for use with specific disorders; for to clarify responses. Also, the interviewer may
example,the SADS-LB provides expanded cover- choose to skip sections ofthe interview based on
age ofbipolar disorder,the SADS-LA does so for the interviewee’s responses to screening ques-
anxiety disorders,and recent versions,such as the tions.Additional sources ofinformation,such as
SADS-LA-IV,have begun to incorporate DSM-IV medical records and family members,may also
in addition to RDC criteria (Summerfeldt & be consulted to enhance diagnostic accuracy.
Antony,2002). The SADS displays strong psychometric
Of the available versions, the SADS and properties. Evidence from a number of studies
SADS-L are the most widely used. The SADS-L indicates good to excellent reliabilities for the
provides lifetime coverage, and the SADS pro- SADS at all levels ofassessment,including diag-
vides more information about current episodes nosis, summary scales, and specific symptoms
(Summerfeldt & Antony, 2002). Twenty-three (Summerfeldt & Antony, 2002). There is also
major diagnostic categories, as defined by the considerable evidence for the validity of SADS
RDC, are covered by the SADS, with the mood diagnoses (e.g.,concurrent,predictive validity);
disorders category including major depressive, for example,SADS diagnosis and summary scale
manic-depressive, and minor depressive disor- scores have been found to predict course,symp-
ders.Scores on eight dimensional summary scales toms, and outcome for a range of disorders,
are also provided,four ofwhich assess aspects of including schizophrenia, bipolar disorder, and
depression,including depressive mood and idea- major depression (Summerfeldt & Antony,
tion, endogenous features, depressive-associated 2002).In terms of the assessment of depression
features,and suicidal ideation and behavior. in particular, the SADS has demonstrated high
Although the general format differs across interrater reliability,and has been found to cor-
versions, the SADS generally consists of three relate with independent measures ofdepression
components. The first component is a brief (Dozois & Dobson,2002).
overview of the client’s background and demo- The SADS is not without limitations
graphics, such as education, peer relations, (Summerfeldt & Antony, 2002). The SADS
and hospitalizations, and an assessment of the assesses fewer diagnoses than other diagnostic
course of any past illnesses. Part I of the diag- interviews. With an administration time of
nostic part of the SADS assesses individual approximately 90–120 minutes, the SADS is
symptoms ofthe disorders covered,both for the also quite lengthy,and its use takes considerable
worst period of the current episode and for the training,both ofwhich may limit its use in clini-
current period,defined as the past week,which cal settings (Dozois & Dobson,2002).However,
is meant to minimize the impact ofdaily symp- its strengths include its ability to make fine
tom fluctuation. Most symptoms are rated on distinctions between subtypes of mood disorder
multipoint scales (i.e.,three- or six-point scales) and its strong psychometric properties and exten-
in terms offrequency and intensity,with a rating sive research base (Dozois & Dobson, 2002;
of0 applied ifthe item is not applicable or there Summerfeldt & Antony, 2002). Although its
is no information available.Cut points on these utility in some clinical situations may be limited,
scales identify clinically significant symptoms, the SADS is particularly suited to research situa-
and numeric ratings are also accompanied by tions requiring diagnostic precision (Dozois &
descriptive severity anchors. Dobson,2002).
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Major Depressive Disorder 139
Structured Clinical Interview for DSM-IV Axis I are used as necessary, and a skip-out option is
Disorders. The SCID-I (First,Spitzer,Gibbon,& also available ifthe interviewee does not meet a
Williams,1995,1996) probably is the most widely critical criterion required for a given disorder.
used semistructured diagnostic interview among Administration time generally varies between 45
North American researchers (Summerfeldt & and 90 minutes,although the average interview
Antony,2002).Originally introduced to increase for depressed people generally takes less than
diagnostic reliability by operationalizing DSM-III 60 minutes (Dozois & Dobson,2002).
diagnostic criteria, the SCID has undergone a The SCID for DSM-IV is new,and therefore
number ofrevisions,with the most recent version there is little evidence supporting its psychomet-
reflecting DSM-IVcriteria.A separate version of ric properties (Nezu, Nezu, McClure, & Zwick,
the SCID is available for diagnosing Axis II per- 2002).However,reliability data are available for
sonality disorders (SCID-II), and there are two earlier versions ofthe SCID,which indicate wide
primary versions ofthe SCID available for assess- variability in interrater agreement (as assessed by
ment ofAxis I disorders:a clinical version (SCID- the kappa coefficient) across disorders and
CV) and a research version (SCID-I). The within categories, including depression (Dozois
SCID-CV was designed to assess the disorders & Dobson, 2002). Findings in general indicate
most commonly seen in clinical settings (e.g., acceptable reliabilities for disorders commonly
mood, substance use, and anxiety disorders), seen in clinical settings,including major depres-
whereas the SCID-I is much longer and allows sive disorder and anxiety disorders (Summerfeldt
assessment ofmore disorders and more in-depth & Antony, 2002). As Summerfeldt and Antony
examination ofsubtypes and course and severity observe, the variability in reported kappas may
specifiers. result at least in part from variation in the skill
The SCID allows the assessment of 51 DSM- and training of the interviewer because the
IV Axis I disorders, organized in terms of nine SCID relies largely on clinical judgment and
diagnostic modules (mood episodes, psychotic diagnostic skill. The validity of the SCID
symptoms, psychotic disorders differential, depends largely on the validity ofthe DSM-IV,to
mood disorders differential, substance use dis- which it is aligned. There is some evidence for
orders,anxiety disorders,somatoform disorders, correspondence between the SCID and other
eating disorders, and adjustment disorders), standardized measures and symptom ratings,
and the interview can be customized to include but determining validity is difficult given the lack
only the modules deemed relevant. Like the ofa diagnostic gold standard (Dozois & Dobson,
SADS, the SCID begins with an open-ended 2002).As Summerfeldt and Antony observe,fur-
overview of demographic information and ther investigation of the validity of the SCID is
the patient’s current presenting complaint warranted.
and level of functioning, as well as history of The SCID shares a number ofthe limitations
psychopathology and treatment,which not only of the SADS, including the need for training
provides the interviewer with important infor- on the part of interviewers. Summerfeldt and
mation but also assists in building rapport and Antony (2002) note a number of other limita-
providing context for the subsequent interview tions, including possible threats to reliability
(Summerfeldt & Antony, 2002). A series of 12 arising from its semistructured format, greater
questions are then administered to determine susceptibility to response styles and deliberate
which modules to administer before the inter- faking because of its high face validity, and the
view proper begins. fact that information about subthreshold condi-
Depending on the modules used, the SCID tions is lost because of its decision tree format
varies in length. Each diagnostic section and use ofskip-outs.However,these authors also
includes both required probe questions and point to the SCID’s many advantages,including
suggested follow-up questions. Based on the its breadth of coverage and its alignment with
respondent’s answers, the interviewer deter- the DSM.Compared with the SADS,the SCID is
mines whether diagnostic criteria are absent, more comprehensive,takes less time to adminis-
subthreshold, or present, with a fourth option ter,is more congruent with DSM-IVcriteria,and
available if information is insufficient to rate a offers a clinician version; therefore, it may be
given item.Both probe and follow-up questions, the preferred structured interview in diagnosing
which may involve asking for specific examples, depression (Dozois & Dobson,2002).
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140 SPECIFIC DISORDERS
Clinician Rating of Symptoms: The Hamilton optimal assessment strategy ifthe goal is diagno-
Rating Scale for Depression.The Hamilton Rating sis and are particularly well suited to research sit-
Scale for Depression (HRSD; Hamilton, 1960, uations necessitating a high degree ofdiagnostic
1967) is the most commonly used clinician rating precision (Dozois & Dobson, 2002). The utility
instrument of depressive symptoms (Dozois & ofsuch measures in clinical situations is limited,
Dobson,2002).Widely used in both clinical and however,and clinicians are more likely to use less
research settings,the HRSD is commonly viewed structured and formal interviews, often called
as a gold standard among depression scales clinical interviews,in order to assess client symp-
and was designed to assess severity ofsymptoms toms (Barbour & Davison,2004).As Dozois and
among people diagnosed with a depressive disor- Dobson (2002, p. 272) observe, “much of the
der and to assess change in symptoms over time information necessary for the assessment of
(Nezu et al.,2002).The HRSD is not a structured depression results from the clinical interview.”
interview, but it does rely on information gath- The format and specific content ofthe clinical
ered through an interview procedure.Specifically, interview depend on a number offactors,includ-
the scale consists of 21 items and takes approxi- ing the particular goal of the assessment and
mately 10 minutes to complete after a 30-minute, the theoretical orientation of the interviewer
open-ended interview to gather the required (Barbour & Davison,2004;Groth-Marnat,1999).
information. Other sources may also be inter- For example,whereas a more client-centered clin-
viewed ifthe accuracy ofthe patient’s report is in ician might work to enhance the process of self-
question (Hamilton,1967).Ofthe 21 items ofthe change through a more nondirective interview
original HRSD,17 are scored in terms ofseverity style, a behavioral interview probably would
during the past few days or week. Items focus work to obtain particular information about
largely on behavioral and somatic symptoms of external consequences ofbehavior through more
depression,such as insomnia,psychomotor retar- structured questioning (Groth-Marnat, 1999).
dation,and appetite and weight change,although Some general areas of assessment include the
specific items differ across versions (Nezu,Ronan, history of the problem, such as initial onset,
Meadows,& McClure,2000). antecedents and consequences, and treatment
The fact that numerous versions ofthe HRSD history; family background, including family
are in use complicates examination ofthe scale’s constellation, cultural background, and emo-
psychometric properties across investigations. tional and medical history;and personal history,
However, the HRSD appears to be a reliable including pertinent information regarding
measure that is sensitive to treatment change, infancy, childhood, adolescence, and early, mid-
and several lines of evidence support its validity dle, and late adulthood (Groth-Marnat, 1999).
(Dozois & Dobson,2002;Nezu et al.,2002;Nezu, A combination of both open-ended and more
Ronan,et al.,2000).Some ofthe identified limi- directive questioning is generally used,depending
tations of the HRSD include an emphasis on on client characteristics and the type ofinforma-
somatic items relative to mood and cognitive tion required.Several texts are available that pro-
symptoms, lack of evidence for discriminant vide in-depth information and recommendations
validity, inconsistent item weightings, and a for the initial clinical interview (e.g., Morrison,
focus on symptoms over the past week rather 1995;Othmer & Othmer,1994).
than 2 weeks,as required by DSM-IVdiagnostic Among the greatest advantages of less struc-
criteria (Dozois & Dobson,2002).Despite these tured interviewing are its flexibility and ideo-
limitations, the measure exhibits high clinical graphic focus,which allows in-depth exploration
utility and research applicability (Nezu, Ronan, of particular issues through follow-up on
et al., 2000); given its utility in assessing treat- specific responses (Groth-Marnat, 1999). Such
ment targets and outcome,along with its wide- interviews can be modified depending on the
spread use, Dozois and Dobson recommend particular situation and also allow the develop-
routine use ofthe HRSD in clinical practice. ment of rapport and client-self-exploration
(Groth-Marnat,1999).However,although flexi-
bility is one of the greatest inherent strengths of
Clinical Interviewing
the clinical interview, it is also associated with
As noted earlier, structured interviews, such the potential weakness of interviewer bias (i.e.,
as the SADS and SCID, probably represent the the halo effect, confirmatory bias, the primacy