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Revista Brasileira de Psiquiatria
Online version ISSN 1809452X
Rev. Bras. Psiquiatr. vol.29 no.1 São Paulo Mar. 2007 Epub Nov 27, 2006
http://dx.doi.org/10.1590/S151644462006005000024
ORIGINAL ARTICLE
Validity and limitations of the Brazilian version of
the Composite International Diagnostic Interview
(CIDI 2.1)
Validade e limitações da versão brasileira do Composite
International Diagnostic Interview (CIDI 2.1)
Maria Inês QuintanaI; Fábio Leite GastalII; Miguel Roberto JorgeI;
Cláudio Torres MirandaIII; Sérgio Baxter AndreoliI,IV
IUniversidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil IINational Hospital Accreditation Organization of Brazil, Brasília (DF), Brazil
IIIPan American Health Organization, Division of Mental Health, Washington, DC, USA IVUniversidade Católica de Santos (UNISANTOS), Santos (SP), Brazil
Correspondence
ABSTRACT
OBJECTIVE: To study the concurrent validity of the Brazilian Composite International Diagnostic Interview 2.1 using as gold standard the clinical diagnoses based on the ICD10 criteria and the Longitudinal, Expert, All Data (LEAD) procedure.
METHOD: The sample was composed of 185 subjects selected at psychiatric hospitals, psychiatric outpatient units, the community, and primary care services. These individuals were intentionally selected according to 9 diagnostic groups. Instruments: Composite International Diagnostic Interview (CIDIcore) version 2.1 (paper andpencil) administered by 16 trained interviewers. Analysis: concurrent validity of diagnoses of the Composite International Diagnostic Interview 12month.
RESULTS: Values found for sensitivity and specificity in each diagnosis were: alcoholrelated disorders (79.5%/97.2%); psychoactive substancerelated disorders (77.3%/100%); schizophrenia and other psychotic disorders (28.6%/93.9%); manic episode and bipolar affective disorder (38.9%/96.4%); depressive disorder (82.5%/ 93.8%); phobicanxiety disorder (80.6%/93.5%); obsessivecompulsive disorder (18.2%/98.9%); somatoform disorder (41.7%/90.8%); eating disorder (45.5%/100.0%).
CONCLUSION: The Composite International Diagnostic Interview proved to be valid for diagnoses of alcohol related disorders, psychoactive substancerelated disorders, depressive disorder and phobicanxiety disorder. The probable explanations for the poor performance for the other diagnoses were: necessity of some clinical judgement by the lay interviewer; difficulty to use the Probe Flow Chart; interviewees' difficulty of
understanding; and lack of mechanisms to certify the veracity of the information.
Descriptors: Diagnosis; Psychiatric status rating scales; Validity of tests; Interview, psychological
RESUMO
OBJETIVO: Validação concorrente da versão brasileira do Composite International Diagnostic Interview 2.1, utilizando como padrão ouro o diagnóstico médico baseado nos critérios diagnósticos da CID10 e critérios
Longitudinal, Experts Clinicians, All Data (LEAD).
MÉTODO: Amostra composta por 185 indivíduos procedentes de hospitais psiquiátricos, ambulatórios de especialidades psiquiátricas, serviços comunitários e atenção primária à saúde, selecionados intencionalmente segundo nove grupos diagnósticos. Instrumentos: CIDI 2.1 (lápis e papel), versão para diagnósticos ao longo da vida, aplicado por 16 entrevistadores treinados. Análise: validade concorrente dos diagnósticos do Composite International Diagnostic Interview no último ano.
RESULTADOS: Os valores encontrados de sensibilidade e especificidade foram: transtornos decorrentes do uso de álcool (79,5%/97,2%); transtornos decorrentes do uso de substâncias psicoativas (77,3%/100%);
esquizofrenia e outros transtornos psicóticos (28,6%/93,9%); episódio maníaco e transtorno afetivo bipolar (38,9%/96,4%); transtorno depressivo (82,5%/93,8%); transtorno fóbicoansioso (80,6%/93,5%); transtorno obsessivocompulsivo (18,2%/98,9%); transtorno somatoforme (41,7%/90,8%); e transtorno alimentar (45,5%/100,0%).
CONCLUSÃO: O Composite International Diagnostic Interview mostrouse válido para os diagnósticos de transtornos decorrentes do uso de álcool e substâncias psicoativas, transtorno depressivo e transtorno fóbico ansioso. As prováveis explicações para o pior desempenho nos demais diagnósticos foram: necessidade de algum julgamento clínico do entrevistador leigo; dificuldade no manuseio do Diagrama de Especificação de Resposta; dificuldade de compreensão dos entrevistados; e falta de mecanismos para atestar a veracidade das informações.
Descritores: Diagnóstico; Escala de graduação psiquiátrica; Validade dos testes; Entrevista, psicológica
Introduction
The Composite International Diagnostic Interview (CIDI) is a fully standardized, structured interview that provides a psychiatric diagnosis through computerized algorithms1 according to the International Classification of Diseases, 10th edition (ICD10),2 and the Diagnostic and Statistical Manual of the American Psychiatric Association, 4th edition (DSMIV).3 The CIDI was developed in 1980 by the World Health Organization (WHO) in collaboration with the former US Alcohol, Drug Abuse and Mental Health Administration (ADMHA) as a Joint Project for the Diagnosis and Classification of Mental Disorders, and Alcohol and DrugRelated Problems. Its greatest appeal is that it was designed to be administered by trained lay interviewers in epidemiological studies, clinical trials and research centers.48 It can be administered to individuals aged above 18 years, regardless their social, economic and cultural status, and does not depend on the patients' literacy.79
The CIDI is available in paperandpencil and computeradministered forms (selfadministered) with a diagnostic coverage for both lifetime (Core version) and 12month assessment. The average time to administer the
questionnaire is 75 minutes.8 The questions are explicit and positive answers are further explored by a specified probing system, the Probe Flow Chart (PFC). The PFC leads the interviewer to a standardized decision tree (algorithm) that will determine if the symptom was present but was not important enough for the individual to seek assistance (code 2); if the symptom occurred but was due to the use of medication, drug, alcohol, or caused by trauma or a physical disorder (code 3 and 4) or, finally, if it is a psychiatric symptom (code 5). The CIDI comprises 288 symptom questions distributed throughout 14 sections, 10 of which are for diagnostic purposes and 4 are nondiagnostic (Table 1). Training for the use of the CIDI 2.1 should follow the norms and regulations established by the WHO.8
The objective of this study is to assess the concurrent validity and the limitations of the CIDI 2.1 Core version for 12month diagnosis in mental health services in Brazil, using as gold standard the clinical diagnoses based on the ICD10 criteria.
Method
This study is part of the project to assess the "Performance of the Composite International Diagnostic Interview (CIDI 2.1) in Brazilian mental health services," whose first stage was the assessment of the instrument's reliability.10 At this stage its validation will be presented. The gold standard used was the clinical diagnoses formulated by experienced psychiatrists, using the ICD10 criteria and based on the Spitzer's LEAD procedure: "Longitudinal" (longitudinal assessment of symptoms), "Expert" (diagnosis formulated by specialists), "All Data" (all available information).11
1. Subjects
The sample was composed of 185 subjects allocated to each of the nine diagnostic sections of the CIDI to be validated (except for the tobacco section). Subjects were intentionally selected from different mental health services: psychiatric hospitals (Clínica Olivé Leite, PelotasRS; Hospital Espírita, PelotasRS; and UNIFESP, São PauloSP; n = 81), mental health outpatient units (Clínica Olivé Leite, UFPel, PelotasRS; and UNIFESP, São PauloSP; n = 54), community services (NGO, Clínica Olivé Leite, UFPel; n = 6) and a primary care center (UFPel; n = 40). Patients with severe intellectual impairment, incapacitating organic psychoses and without definitive diagnosis (diagnostic doubts) were excluded from the study.
The sample was selected by convenience so it would cover all the CIDI diagnoses since some of them present a low prevalence.
2. Instruments 1) CIDI 2.1
The CIDI 2.1 was translated into Portuguese by a bilingual psychiatrist, according to WHO guidelines. There was no backtranslation, although the sections were presented to experienced psychiatrists in order to evaluate translation aspects such as psychopathological phenomena, terminology and cultural adaptation according to RubioStipec's recommendations.14 Remarks and suggestions of the specialists were incorporated into the final version of the questionnaire. Interviewers were submitted to the standard training of the CIDI 2.1 according to WHO guidelines.8 The interviewer's team was composed of 13 first year medical students, with no training in
psychiatry or psychology, and 3 mental health researchers (2 psychologists and 1 social worker). The interview with the CIDI 2.1 occurred on the day that the psychiatrist was consulted about the subject's diagnosis. The interviewers, however, were blind to the clinical diagnosis and administered all the instrument's sections. 3. Procedures
centers, the inclusion criteria were modified in order to include individuals without psychiatric diagnosis. In this setting, before being examined by an experienced psychiatrist, patients or their accompanying person answered the Self Report Questionnaire (SRQ30),1213 and then were classified according to the cutoff point of 7/8. All interviewers where blind for the medical diagnostic and the SRQ, and there was no previous contact between the interviewer and the respondent.
The study was approved by the Research Ethics Committee of the Universidade Federal de São Paulo.
4. Analysis
The concurrent validation was studied for 12month diagnoses, and indicators of sensitivity, specificity and incorrect classification rate were calculated. Confidence interval of 95% was calculated to sensitivity and specificity by the following formula: sensibility ± 1.96 and especificity ± 1.96
. Inconsistent results of CI 95%, such as less than 0 (zero) or more than 1, were approximated to 0 and 100% receptiveness. The Kappa coefficient was calculated to allow comparisons with other studies.
In all individuals presenting false negative result, the diagnoses were inspected to determinate de possible error causes.
Results
The sample was composed of 185 subjects, of which 53% (n = 98) were women with a mean age of 37 years (1673 years; sd: 12.9), and a mean of 1.7 children per subject (011; sd: 1.8). Regarding the marital status, 39.5% (n = 73) had never been married, 36.8% (n = 68) were married, 19.5% (n = 38) were separated or divorced, and 3.2% (n = 6) were widowers. Mean schooling was 7 years (020 years; sd: 3.8), but 86.5% (n = 160) were not studying and 68.1% (n = 126) were unemployed.
The average duration of the interview was 2 hrs 30 min, varying from 50 minutes (subject with no psychiatric diagnosis) to 3 hrs 40 min (subject with Eating Disorder diagnosis). Most interviews (80%) where completed in one session.
Clinicians formulated in average 1.3 diagnoses per subject, the CIDI generated 1.2 diagnoses per subject and when the exclusion criteria of the ICD10 was not taken into account, this mean increased to 1.5 diagnoses per subject.
The validity indicators of the specific sections are shown in Table 2. For 12month diagnoses, the CIDI had sensitivity above 70% for alcohol and psychoactive substance abuse and dependence, depressive and phobic anxiety disorders and below 50% for psychotic, manic episode and bipolar affective disorder, obsessive compulsive disorder, somatoform and eating disorders.
Discussion
The interview with the CIDI at mental health services was well accepted10 and there were no refusals to participate. Psychiatrists formulated more diagnoses per patient than the CIDI, which is in disagreement with the literature.15 This was probably due to the instructions and the discussion with psychiatrists to include all diagnoses.
Our results are in agreement with those reported in the literature, i.e., sensitivity above 70% for diagnoses of alcohol dependence syndrome,16 depressive disorder,16,1819 phobicanxiety disorder,1718 and sensitivity below 70% for diagnoses of schizophrenia and other psychotic disorders,17,20 manic episode and bipolar affective disorder,17 somatoform disorder21 and eating disorder.17,22 Nevertheless, some results are different from previous studies. Komiti et al. found lower sensitivity rates for generalized anxiety (12%) and social phobia (63%).15 Andrews et al. found higher sensitivity rates for the diagnosis of obsessivecompulsive disorder (85.5%).18
We found advantages in the CIDI, such as standardization of data collection, widening and deepening the investigation field of the physician,15,2324 standardization of the communication between different professionals, and utilization of lay interviewers as a way to reduce costs in population studies.
The rigidity of the rules and the inflexibility of the diagnostic algorithms caused the detection of only the number of occurred symptoms and not their severity or hierarchical importance. For instance, the subject should present six depressive symptoms for a diagnosis of depression, regardless of the symptoms. Therefore, sleeping
problems have the same weight in formulating the diagnostic as suicidal thoughts or attempts.
The need of clinical judgment occurs in some questions that involve cultural aspects. This was observed particularly in the schizophrenia section, which investigates symptoms that are very subtly different from the normal. These limitations can by minimized with strong training focusing these difficulties.
Other limitations are: the interviewees' difficulty of understanding, limitation of information sources for
diagnostic formulation, lack of mechanisms to verify the veracity of the information (intentional or unintentional denial of symptoms and recall of the symptom), and long duration of the interview.
The probable explanations for the low sensitivity rate of some sections are different for each diagnosis, but are related to the abovementioned limitations. Thus, for schizophrenia and other psychotic disorders, the worse performance was due to the need of clinical judgment by the interviewer and the limited capability of the patient to provide information. For manic episode and bipolar affective disorder, the lack of mechanisms to verify the veracity of the information; for somatoform disorder, the need of clinical judgment and the difficult
management of the Probe for Chart (PFC); for obsessivecompulsive disorder and eating disorder, the lack of mechanisms to verify the veracity of the information and the limited capability of the patient to provide information.
The CIDI indirectly requires some knowledge or judgment capacity to identify organic disorders and mental symptoms. The most common difficulties were: 1) the interviewer should understand the interviewees' answers and decide in which category they fit and 2) at some moments, the questionnaire has rules through which the interviewer should judge and codify a symptom mentioned by the interviewee. Questions such as: "has the interviewee felt worthless/guilty only due to depression?," require a minimum level of clinical experience to decide about the presence of the symptom. Besides, different cultural conceptions, religious ideas and sociocultural level may influence this judgment.25
Other complication generated by the lack of clinical expertise is the information provided by the interviewees about their clinical diseases, which are unknown to the interviewers. In these cases, in addition to the
interviewer's clinical judgment, the patient should understand the diagnosis he/she had received.21
The patient's phase of the disease is an important factor: subjects in an acute phase showed much difficulty to concentrate in the interview, understand the questions, and answer them accurately.20,2628 The CIDI diagnostic accuracy decreases in the acute phase of schizophrenia.29 As to chronic phases, the fear of stigmatization makes individuals deny or minimize their experience with psychotic symptoms.25,27,30 These difficulties
associated with psychosis have frequently generated opinions against the use of structured instruments for more chronic diseases such as schizophrenia.31
The training of the professionals who will administer the CIDI in the clinical setting is, as described above, a limiting factor. The experience of WHO Collaborating Center in Brazil and of other training centers for CIDI shows that specialists (psychiatrists) are not good interviewers of structured questionnaires, especially when they are very experienced, as they have much difficulty with rigid rules and closed questions that do not allow a clinical judgment, feeling diminished in their knowledge and underestimated.32 On the other hand, lay
interviewers showed better skills to administer the CIDI in this study, despite the lack of the clinical knowledge, which is required in some situations. These considerations lead to a paradox which may be taken into account when choosing the instrument. However, training of lay interviewers with more attention to the symptoms, and questions that need clinical reasoning and culturally determined interpretations, may minimize its limitations.
Limitation
The validity of some specific disorders could not be studied because it was not possible to identify subjects, for instance, patients with posttraumatic stress disorder. Other disorders were affected by the small size of the sample, such as, obsessivecompulsive disorder, somatoform disorder, and eating disorder. Among them, obsessivecompulsive disorder was the only disorder that had a result in disagreement with the literature, thus we recommend a new study with a larger sample.
Conclusion
determined interpretations.
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Correspondence: Dr. Maria Inês Quintana Rua Dr. Bacelar, 334
04026001 São Paulo, SP, Brazil Phone/fax: (55 11) 50847060 / 7061 Email: [email protected]
Financing: FIDEPS, Clínica Olivé Leite and Fundação de Apoio à Pesquisa do Estado de São Paulo (FAPESP, 98/102531).
Conflict of interests: None Submitted: September 25, 2005 Accepted: September 18, 2006
Universidade Federal de São Paulo (UNIFESP), São Paulo (SP), Brazil.
Rua Pedro de Toledo, 967 casa 1 04039032 São Paulo SP Brazil
