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    Following is a listing of recently published research and related abstracts. A listing of additional research previously published is also available.

    1. McDermut,  W., Fuller, J.R., DiGiuseppe, R., Chelminski, I.,  Zimmerman, M.
    Trait anger and Axis I comorbidity: Implications for Rational Emotive Behavior
    Therapy.
    Journal of Rational Emotive & Cognitive Behavior Therapy. 2009, 27, 79-82.

    2. Gaudiano, B.A., Zimmerman, M. Journal of Clinical Psychiatry 2010, 71, 442-450
    Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Butler Hospital, Psychosocial Research Program, Providence, RI 02906, USA. Brandon_Gaudiano@brown.edu
    Does comorbid posttraumatic stress disorder affect the severity and course of psychotic
    major depression?
     

    Abstract: BACKGROUND: Major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) are commonly comorbid conditions that result in greater severity, chronicity, and impairment compared with either disorder alone. However, previous research has not systematically explored the potential effects of the psychotic subtyping of MDD and comorbid PTSD.
    METHOD: The sample in this retrospective case-control study conducted from December 1995 to August 2006 consisted of psychiatric outpatients with DSM-IV- diagnosed psychotic MDD with PTSD, psychotic MDD without PTSD, or nonpsychotic MDD with PTSD presenting for clinic intake. Clinical indices of severity, impairment, and history of illness were assessed by trained diagnosticians using the Structured Clinical Interview for DSM-IV Axis I Disorders supplemented by items from the Schedule for Affective Disorders and Schizophrenia. RESULTS: In terms of current severity and impairment, the psychotic MDD with PTSD (n = 34) and psychotic MDD only (n = 26) groups were similar to each other, and both tended to be more severe than the nonpsychotic MDD with PTSD group (n = 263). In terms of history of illness, the psychotic MDD with PTSD group tended to show greater severity and impairment relative to either the psychotic MDD only or nonpsychotic MDD with PTSD groups. Furthermore, the psychotic MDD with PTSD patients had an earlier time to depression onset than patients with either psychotic MDD alone or nonpsychotic MDD with PTSD, which appeared to contribute to the poorer history of illness demonstrated in the former group. CONCLUSIONS: Future research should explore the possibility of a subtype of psychotic depression that is associated with PTSD, resulting in a poorer course of illness. The current findings highlight the need for pharmacologic and psychotherapeutic approaches that can be better tailored to psychotic MDD patients with PTSD comorbidity.

    3. J Clin Psychiatry. 2010 Mar;71(3):235-8. Epub 2010 Jan 26. Psychiatrists' and nonpsychiatrist physicians' reported use of the DSM-IV criteria for major depressive disorder. Zimmerman M, Galione J. Bayside Medical Center, 235 Plain Street, Providence, RI 02905, USA. mzimmerman@lifespan.org  

    Abstract: OBJECTIVE: Several studies of nonpsychiatrist physicians suggest that there are deficits in the knowledge and application of the diagnostic criteria for major depressive disorder (MDD). This research raises questions about the clinical utility of the MDD criteria. The goal of the present study was to determine psychiatrists' reported use of the DSM-IV criteria for MDD to diagnose depression and to compare their use to the use by nonpsychiatrist physicians. METHOD: The subjects were 291 psychiatrists and 40 nonpsychiatrist physicians who attended a continuing medical education conference in 2006 or 2007 on the treatment and management of depression. Prior to a lecture, the subjects completed a questionnaire that included a question regarding how frequently the DSM-IV diagnostic criteria for MDD are used when diagnosing depression. RESULTS: Nearly one-quarter of the psychiatrists indicated that they usually did not use the DSM-IV MDD criteria when diagnosing depression, and nearly half of the nonpsychiatrist physicians indicated that they rarely used the DSM-IV MDD criteria to diagnose depression. CONCLUSIONS: A substantial minority of psychiatrists and the majority of nonpsychiatrist physicians reported that they often do not use the DSM-IV MDD criteria when diagnosing depression. These findings raise questions about the clinical utility of the MDD criteria. These results, along with other studies demonstrating problems with recalling the MDD criteria, suggest that clinical utility should be considered in discussions of revising these criteria for DSM-V.


    4. J Clin Psychiatry. 2010 Apr;71(4):484-90. Underrecognition of clinically significant side effects in depressed outpatients. Zimmerman M, Galione JN, Attiullah N, Friedman M, Toba C, Boerescu DA, Ragheb M. Bayside Medical Center, 235 Plain Street, Providence, RI 02905, USA. mzimmerman@lifespan.org  

    Abstract: OBJECTIVE: The presence of medication side effects is one of the most frequent reasons depressed patients discontinue medication, and premature discontinuation of medication is associated with poorer outcome in the treatment of depression. Despite the clinical importance of detecting side effects, few studies have examined the adequacy of their detection and documentation by clinicians. We are not aware of any studies comparing psychiatrists' clinical assessments to a standardized side effects checklist in depressed patients receiving ongoing treatment in clinical practice. The goal of the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project was to test the hypothesis that fewer side effects would be recorded by psychiatrists in their patients' charts compared to the number reported by patients on a side effects checklist. METHOD: Three hundred depressed outpatients (diagnosed according to DSM-IV criteria) in ongoing treatment completed a self-administered version of the Toronto Side Effects Scale (TSES). The patients rated the frequency of each of the 31 side effects and the degree of trouble caused by them. A research assistant reviewed patients' charts to extract side effects information recorded by the treating psychiatrist. The study was conducted from June 2008 to July 2008. RESULTS: The mean number of side effects reported by the patients on the TSES was 20 times higher than the number recorded by the psychiatrists (P < .01). When the self- reported side effects were limited to frequently occurring or very bothersome side effects, the rate was still 2 to 3 times higher (P < .01).
    CONCLUSIONS: Psychiatrists may not be aware of most side effects experienced by psychiatric outpatients receiving ongoing pharmacologic treatment for depression.

    5. Addict Behav. 2009 Jun-Jul;34(6-7):587-92. Epub 2009 Apr 1. Diagnosing alcohol abuse in alcohol dependent individuals: diagnostic and clinical implications. Ray LA, Hutchison KE, Leventhal AM, Miranda R Jr, Francione C, Chelminski I, Young D, Zimmerman M. Department of Psychology, University of California, Los Angeles, 1285 Franz Hall, Box 951563, Los Angeles, CA 90095-1563, United States. lararay@psych.ucla.edu  

    Abstract: In DMS-IV, the diagnosis of alcohol abuse is precluded by the diagnosis of alcohol dependence. The goal of this study was to examine the diagnostic and clinical implications of diagnosing alcohol abuse among alcohol dependent individuals. Treatment-seeking psychiatric outpatients with a lifetime history of alcohol dependence (n=544), some of whom (n=45) did not meet lifetime criteria for alcohol abuse completed in-depth, face-to-face, semi-structured clinical assessments of DSM-IV axis I and axis II psychopathology. Alcohol dependent patients who did not meet criteria for alcohol abuse were significantly more likely to be female, have a later age of onset for alcohol dependence, have fewer dependence symptoms, and have a lower rate of positive family history for alcoholism, and were less likely to report a lifetime history of DSM-IV drug use disorders and PTSD. These findings suggest that diagnosing alcohol abuse among alcohol dependent patients may be clinically useful as an index of severity and higher likelihood of comorbid drug abuse and dependence. Future studies are needed to establish whether these differences are clinically significant in terms of the course of the disorder and response to treatment.


    6. Compr Psychiatry. 2010 Mar-Apr;51(2):99-105. Epub 2009 Jul 9. Clinical characteristics of depressed outpatients previously overdiagnosed with bipolar disorder. Zimmerman M, Ruggero CJ, Chelminski I, Young D. Department of Psychiatry and Human Behavior, Brown University School of Medicine, Providence, RI 02905, USA. mzimmerman@lifespan.org  

    Abstract: The diagnosis of bipolar disorder in depressed patients requires the ascertainment of prior episodes of mania and hypomania. Several research reports and commentaries have suggested that bipolar disorder is underrecognized and that many patients with nonbipolar major depressive disorder have, in fact, bipolar disorder. In a previous article from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we reported the opposite phenomenon-that bipolar disorder is often overdiagnosed in psychiatric outpatients. An important question that has not been previously examined is whether there is a particular clinical or demographic profile associated with bipolar disorder overdiagnosis among depressed patients. Forty psychiatric outpatients with current major depressive disorder reported having been previously diagnosed with bipolar disorder, which was not confirmed when interviewed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID). Psychiatric diagnoses, clinical and demographic variables were compared in these 40 patients and 233 depressed patients who were not diagnosed with bipolar disorder. Patients were interviewed by a highly trained diagnostic rater who administered the SCID for DSM-IV Axis I disorders, the Structured Interview for DSM-IV Personality for DSM-IV Axis II disorders, and the Schedule for Affective Disorders and Schizophrenia for clinical features of depression. The depressed patients who were overdiagnosed with bipolar disorder were diagnosed with a significantly higher number of Axis I disorders and were more likely to be diagnosed with specific phobia, posttraumatic stress disorder, and drug abuse/dependence. The patients overdiagnosed with bipolar disorder were also significantly more likely to be diagnosed with a current personality disorder and were more chronically ill with greater psychosocial impairment. Thus, the results suggest that depressed outpatients who had previously been overdiagnosed with bipolar disorder were more chronically and severely ill than depressed outpatients who had not been overdiagnosed.


    7. J Clin Psychiatry. 2010 Sep;71(9):1212-7. Epub 2010 Mar 23. Screening for bipolar disorder and finding borderline personality disorder. Zimmerman M, Galione JN, Ruggero CJ, Chelminski I, Young D, Dalrymple K, McGlinchey JB. Department of Psychiatry and Human Behavior, Brown Medical School, Department of Psychiatry Rhode Island Hospital, Providence, USA. mzimmerman@lifespan.org  

    Abstract: OBJECTIVE: Bipolar disorder and borderline personality disorder share some clinical features and have similar correlates. It is, therefore, not surprising that differential diagnosis is sometimes difficult. The Mood Disorder Questionnaire (MDQ) is the most widely used screening scale for bipolar disorder. Prior studies found a high false-positive rate on the MDQ in a heterogeneous sample of psychiatric patients and primary care patients with a history of trauma. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we examined whether psychiatric outpatients without bipolar disorder who screened positive on the MDQ would be significantly more often diagnosed with borderline personality disorder than patients who did not screen positive. METHOD: The study was conducted from September 2005 to November 2008. Five hundred thirty-four psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV and Structured Interview for DSM-IV Personality Disorders and asked to complete the MDQ. Missing data on the MDQ reduced the sample size to 480. Approximately 10% of the study sample were diagnosed with a lifetime history of bipolar disorder (n = 52) and excluded from the initial analyses. RESULTS: Borderline personality disorder was 4 times more frequently diagnosed in the MDQ positive group than the MDQ negative group (21.5% vs 4.1%, P < .001). The results were essentially the same when the analysis was restricted to patients with a current diagnosis of major depressive disorder (27.6% vs 6.9%, P = .001). Of the 98 patients who screened positive on the MDQ in the entire sample of patients, including those diagnosed with bipolar disorder, 23.5% (n = 23) were diagnosed with bipolar disorder, and 27.6% (n = 27) were diagnosed with borderline personality disorder. CONCLUSIONS: Positive results on the MDQ were as likely to indicate that a patient has borderline personality disorder as bipolar disorder. The clinical utility of the MDQ in routine clinical practice is uncertain.


    8. Psychol Med. 2010 Mar;40(3):451-7. Epub 2009 Jul 23. A simpler definition of major depressive disorder. Zimmerman M, Galione JN, Chelminski I, McGlinchey JB, Young D, Dalrymple K, Ruggero CJ, Witt CF. Department of Psychiatry and Human Behavior, Brown Medical School, Providence and Rhode Island Hospital, Providence, RI, USA. mzimmerman@lifespan.org  

    Abstract: BACKGROUND: The DSM-IV symptom criteria for major depressive disorder (MDD) are somewhat lengthy, with many studies showing that treatment providers have difficulty recalling all nine symptoms. Moreover, the criteria include somatic symptoms that are difficult to apply in patients with medical illnesses. In a previous report, we developed a briefer definition of MDD that was composed of the mood and cognitive symptoms of the DSM-IV criteria, and found high levels of agreement between the simplified and full DSM-IV definitions. The goal of the present study was to replicate these findings in another large sample of psychiatric out-patients and to extend the findings to other patient samples. METHOD: We interviewed 1100 psychiatric out-patients and 210 pathological gamblers presenting for treatment and 1200 candidates for bariatric surgery. All patients were interviewed by a diagnostic rater who administered a semi-structured interview. We inquired about all symptoms of depression for all patients. RESULTS: In all three samples high levels of agreement were found between the DSM- IV and the simpler definition of MDD. Summing across all 2510 patients, the level of agreement between the two definitions was 95.5% and the kappa coefficient was 0.87. CONCLUSIONS: After eliminating the four somatic criteria from the DSM-IV definition of MDD, a high level of concordance was found between this simpler definition and the original DSM-IV classification. This new definition offers two advantages over the current DSM-IV definition--it is briefer and it is easier to apply with medically ill patients because it is free of somatic symptoms.


    9. Bipolar Disord. 2009 Nov;11(7):759-65. Performance of the mood disorders questionnaire in a psychiatric outpatient setting. Zimmerman M, Galione JN, Ruggero CJ, Chelminski I, McGlinchey JB, Dalrymple K, Young D. Department of Psychiatry and Human Behavior, Brown University School of Medicine, Providence, RI 02905, USA. mzimmerman@lifespan.org  

    Abstract: OBJECTIVES: The Mood Disorders Questionnaire (MDQ) has been the most widely studied screening questionnaire for bipolar disorder, though few studies have examined its performance in a heterogeneous sample of psychiatric outpatients. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined the operating characteristics of the MDQ in a large sample of psychiatric outpatients presenting for treatment. METHODS: A total of 534 psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV and asked to complete the MDQ. Missing data on the MDQ reduced the number of patients to 480, 10.4% (n = 52) of whom were diagnosed with bipolar disorder. RESULTS: Based on the scoring guidelines recommended by the developers of the MDQ, the sensitivity of the scale was only 63.5% for the entire group of bipolar patients. The specificity of the scale was 84.8%, and the positive and negative predictive values were 33.7% and 95.0%, respectively. When impairment was not required to define a case on the MDQ, then sensitivity increased to 75.0%, specificity dropped to 78.5%, positive predictive value was 29.8%, and negative predictive value was 96.3%. CONCLUSIONS: In a large sample of psychiatric outpatients, we found that the MDQ, when scored according to the developers' recommendations, had inadequate sensitivity as a screening measure. After the threshold to determine MDQ caseness was lowered by not requiring moderate or severe impairment, the sensitivity of the scale increased, but specificity decreased, and positive predictive value remained below 30%. These results raise questions regarding the MDQ's utility in routine clinical practice.


    10. J Pers Disord. 2010 Dec;24(6):763-72. A comparison of depressed patients with and without borderline personality disorder: implications for interpreting studies of the validity of the bipolar spectrum. Galione J, Zimmerman M. Department of Psychiatry and Human Behavior, Brown University School of Medicine, Rhode Island Hospital, Providence, RI, USA.

    Abstract: The nosological status of borderline personality disorder as it relates to the bipolar disorder spectrum has been controversial. Studies have supported, in part, the validity of the bipolar spectrum by demonstrating that these patients, compared to patients with nonbipolar depression, are characterized by earlier age of onset of depression, recurrent depressive episodes, comorbid anxiety and substance use disorders and increased suicidality. However, all of these factors have likewise been found to distinguish depressed patients with and without borderline personality disorder. A family history of bipolar disorder is one of the few disorder specific validators. In the present study from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compared the demographic and clinical characteristics of depressed patients with and without borderline personality disorder. We hypothesized that many of the factors used to validate the bipolar spectrum will also distinguish depressed patients with and without borderline personality disorder except, however, a family history of bipolar disorder. Two thousand nine hundred psychiatric outpatients at Rhode Island Hospital were evaluated with the Structured Clinical Interview for DSM-IV (SCID) and Structured Interview for DSM-IV Personality Disorders (SIDP-IV). Family history information regarding first-degree relatives was obtained from the patient using the Family History Research Diagnostic Criteria. One hundred and one patients with borderline personality disorder plus major depressive disorder were compared to 947 patients with major depressive disorder alone on the prevalence of bipolar disorder validators. Compared to depressed patients without borderline personality disorder, depressed patients with borderline personality disorder had a younger age of onset, more depressive episodes, a greater likelihood of experiencing atypical symptoms and had a higher prevalence of comorbid anxiety disorders, substance use disorders, and number of previous suicide attempts. The depressed patients with borderline personality disorder did not significantly differ from the patients without borderline personality disorder on morbid risk for bipolar disorder in first degree relatives. In addition, patients with a diagnosis of bipolar disorder had a significantly higher morbid risk of bipolar disorder in first degree relatives than the borderline personality disorder group. The findings indicate that many factors used to validate the bipolar spectrum are not disorder specific. These results raise questions about studies of the validity of the broad bipolar spectrum that do not assess borderline personality disorder. Our results do not support inclusion of borderline personality disorder as part of the bipolar spectrum.


    11. Compr Psychiatry. 2010 Jul-Aug;51(4):340-6. Epub 2009 Dec 21. Adifferent approach toward screening for bipolar disorder: the prototype matching method. Zimmerman M, Galione JN, Ruggero CJ, Chelminski I, Young D. Department of Psychiatry and Human Behavior, Brown University School of Medicine, Providence, RI 02905, USA. mzimmerman@lifespan.org  

    Abstract: Most screening scales for psychiatric disorders consist of a series of questions about the signs and symptoms of the disorder of interest, and to determine whether a patient screens positive, the scores of the individual items are summed and the total score is compared with an empirically derived threshold. A problem with the score summation approach toward case identification on screening scales is that different studies may find that different thresholds are optimal for distinguishing cases from noncases. An alternative approach toward screening is the prototype matching approach, in which respondents are asked to indicate how well their clinical history matches the described prototype. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we compared the symptom summation and prototype matching approaches toward screening for bipolar disorder in a large sample of psychiatric outpatients. Nine hundred sixty-one psychiatric outpatients were interviewed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition and completed the Bipolar Spectrum Disorders Scale (BSDS). The BSDS is a unique screening scale consisting of a prototypic description of bipolar disorder. The respondent checks off which items in the prototypic paragraph describes them and also answers a single multiple-choice question at the end of the paragraph asking how well the paragraph describes them. The results of a receiver operating curve analysis found that the score summation and prototype matching approaches toward screening on the BSDS performed equally well. These findings provide preliminary evidence that an alternative approach toward psychiatric screening, the prototype matching approach, is as effective as the traditional score summation method. This raises the intriguing possibility of developing a combined screening scale/educational instrument that can be formatted as a brochure and thus placed in clinicians' waiting rooms, thereby facilitating use of the measure.

    12. J Psychiatr Res. 2010 Apr;44(6):405-8. Epub 2009 Nov 3. Borderline personality disorder and the misdiagnosis of bipolar disorder. Ruggero CJ, Zimmerman M, Chelminski I, Young D. Department of Psychology, University of North Texas, Denton, TX, USA. Camilo.Ruggero@unt.edu  

    Abstract: Recent reports suggest bipolar disorder is not only under-diagnosed but may at times be over-diagnosed. Little is known about factors that increase the odds of such mistakes. The present work explores whether symptoms of borderline personality disorder increase the odds of a bipolar misdiagnosis. Psychiatric outpatients (n=610) presenting for treatment were administered the Structured Clinical Interview for DSM-IV (SCID) and the Structured Interview for DSM-IV Personality for DSM-IV axis II disorders (SIDP- IV), as well as a questionnaire asking if they had ever been diagnosed with bipolar disorder by a mental health care professional. Eighty-two patients who reported having been previously diagnosed with bipolar disorder but who did not have it according to the SCID were compared to 528 patients who had never been diagnosed with bipolar disorder. Patients with borderline personality disorder had significantly greater odds of a previous bipolar misdiagnosis, but no specific borderline criterion was unique in predicting this outcome. Patients with borderline personality disorder, regardless of how they meet criteria, may be at increased risk of being misdiagnosed with bipolar disorder.


    13. Personality Disorders: Theory, Treatment, and Research, 2010, 1, 22-37 Huprich, S.K., Schmitt, T., Richard, D.C.S., Chelminski, I., Zimmerman, M. Comparing factor analytic models of the DSM-IV personality disorder symptoms in psychiatric outpatients.  


    14. Acta Psychiatr Scand. 2010 Jun;121(6):462-70. Epub 2009 Sep 18. The relationship between childhood trauma history and the psychotic subtype of major depression. Gaudiano BA, Zimmerman M. Department of Psychiatry & Human Behavior, Alpert Medical School of Brown University, Providence, RI, USA. brandon_gaudiano@brown.edu  

    Abstract: OBJECTIVE: Increasing evidence exists linking childhood trauma and primary psychotic disorders, but there is little research on patients with primary affective disorders with psychotic features. METHOD: The sample consisted of adult out-patients diagnosed with major depressive disorder (MDD) at clinic intake using a structured clinical interview. Patients with MDD with (n = 32) vs. without psychotic features (n = 591) were compared as to their rates of different types of childhood trauma. RESULTS: Psychotic MDD patients were significantly more likely to report histories of physical (OR = 2.81) or sexual abuse (OR = 2.75) compared with non-psychotic MDD patients. These relationships remained after controlling for baseline differences. Within the subsample with comorbid post-traumatic stress disorder, patients with psychotic MDD were significantly more likely to report childhood physical abuse (OR = 3.20). CONCLUSION: Results support and extend previous research by demonstrating that the relationship between childhood trauma and psychosis is found across diagnostic groups.


    15. J Nerv Ment Dis. 2010 May;198(5):339-42. Detecting differences in diagnostic assessment of bipolar disorder. Zimmerman M, Ruggero CJ, Galione JN, McGlinchey JB, Dalrymple K, Chelminski I, Young D. Department of Psychiatry and Human Behavior, Brown School of Medicine, Providence, RI 02905, USA. mzimmerman@lifespan.org  

    Abstract: During the past 25 years, semistructured diagnostic interviews have been the standard for diagnostic evaluations in research relying on reliable and valid psychiatric assessment and diagnosis. However, the use of semistructured interviews still requires interpretation of the diagnostic criteria and does not preclude the application of different diagnostic thresholds. The goal of this report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project is to illustrate how a self-report scale can be used to detect systematic differences in the application of diagnostic criteria for bipolar disorder and to demonstrate the wide variation in how broadly different groups tend to diagnose bipolar disorder. We compared the frequency of bipolar diagnoses in 4 studies that examined the performance of mood disorders questionnaire (MDQ) with the Structured Clinical Interview for DSM-IV (SCID). We also compared the prevalence rate of MDQ cases and the ratio of SCID diagnoses with MDQ cases. The frequency of bipolar disorder in the 4 studies ranged from 10.9% to 76.2%-a 7-fold difference in prevalence rates. The frequency of MDQ-positive cases ranged from 17.8% to 31.2%, less than a 2- fold difference in prevalence rates. Thus, there was much less variability in MDQ rates than diagnosis rates. Moreover, the rank order of the prevalence of MDQ cases differed from the rank order of the prevalence of SCID diagnoses. The SCID/MDQ ratio significantly differed between the studies. These findings demonstrate how systematic differences in diagnostic practice might be detected using a self-administered scale such as the MDQ. The results also underscore that wide variation exists in the bias toward diagnosing bipolar disorder, even after controlling for differences in prevalence among samples.


    16. J Clin Psychiatry. 2010 May;71(5):534-42. Epub 2010 Mar 9. A clinically useful anxiety outcome scale. Zimmerman M, Chelminski I, Young D, Dalrymple K. Bayside Medical Center, 235 Plain St, Providence, RI 02905, USA. mzimmerman@lifespan.org  

    Abstract: OBJECTIVE: Standardized scales are increasingly being recommended to measure outcome when treating psychiatric disorders in routine clinical practice. If the standard of care is to change and scales are to be incorporated into clinical practice, then it will be necessary to develop measures that are feasible to use as well as have good psychometric properties. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we describe the reliability and validity of the Clinically Useful Anxiety Outcome Scale (CUXOS). The CUXOS was designed to be a brief (completed in less than 2 minutes), quickly scored (in less than 15 seconds), clinically useful measure that is reliable, valid, and sensitive to change. METHOD: Nearly 1,000 psychiatric outpatients completed the CUXOS and were rated on clinician severity indices of depression, anxiety, and anger. A subset of patients completed other self-report symptom severity scales in order to examine discriminant and convergent validity, and a subset completed the CUXOS twice in order to examine test- retest reliability. Sensitivity to change was examined in patients with panic disorder and generalized anxiety disorder. RESULTS: On average, the CUXOS took less than 1.5 minutes to complete. The scale had high internal consistency and test-retest reliability, and was more highly correlated with other self-report measures of anxiety than with measures of depression, substance use problems, eating disorders, and anger. The CUXOS was more highly correlated with clinician severity ratings of anxiety than with depression and anger, and CUXOS scores were significantly higher in psychiatric outpatients with anxiety disorders than in patients with other psychiatric disorders. Finally, the CUXOS was a valid measure of symptom change. CONCLUSIONS: The results of this large validation study of the CUXOS show that it is a reliable and valid measure of anxiety that is feasible to incorporate into routine clinical practice.


    17. Can J Psychiatry. 2010 Sep;55(9):568-76. Frequency and correlates of gambling problems in outpatients with major depressive disorder and bipolar disorder. Kennedy SH, Welsh BR, Fulton K, Soczynska JK, McIntyre RS, O'Donovan C, Milev R, le Melledo JM, Bisserbe JC, Zimmerman M, Martin N. University of Toronto, Ontario, Canada. sidney.kennedy@uhn.on.ca  

    Abstract: OBJECTIVE: To investigate the frequency of gambling in people who have been diagnosed with major depressive disorder (MDD) or bipolar disorder (BD). Secondary objectives were to examine: sex differences in the rates of gambling behavior, the temporal relation between onset of mood disorders and problem gambling, psychiatric comorbidities associated with problem gambling, and the influences of problem gambling on quality of life. METHOD: People (aged 18 years and older) who met criteria for lifetime Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision-defined MDD or BD I or II, and were confirmed by the Mini International Neuropsychiatric Interview, were enrolled. Participants were recruited from 5 sites in Canada and 1 in the United States. Prevalence of past-year problem gambling was assessed with the Canadian Problem Gambling Index. Associated comorbidities with problem gambling are presented. RESULTS: A total of 579 participants were enrolled (female: n = 379, male: n = 200). Prevalence of problem gambling did not differ significantly between the MDD (12.5%) and the BD (12.3%) groups. There was a significant difference in the prevalence of problem gambling between males (19.5%) and females (7.8%) in the BD group (chi- square = 8.695, df = 1, P = 0.003). Among people meeting criteria for problem gambling, the mood disorder was the primary onset condition in 71% of cases. People with a mood disorder with comorbid current panic disorder (OR = 1.96; 95% CI 1.02 to 3.75), obsessive-compulsive disorder (OR = 1.86; 95% CI 1.01 to 3.45), specific phobia (OR = 2.36; 95% CI 1.17 to 4.76), alcohol dependence (OR = 5.73; 95% CI 3.08 to 10.65), or lifetime substance dependence (OR = 2.05; 95% CI 1.17 to 3.58), had significantly increased odds of problem gambling. Problem gambling across MDD and BD populations was also associated with lower quality of life ratings. CONCLUSION: These results reaffirm a higher prevalence of gambling both in BD and in MDD populations, compared with previously published community samples. Our study also identifies risk factors for gambling behaviors within these populations.


    18. BMJ. 2010 Feb 22;340:c855. doi: 10.1136/bmj.c855. Is underdiagnosis the main pitfall in diagnosing bipolar disorder? No. Zimmerman M. Rhode Island Hospital, Bayside Medical Building, 235 Plain Street, Providence, RI 02905, USA. mzimmerman@lifespan.org Comment on: BMJ. 2010;340:c854.


    19. J Nerv Ment Dis. 2010 Jun;198(6):452-4. Overdiagnosis of bipolar disorder and disability payments. Zimmerman M, Galione JN, Ruggero CJ, Chelminski I, Dalrymple K, Young D. Department of Psychiatry and Human Behavior, Brown Medical School, Providence, RI 02905, USA. mzimmerman@lifespan.org  

    Abstract: The diagnosis of bipolar disorder has received increasing attention during the past decade. Several research reports have suggested that bipolar disorder is under-recognized, and that many patients, particularly those with major depressive disorder, have, in fact, bipolar disorder. More recently, some reports have suggested that bipolar disorder is also overdiagnosed at times. There are several possible reasons for bipolar disorder overdiagnosis. In the present study, we examined whether secondary gain associated with receiving disability payments might be partially responsible for bipolar disorder overdiagnosis. A total of 82 psychiatric outpatients reported having been previously diagnosed with bipolar disorder, which was not confirmed when interviewed with the Structured Clinical Interview for DSM-IV. The percentage of patients receiving disability payments and the duration of disability payments were compared in these 82 patients and 528 patients who were not diagnosed with bipolar disorder. Compared with the patients who had never been diagnosed with bipolar disorder, the patients overdiagnosed with bipolar disorder were significantly more likely to have received disability payments at some point during the past 5 years, and were receiving disability payments for significantly more weeks. We conducted a regression analysis controlling for the number of lifetime diagnoses, and overdiagnosis of bipolar disorder was a significant predictor of disability status (OR = 3.8; 95% CI, 1.6-8.8). Thus, an unconfirmed diagnosis of bipolar disorder was significantly associated with receiving disability benefits.

    20. Psychol Addict Behav. 2010 Jun;24(2):360-5. The relative roles of bipolar disorder and psychomotor agitation in substance dependence. Leventhal AM, Zimmerman M. Department of Preventive Medicine, University of Southern California Keck School of Medicine, Alhambra, CA 91803, USA. adam.leventhal@usc.edu  

    Abstract: Previous studies have shown that both bipolar disorder (BPD) and psychomotor agitation (PMA) are associated with substance dependence. These two findings have yet to be integrated, despite evidence that PMA is closely linked with the bipolar spectrum. Accordingly, the current study examined whether BPD and PMA had unique or overlapping associations with substance dependence disorders. Participants were 2,300 individuals seeking outpatient psychiatric treatment. Before treatment, participants were assessed using structured clinical interviews, which yielded DSM-IV psychiatric diagnoses and clinical ratings of mood symptoms. Current PMA and lifetime BPD were present in 483 and 172 (bipolar I, n = 71; bipolar II, n = 101) participants, respectively. Current PMA and lifetime BPD each were associated with increased prevalence of lifetime nicotine, alcohol, and drug dependence (ORs >or= 1.52, ps <or= .0004). These associations remained significant when controlling for demographic characteristics and comorbid psychiatric disorders, except the link between agitation and alcohol dependence, which was reduced to a trend (p = .058). Although BPD and PMA were associated with each other, these two factors demonstrated unique, nonoverlapping relationships to nicotine, alcohol, and drug dependence. Individuals with both PMA and BPD exhibited especially high rates of comorbid substance dependence. The present results replicate and extend previous findings documenting the relations of BPD and PMA to substance dependence. BPD and PMA may represent independent psychopathological correlates of substance dependence. Future research should explore the theoretical and clinical significance of these potentially distinct relations to substance dependence.


    21. Psychology of Men and Masculinity in press Ray, L., Primack, J., Chelminski, I., Young, D., Zimmerman, M. Diagnostic and clinical profiles of treatment seeking men with and without a lifetime history of substance use disorders.  


    22. Depress Anxiety. 2010 Oct;27(10):977-81. Validity of a simpler definition of major depressive disorder. Zimmerman M, Galione JN, Chelminski I, Young D, Dalrymple K, Witt CF. The Department of Psychiatry and Human Behavior, Rhode Island Hospital, Brown Medical School, Providence, USA. mzimmerman@lifespan.org  

    Abstract: BACKGROUND: In previous reports from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we developed a briefer definition of major depressive disorder (MDD), and found high levels of agreement between the simplified and DSM-IV definitions of MDD. The goal of the present study was to examine the validity of the simpler definition of MDD. We hypothesized that compared to patients with adjustment disorder, patients with MDD would be more severely depressed, have poorer psychosocial functioning, have greater suicidal ideation at the time of the intake evaluation, and have an increased morbid risk for depression in their first-degree family members. METHODS: We compared 1,486 patients who met the symptom criteria for current MDD according to either DSM-IV or the simpler definition to 145 patients with a current diagnosis of adjustment disorder with depressed mood or depressed and anxious mood. RESULTS: The patients with MDD were more severely depressed, more likely to have missed time from work due to psychiatric reasons, reported higher levels of suicidal ideation, and had a significantly higher morbid risk for depression in their first-degree family members. Both definitions of MDD were valid. CONCLUSIONS: The simpler definition of MDD was as valid as the DSM-IV definition. This new definition offers two advantages over the DSM-IV definition-it is briefer and therefore more likely to be recalled and applied in clinical practice, and it is free of somatic symptoms thereby making it easier to apply with medically ill patients.


    23. CNS Spectr. 2009 Dec;14(12 Suppl 12):4-7. Introduction: selecting an antidepressant. Zimmerman M. Department of Psychiatry and Human Behavior at Brown University School of Medicine, Providence, RI, USA. mzimmerman@lifespan.org  


    24. Depress Anxiety. 2010 Nov;27(11):1044-9. doi: 10.1002/da.20716. Epub 2010 Jun 23 Recognition of irrationality of fear and the diagnosis of social anxiety disorder and specific phobia in adults: implications for criteria revision in DSM-5. Zimmerman M, Dalrymple K, Chelminski I, Young D, Galione JN. The Department of Psychiatry and Human Behavior, Brown Medical School, Providence, Rhode Island, USA. mzimmerman@lifespan.org  

    Abstract: BACKGROUND: In DSM-IV, the diagnosis of social anxiety disorder (SAD) and specific phobia in adults requires that the person recognize that his or her fear of the phobic situation is excessive or unreasonable (criterion C). The DSM-5 Anxiety Disorders Work Group has proposed replacing this criterion because some patients with clinically significant phobic fears do not recognize the irrationality of their fears. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project we determined the number of individuals who were not diagnosed with SAD and specific phobia because they did not recognize the excessiveness or irrationality of their fear. METHODS: We interviewed 3,000 psychiatric outpatients and 1,800 candidates for bariatric surgery with a modified version of the Structured Clinical Interview for DSM- IV. In the SAD and specific phobia modules we suspended the skip-out that curtails the modules if criterion C is not met. Patients who met all DSM-IV criteria for SAD or specific phobia except criterion C were considered to have "modified" SAD or specific phobia.
    RESULTS: The lifetime rates of DSM-IV SAD and specific phobia were 30.5 and 11.8% in psychiatric patients and 11.7 and 10.2% in bariatric surgery candidates, respectively. Less than 1% of the patients in both samples were diagnosed with modified SAD or specific phobia. CONCLUSION: Few patients were excluded from a phobia diagnosis because of criterion C. We suggest that in DSM-5 this criterion be eliminated from the SAD and specific phobia criteria sets.


    25. Compr Psychiatry. 2011 Mar-Apr;52(2):146-50. Epub 2010 Jun 26. Impact of obesity on the psychometric properties of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for major depressive disorder. Zimmerman M, Hrabosky JI, Francione C, Young D, Chelminski I, Dalrymple K, Galione JN. Department of Psychiatry and Human Behavior, Brown Medical School, Providence, RI 02905, USA. mzimmerman@lifespan.org  

    Abstract: Obesity is associated with several symptoms that are components of the diagnostic criteria for major depressive disorder (MDD). Compared with nonobese individuals, obese individuals report more fatigue, sleep disturbance, and overeating. Obesity might, therefore, impact the psychometric properties of the MDD criteria. The goal of the present report from the Rhode Island Hospital Methods to Improve Diagnostic Assessment and Services project was to examine the impact of obesity on the psychometric characteristics of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition symptom criteria for major depression. Two thousand four hundred forty-eight psychiatric outpatients were administered a semistructured diagnostic interview. We inquired about all symptoms of depression for all patients. The mean sensitivity of the 9 criteria in the nonobese and obese patients was nearly identical (74.6% vs 74.3%). The mean specificity was slightly higher in the nonobese patients (82.0% vs 79.5%). No symptom was more specific in the obese than the nonobese patients, whereas the specificity of increased appetite, increased weight, and fatigue was more than 5% lower in the obese patients. Increased appetite, increased weight, hypersomnia, and fatigue had a higher sensitivity in the obese than the nonobese patients, whereas decreased appetite, weight loss, and diminished concentration had a higher sensitivity in the nonobese than the obese patients. Thus, although there were small differences between obese and nonobese patients in the operating characteristics of some symptoms, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for MDD generally performed equally well for obese and nonobese patients.

    26. Primary Psychiatry 2010, 17, 46-53. Zimmerman, M., Young, D., Chelminski, I., Dalrymple, K. How can you improve quality without measuring outcome? Getting from here to there.  

    27. Bipolar Disord. 2010 Aug;12(5):528-38. Performance of the Bipolar Spectrum Diagnostic Scale in psychiatric outpatients. Zimmerman M, Galione JN, Chelminski I, Young D, Ruggero CJ. Department of Psychiatry and Human Behavior, Brown Medical School, Providence, RI, USA. mzimmerman@lifespan.org  

    Abstract: OBJECTIVES: Recent research has suggested that bipolar disorder, when defined to include milder variants such as bipolar II disorder and bipolar disorder not otherwise specified (NOS), is more prevalent than had been previously reported and often underrecognized. Recommendations for improving the detection of bipolar disorder have included careful clinical evaluations inquiring about a history of mania and hypomania and the use of screening questionnaires. The Bipolar Spectrum Diagnostic Scale (BSDS) was designed to be particularly sensitive to the milder variants of bipolar disorder. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined the operating characteristics of the BSDS in a large sample of psychiatric outpatients presenting for treatment. METHODS: A total of 1,100 psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV and asked to complete the BSDS. Missing data on the BSDS reduced the sample size to 961, approximately 10% (n = 90) of whom were diagnosed with bipolar disorder. RESULTS: The sensitivity of the BSDS was similar for bipolar I disorder, bipolar II disorder, and bipolar disorder NOS/cyclothymia. A receiver operating curve (ROC) analysis indicated that cutoffs of 11 and 12 maximized the sum of sensitivity and specificity for the entire group of patients with bipolar disorder (area under curve = 0.80, p < 0.001). The cutoff point associated with 90% sensitivity for the entire sample of patients with bipolar disorder was 8. At this cutoff the specificity of the scale was 51.1% and positive predictive value was 16.0%. We compared the patients with and without bipolar disorder on each of the BSDS symptom items. The odds ratios were higher for the items assessing hypomanic/manic symptoms than items assessing depressive symptoms. We therefore examined the performance of a subscale composed only of the hypomania/mania items. The area under the curve in the ROC analysis was nearly identical to that of the entire scale (0.81, p < 0.001). CONCLUSIONS: With its high negative predictive value, the BSDS was excellent at ruling out a diagnosis of bipolar disorder; however, the low positive predictive value indicates that it is not good at ruling in the diagnosis. These data raise questions about the use of the BSDS as a screening measure in routine clinical psychiatric practice.


    28. Expert Rev Neurother. 2010 Jul;10(7):1019-21. Problems diagnosing bipolar disorder in clinical practice. Zimmerman M.


    29. Annals of Clinical Psychiatry, in press. Zimmerman, M., Galione, J.N., Attiullah, N., Friedman, M., Toba, C., Boerescu, D.A., Ragheb, M. Depressed patients perspectives of two measures of outcome: The Quick Inventory of Depressive Symptomatology (QIDS) and the Remission from Depression Questionnaire (RDQ).


    30. Journal of Abnormal Psychology, 2010, 119, 886-895. Cooper, L.D., Balsis, S., Zimmerman, M. Criteria combinations in the personality disorders: Challenges associated with a polythetic diagnostic system.  

    Converging research on the diagnostic criteria for personality disorders (PDs) reveals that most criteria have different psychometric properties. This finding is inconsistent with the PD diagnostic system according to the Diagnostic and Statistical Manual of Mental Health Disorders (4th ed.; American Psychiatric Association, 1994), which weights each criterion equally. The purpose of the current study was to examine the potential effects of using equal weights for differentially functioning criteria. Data from over 2,100 outpatients were used to analyze and score response patterns to the diagnostic criteria for 9 PDs within an item response theory framework. Results indicated that combinations that included the same number of endorsed criteria yielded differing estimates of PD traits, depending on which criteria were met. Moreover, trait estimates from subthreshold criteria combinations often overlapped with diagnostic (at-threshold or higher) combinations, indicating that there were subthreshold combinations of criteria that indicated as much or more PD than did some combinations at the diagnostic threshold. These results suggest that counting the number of criteria an individual meets provides only a coarse estimation of his or her PD trait level. Implications for the assessment of polythetically defined mental disorders and for the PD proposal for the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders are discussed.


    31. Psychiatry Res. 2011 Feb 28;185(3):444-9. Epub 2010 Jul 24. Psychiatric diagnoses in patients who screen positive on the Mood Disorder Questionnaire: Implications for using the scale as a case-finding instrument for bipolar disorder. Zimmerman M, Galione JN, Chelminski I, Young D, Dalrymple K. Department of Psychiatry and Human Behavior, Brown Medicine School, Providence, RI, USA. mzimmerman@lifespan.org  

    Abstract: Bipolar disorder is prone to being overlooked because its diagnosis is more often based on retrospective report than cross-sectional assessment. Recommendations for improving the detection of bipolar disorder include the use of screening questionnaires. The Mood Disorder Questionnaire (MDQ) is the most widely studied self-report screening scale that has been developed to improve the detection of bipolar disorder. Although developed as a screening scale, the MDQ has also been used as a case-finding measure. However, studies of the MDQ in psychiatric patients have found high false positive rates, though no study has determined the psychiatric diagnoses associated with false positive results on the MDQ. The goal of the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project was to identify the psychiatric disorders associated with increased false positive rates on the MDQ. Four hundred eighty psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM- IV (SCID) and completed the MDQ. After excluding the 52 patients diagnosed with a lifetime history of bipolar disorder we compared diagnostic frequencies in patients who did and did not screen positive on the MDQ. Based on the Hirschfeld et al. scoring guidelines of the MDQ, 15.2% (n=65) of the 428 nonbipolar patients screened positive on MDQ. Compared to patients who screened negative, the patients who screened positive were significantly more likely have a current and lifetime diagnosis of specific phobia, posttraumatic stress disorder, alcohol and drug use disorders, any eating disorder, any impulse control disorder, and attention deficit disorder. Results were similar using a less restrictive threshold to identify MDQ cases. That is, MDQ caseness was associated with significantly elevated rates of anxiety, impulse control, substance use, and attention deficit disorders. Studies using the MDQ as a stand-alone proxy for the diagnosis of bipolar disorder should consider whether the presence of these other forms of psychopathology could be responsible for differences between individuals who screen positive and negative on the scale.


    32. Br J Psychiatry. 2010 Oct;197(4):326-7. Evaluation of evidence for the psychotic subtyping of post-traumatic stress disorder.Gaudiano BA, Zimmerman M. Department of Psychiatry & Human Behavior, Alpert Medical School of Brown University, and Psychosocial Research Program, Butler Hospital, Providence 02906, USA. Brandon_Gaudiano@brown.edu Comment in: Br J Psychiatry. 2011 Feb;198:156; author reply 156.

    Abstract: Psychotic symptoms may occur in 15-64% of individuals with post-traumatic stress disorder, suggesting that the syndrome  could be subtyped in a similar fashion to mood disorders.In our study of 1800 psychiatric out-patients who completed comprehensive diagnostic interviews, the lifetime  prevalence of psychotic symptoms in people with PTSD was 17% (odds ratio (OR) = 3.48, 95% CI 2.32-5.21). However, after excluding   people with  comorbid conditions also known to be associated with psychotic symptoms  this dropped to only 2.5% (OR) = 0.60, 95%  CI 0.08-4.52). In contrast, rates of psychotic major  depression did not change after excluding these same comorbidities. Our results  do not support the official  psychotic subtyping of PTSD.


    33. Concordance between a simpler definition of major depressive disorder and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition: an independent replication in an outpatient sample Original Research Article
    Comprehensive Psychiatry, In Press, Corrected Proof, Available online 1 September 2010
    Mark Zimmerman, Benjamin O. Emmert-Aronson, Timothy A. Brown

    Abstract: The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) symptom criteria for major depressive disorder (MDD) are somewhat lengthy with several studies showing that clinicians have difficulty recalling all 9 symptoms. Moreover, the criteria include somatic symptoms that are difficult to apply in patients with medical illnesses. To address these problems, a simpler definition of MDD was developed that did not include the somatic symptoms. Previous reports found high levels of agreement between the simplified and full DSM-IV definition of MDD. However, the same research group has conducted all previous studies of psychiatric patients. The goal of the present study was to determine if a high level of concordance between the 2 definitions would be replicated in an independent setting. We interviewed 2907 psychiatric outpatients presenting for treatment at the Boston University Center for Anxiety and Related Disorders. A trained diagnostic rater administered a semistructured interview and inquired about all symptoms of depression for all patients. A high level of agreement was found between the DSM-IV and the simpler definition of MDD. The absolute level of agreement between the 2 definitions was 95.5% and the κ coefficient was 0.88. Thus, consistent with previous studies, a high level of concordance was found between a simpler definition of MDD and the DSM-IV definition. This new definition offers 2 advantages over the current DSM-IV definition— it is briefer, and it is easier to apply with medically ill patients because it is free of somatic symptoms. Implications of these findings for DSM-5 are discussed.


    34. Journal of Personality Disorders, in press. Zimmerman, M. A critique of the proposed prototype rating system for personality disorders in DSM-5.  


    35. Bipolar Disord. 2010 Nov;12(7):720-6. doi: 10.1111/j.1399-5618.2010.00869.x. Sustained unemployment in psychiatric outpatients with bipolar disorder: frequency and association with demographic variables and comorbid disorders. Zimmerman M, Galione JN, Chelminski I, Young D, Dalrymple K, Ruggero CJ. Department of Psychiatry and Human Behavior, Brown Medical School, 135 Plain Street, Providence, RI 02905, USA. mzimmerman@lifespan.org  

    Abstract: OBJECTIVES: The negative impact of bipolar disorder on occupational functioning is well established. However, few studies have examined the persistence of unemployment, and no studies have examined the association between diagnostic comorbidity and sustained unemployment. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we described the amount of time unemployed in the five years before the evaluation in a large cohort of outpatients diagnosed with bipolar disorder, and determined the demographic and clinical correlates of sustained unemployment. METHODS: A total of 206 patients diagnosed with DSM-IV bipolar I or bipolar II disorder were interviewed with semi-structured interviews assessing comorbid Axis I and Axis II disorders, demographic and clinical variables. The interview included an assessment of the amount of time missed from work due to psychiatric reasons during the past five years. Persistent unemployment was defined as missing up to two years or more from work. RESULTS: Less than 20% of the patients reported not missing any time from work due to psychiatric reasons, and more than one-third missed up to two years or more from work. Prolonged unemployment was associated with increased rates of current panic disorder and a lifetime history of alcohol abuse or dependence. Patients with prolonged unemployment were older and experienced more episodes of depression.
    CONCLUSIONS: Most patients presenting for the treatment of bipolar disorder have missed some time from work due to psychiatric reasons, and the persistence of employment problems is considerable. Comorbid psychiatric disorders are a potentially treatable risk factor for sustained unemployment. It is therefore of public health significance to determine if current treatments are effective in bipolar disorder patients with current panic disorder, and if not, to attempt to develop treatments that are effective.

    36. Personality Disorders: Theory, Research and Treatment, in press.
    Zimmerman, M.
    Is there adequate empirical justification for radically revising the Personality Disorders section for DSM-5?  

    37. American Journal of Drug and Alcohol Abuse, in press.
    Clinical correlates of desire for treatment for current alcohol dependence in patients with
    a primary psychiatric disorder.

    Ray, L.A., Hart, E., Chelminski, I., Young, D., & Zimmerman, M.

    38. Comprehensive Psychiatry, in press.
    Are screening scales for bipolar disorder good enough to be used in clinical practice?
    Zimmerman, M., Galione, J.N., Ruggero, C.J., Chelminski, I., Dalrymple, K. & Young,
    D.

    39. Clinical Neuropsychiatry, in press.
    Using outcome measures to promote better outcomes.
    Zimmerman, M., Chelminski, I., Young, D. & Dalrymple, K.

    40. Depression and Anxiety, in press.
    Diagnosing social anxiety disorder in the presence of obesity: Implications for a
    proposed change in DSM-5.

    Dalrymple, K., Zimmerman, M., Galione, J.N., Hrabosky, J., Chelminksi, I., Young,
    D., & O’Brien, E.

    41. Journal of Psychiatric Research, in press.
    Severe insomnia is associated with more severe presentation and greater functional
    deficits in depression.

    O’Brien, E.M., Chelminski, I., Young, D., Dalrymple, K., Hrabosky, J., &
    Zimmerman, M.

    42. Psychiatry Research, in press.
    Treatment-seeking for social anxiety disorder in a general outpatient psychiatry
    setting.

    Dalrymple, K., & Zimmerman, M. 

    43. J Anxiety Disord. 2011 Jan;25(1):131-7. Epub 2010 Aug 19.
    Age of onset of social anxiety disorder in depressed outpatients.
    Dalrymple KL, Zimmerman M.
    Source
    Department  of Psychiatry and Human Behavior, Warren  Alpert Medical  School of Brown University, United States.  Kristy_dalrymple@brown.edu

    Abstract: Onset of social anxiety disorder (SAD) often precedes that of major depressive disorder (MDD) in patients with this comorbidity pattern. The current study examined the association between three SAD onset groups (childhood, adolescent, adulthood) and clinical characteristics of 412 psychiatric outpatients diagnosed with MDD and SAD based on a semi-structured diagnostic interview. Childhood and adolescent SAD onset groups were more likely to report an onset of MDD prior to age 18 and have made at least one prior suicide attempt compared to the adulthood onset group. The childhood SAD onset group also was more likely to have chronic MDD, poorer past social functioning, and an increased hazard of MDD onset compared to the adulthood onset group. Findings suggest that patients with an onset of SAD in childhood or adolescence may be particularly at risk for a more severe and chronic course of depressive illness.

    44. Journal of Clinical Psychiatry, in press.
    Does the presence of one feature of borderline personality disorder have clinical
    significance?: Implications for dimensional ratings of personality disorders.

    Zimmerman, M., Chelminski, I., Young, D., Dalrymple, K., & Martinez, J.

    45. Journal of Clinical Psychiatry, in press.
    Web-based assessment of depression in patients treated in clinical practice:
    Reliability, validity and patient acceptance.

    Zimmerman, M. & Martinez, J.

    46. Journal of Personality Disorders, in press.
    Is dimensional scoring of borderline personality disorder only important for
    subthreshold levels of severity?

    Zimmerman, M., Chelminski, I., Young, D., Dalrymple, K., & Martinez, J.