The Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project is an ongoing clinical research study involving the integration of research assessment methods into routine clinical practice.
More than 2,000 psychiatric outpatients presenting for treatment in a hospital-affiliated, community-based, practice setting have been comprehensively evaluated with semistructured diagnostic interviews including the SCID for Axis I disorders and SIDP for Axis II disorders. Information on childhood trauma, family history of psychiatric disorders, psychosocial functioning, and demographic features has been obtained as well. A subset of patients has been longitudinally tracked in order to compare the outcome of individuals with different disorders and examine which factors are associated with outcome.
Outpatients are being evaluated in order to monitor the parameters of treatment in clinical care. The focus of this project is ambitious, and the ultimate goal is the prediction of treatment course and outcome from baseline characteristics (e.g., diagnoses, symptoms, and demographics). Because comorbidity is the rule rather than the exception in individuals seeking clinical services, individuals are assessed at baseline for mood, anxiety, eating, substance use, somatoform, impulse control, and personality disorders. As a result, standardized assessments typically used in research protocols have been incorporated into routine clinical practice. We primarily see an insured population, and this project serves as a clinical laboratory wherein the course and comparative outcome of psychological and psychiatric treatment can be monitored.
A primary focus of this project is the development and investigation of newly constructed measures for clinician ratings of symptom severity/impairment and self-report questionnaires for patients. Projects have included validation of a questionnaire designed to assess DSM-IV major depressive disorder (Diagnostic Inventory for Depression, DID), and a questionnaire which screens for a broader compliment of DSM-IV diagnoses (the Psychiatric Diagnostic Screening Questionnaire, PDSQ). The studies of the PDSQ were funded by two NIMH grants. Recently we have been awarded our second NIMH grant to develop a multidimensional scale that assesses both psychopathology and psychosocial function (the Multidimensional Assessment of Symptoms and Psychosocial Functioning, MASP). The Patient Oriented Screening and Education Scale (POSES) is currently under development, and represents a unique approach towards screening for psychiatric disorders. A grant has recently been submitted to NIMH to support the development of the POSES.
Little empirical work has been done on the treatment of pathological gambling (PG). Until recently, the published pharmacological treatment of PG has involved fewer than 20 patients. The RIGTP has recently embarked on a program of research that will extend over the next decade as we examine the respective and combined benefits of medication and psychotherapy in the treatment of PG. Recently completed projects include two open-label studies of the effectiveness of citalopram and naltrexone. Funding from NIMH is imminent to support the development of a new instrument to assess the course and outcome of PG.
The methods used in studies establishing the efficacy of antidepressant medications are at variance from how depression is treated in routine clinical practice. In particular, the rigorous inclusion and exclusion criteria used to select subjects for participation in efficacy studies potentially limits the generalizability of the results of these trials. It is currently unknown how much impact these inclusion and exclusion criteria have on the representativeness of subjects treated in efficacy trials. As part of the MIDAS project we have been examining how many depressed patients treated in routine clinical practice would meet standard inclusion and exclusion criteria for an efficacy trial. We also have examined the effectiveness of antidepressant treatment in routine clinical practice. We have developed a system that allows clinicians to incorporate outcome ratings into their clinical practice. The database that has accumulated from this has allowed us to examine such questions as the relative effectiveness of switching versus augmentation strategies in treating refractory depression and the outcome of switching medications in patients who has respond to treatment but complain of side effects. An ongoing study is a prospective examination of the factors used by psychiatrists to select antidepressants for their patients.
During the past year we have developed agreements with all of the surgeons in the state who perform gastric bypass (or bariatric) surgery for weight loss to conduct the pre-surgical psychiatric clearance evaluations. We evaluate prospective surgical candidates with comprehensive semistructured interviews for DSM-IV Axis I and Axis II disorders, as well as a supplemental interview module specifically focused on issues related to bariatric surgery. The initial goals of the program are to determine the percentage of patients who are not cleared for surgery due to psychiatric reasons and the reasons for this rule out. During the past two years more than 500 patients have been evaluated. Concurrently, we are planning the development of a screening questionnaire that could be used by the surgeons as a "first pass" screening test to determine which candidates need further psychiatric evaluation and which do not need a more extensive evaluation. Future studies will include following the patients over time to determine predictors of surgical success, changes in psychosocial functioning resulting from the surgery, predictors of these changes, and examination of interventions to improve outcome.