Structured diagnostic interviews are superior to less-structured clinical interviews in deriving reliable psychiatric diagnoses (4– 12) because they facilitate symptom reporting while systematically probing symptoms and behaviors that clinicians may overlook (13, 14), hence reducing variability (15). To improve diagnostic accuracy, several structured clinical interviews, such as the Structured Clinical Interview for DSM-III-R (SCID) (2) and the National Institute of Mental Health Diagnostic Interview Schedule (DIS) (3), have been created and tested. In community mental health settings, the additional costs in clinician time must be compared to the improved accuracy afforded to determine whether it is cost-effective to implement these additional procedures in particular treatment settings. ![]() However, the acceptance of these efforts from nonphysician personnel by the medical profession hinges on evidence of their accuracy as well as their clinical utility. The expansion of the role of psychiatric nurses and other nonphysician mental health professionals to include assistance in acquiring diagnostic information may help to streamline, reduce costs, and improve the thoroughness and accuracy of psychiatric diagnoses. Unfortunately, evaluating symptoms, prior course of illness, and general medical, family, and treatment histories, although essential for obtaining accurate diagnoses (1), is both time consuming and costly, and it is unclear how much of this information is needed to ensure the accuracy of psychiatric diagnoses. Although treatment plans are often based on symptoms rather than diagnostic type, the advent of disease-specific treatment protocols has heightened the necessity for accurate diagnostic procedures. Psychiatrists are primarily responsible for rendering diagnoses that guide medication selection for the severely mentally ill. Whether use of structured interviewing in routine practice improves patient outcomes deserves further study. The patients’ knowledge of their diagnoses was limited, suggesting a need for patient education in this setting. CONCLUSIONS: Combining structured interviewing with a review of the medical record appears to produce more accurate primary diagnoses and to identify more secondary diagnoses than routine clinical methods. In addition, the SCID alone identified five times as many current and past secondary diagnoses as were documented routinely in patients’ charts. Diagnoses rendered by combining the SCID and review of the medical record were the most accurate, followed by the SCID alone, and then diagnoses made by psychiatrists during routine care. RESULTS: Kappa comparisons of the different diagnostic levels showed that adding additional data significantly improved accuracy. The additional time required for each element of the diagnostic procedure was also assessed. Diagnostic outcomes at each step of the procedure were compared to determine whether adding additional data improved diagnostic accuracy. A research psychiatrist or psychologist reviewed the diagnostic data and interviewed each patient to verify or further modify the previous findings. ![]() A research nurse reviewed medical records and amended the SCID diagnoses accordingly. METHOD: The Structured Clinical Interview for DSM-III-R (SCID) was used to interview 200 psychiatric outpatients. ![]() OBJECTIVE: This study determined the extent to which adding structured procedures improved diagnostic accuracy for outpatients with severe mental illness in a community mental health setting.
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