C DIS-5 and C SAM-5

History

The DIS has a long history beginning with the psychiatric epidemiology field. It was first developed in 1978 at the request of the National Institute of Mental Health (NIMH). At that time, the NIMH Division of Biometry and Epidemiology was beginning to organize its Epidemiological Catchment Area (ECA) Program (Robins & Regier, 1991) and needed a comprehensive diagnostic instrument for a large-scale, multicenter epidemiological study that could be administered either by lay interviewers or by clinicians.
Because the DSM-III, published by the American Psychiatric Association in 1980, was to be the official diagnostic system for the country, DSM-III criteria were to be the basis for prevalence counts. To make the selected DSM-III diagnoses, a diagnostic interview had to be able to identify on a lifetime basis the presence and clinical significance of DSM-III criteria, the frequency and severity of symptoms, their temporal clustering, whether symptoms occurred in the absence of circumstances under which they would be part of a normal emotional response, whether symptoms occurred in the absence of physical illnesses or conditions that could account for them, and whether the presence of other psychiatric disorders might preempt the disorder of interest. In 1978, no interviews used in surveys of the general population performed all these tasks in a standard replicable fashion, and the one interview that came closest was the Renard Diagnostic Instrument (RDI) developed at Washington University in St. Louis.

The RDI had been written to operationalize the Washington University Department of Psychiatry interview, which was a list of symptoms serving the Feighner criteria, criteria developed at Washington University to make 14 major psychiatric diagnoses. Operationalizing these symptoms with explicit questions was facilitated by the participation of experienced psychiatrists in the department and transcriptions of their recorded uses of the departmental interview. The developers of the RDI were given primary responsibility for developing the new instrument for the ECA study.

Questions and probes from the RDI and its coding scheme were used and the RDI was adapted to make distinctions between current and past diagnoses and to add questions needed to make diagnoses according to DSM-III criteria. Months of interviews between patients and psychiatrists and psychiatric residents were needed to describe symptoms and develop the most appropriate and understandable diagnostic question for the first version of this landmark assessment. The first version of the DIS was the result of these adaptations and modifications. It was the diagnostic assessment for the ECA and became the one assessment that NIMH strongly suggested everyone use for their studies.

Since its first use in the ECA study, the DIS has been used across a very wide range of projects and was adapted by the World Health Organization to create the Composite International Diagnostic Interview (CIDI). Newer versions of the DIS have been produced to take into account revisions to the APA’s diagnostic manual (DSM-III-R, DSM-IV and now DSM-5). This version preserves some of the original features of the DIS, but it also adds new features.

Scope

Like clinical psychiatric interviews, the DIS distinguishes significant symptoms from the ordinary worries and concerns of daily life by setting requirements for clinical significance, and distinguishes psychiatric symptoms from symptoms caused by physical illness or the side effects of drugs or alcohol. It does this through the Probe Flow Chart, which is the backbone of the assessment.
The DIS was unique at the time it was developed in that it could make diagnoses without requiring clinical personnel for either interviewing or scoring responses. Its questions can be asked and coded by lay interviewers according to clearly stated rules. The coded responses are counted so that diagnoses are made according to the explicit rules in the diagnostic systems served.
The DIS faithfully turns the DSM diagnostic criteria into questions taking into consideration all of the nuances of the criterion.
The DIS has the following assets:

  • It is economical to use because it does not require clinically experienced examiners to administer the interview or to make diagnoses.
  • It offers a lifetime history of symptoms. In addition, it ascertains when symptoms of a disorder first appeared and were most recently experienced and determines clinical significance of most symptoms.
  • With the exception of a few open-ended questions, answers to the interview are completely precoded for prompt diagnostic assessment.
  • Reliability of questions and diagnoses is high because questions and probes are almost entirely specified, making it possible to train interviewers to behave in very similar ways.
  • It is acceptable to both patients and members of the general population. Although it contains questions about sex, drinking, drug use, and police trouble, subjects rarely (less than 0.5%) refuse to answer any of these questions.

In contrast to an overall structure that is consistent with earlier versions, the DIS-5 has been revised to implement many ideas that emerged in the course of field experience.
This experience was both in the ECA study and in a large number of studies in many settings, cultures, and languages. The design of the revision has also profited from experience with the field trials and studies using the CIDI, which was originally based on the DIS and uses the same strategies, and from the development and implementation of the CIDI Substance Abuse Module. It has profited from the Alcohol Use Disorder and Associated Disabilities Interview Schedule (Hasin, Carpenter, McCloud, Smith, & Grant, 1997) and from work on the Diagnostic Interview Schedule for Children (DISC).  Most of all, it has profited from the advice and criticisms of the DIS’s many users.
All questions have been reconsidered in terms of DSM-5 criteria, and refashioned to improve understandability and translatability for use in other countries and in culturally diverse subpopulations of the U.S. There have also been changes in design, which are described next.

  1. Current Syndrome. The DIS-5 ascertains whether each disorder has been present in the last 12 months. The DIS-5 still records how recently any symptom has been present but also determines whether a complete syndrome was present at any time in the last 12 months.
  1. Reduced Diagnostic Coverage. DIS-5 assesses these diagnostic categories, having omitted Separation Anxiety and Somatization from previous versions:
  • DEMOGRAPHICS
  • PANIC DISORDER
  • AGORAPHOBIA
  • SPECIFIC PHOBIA
  • SOCIAL PHOBIA
  • PANIC ATTACK SPECIFIER
  • GENERALIZED ANXIETY DISORDER
  • POSTTRAUMATIC STRESS DISORDER
  • MAJOR DEPRESSIVE EPISODE
  • MAJOR DEPRESSIVE DISORDER
  • DYSTHYMIC DISORDER
  • MANIC EPISODE
  • HYPOMANIC EPISODE
  • BIPOLAR I DISORDER
  • BIPOLAR II DISORDER
  • SCHIZOPHRENIA DISORDER
  • SCHIZOPHRENIFORM DISORDER
  • SCHIZOAFFECTIVE DISORDER
  • OBSESSIVE-COMPULSIVE DISORDER
  • ANOREXIA NERVOSA DISORDER
  • BULIMIA NERVOSA DISORDER
  • ATTENTION-DEFICIT/HYPERACTIVITY DISORDER
  • OPPOSITIONAL DEFIANT DISORDER
  • CONDUCT DISORDER
  • ANTISOCIAL PERSONALITY DISORDER
  • GAMBLING DISORDER

The DIS-5 also now includes the Substance Abuse Module, which makes diagnoses for DSM-5 substance use disorders in a very comprehensive interview format. It covers these disorders:

  • DSM-5 TOBACCO USE DISORDER
  • ICD-10 TOBACCO DEPENDENCE
  • ICD-10 HARMFUL USE OF TOBACCO
  • DSM-5 ALCOHOL USE DISORDER
  • ICD-10 ALCOHOL DEPENDENCE
  • ICD-10 HARMFUL USE OF ALCOHOL
  • DSM-5 CANNABIS USE DISORDER
  • ICD-10 CANNABIS DEPENDENCE
  • ICD-10 HARMFUL USE OF CANNABIS
  • DSM-5 STIMULANT USE DISORDER
  • ICD-10 STIMULANT DEPENDENCE
  • ICD-10 HARMFUL USE OF STIMULANTS
  • DSM-5 STIMULANT USE DISORDER (COCAINE)
  • ICD-10 COCAINE DEPENDENCE
  • ICD-10 HARMFUL USE OF COCAINE
  • DSM-5 STIMULANT USE DISORDER (AMPHETAMINES)
  • DSM-5 SEDATIVE USE DISORDER
  • ICD-10 SEDATIVE/HYPNOTIC DEPENDENCE
  • ICD-10 HARMFUL USE OF SEDATIVE/HYPNOTICS
  • DSM-5 OTHER SUBSTANCE USE DISORDER (CLUB DRUGS)
  • DSM-5 OPIOID USE DISORDER
  • ICD-10 OPIOID DEPENDENCE
  • ICD-10 HARMFUL USE OF OPIOIDS
  • DSM-5 OTHER SUBSTANCE USE DISORDER
  • ICD-10 PCP DEPENDENCE
  • ICD-10 HARMFUL USE OF PCP
  • DSM-5 INHALANT USE DISORDER
  • ICD-10 VOLATILE SOLVENT DEPENDENCE
  • ICD-10 HARMFUL USE OF VOLATILE SOLVENTS
  • DSM-5 CAFFEINE USE DISORDER
  • ICD-10 CAFFEINE DEPENDENCE
  • ICD-10 HARMFUL USE OF CAFFEINE

The diagnosis of dementia in previous versions of the DIS was made only as a current disorder. Previously, it was based solely on failing the Mini-Mental State Exam (MMSE). Follow-up studies of epidemiological samples of the elderly who were initially negative on the MMSE have shown that making even a few MMSE errors predicts deterioration in clinical status over the next few years for many subjects. To improve the interview’s sensitivity to mild dementia, the DIS-IV added items that operationalized the Blessed assessment of dementia, including some tasks difficult enough so that completing them without error served as a reliable indicator that subclinical dementia was absent. In this version, no assessment of cognitive impairment is included for several reasons. Most of the assessments now have a separate charge as they are copyrighted and each investigator wants or uses their own assessment. Some can be administered by non-clinicians but others require licensed clinical assessors.

  1. Question Labels. Labels in the left margin beside each question link that question to the specific criterion or item in the DSM diagnostic manual the question was designed to serve. This allows people to judge the face validity of the question by comparing it to the relevant text in the diagnostic manual.
  1. Increased Precision in Dating the Most Recent Symptom. The DIS-5 no longer asks for the particular month in which the most recent symptom was last present. Instead, it asks if the symptom occurred in the past 12 months.
  1. Expanded Substance Use Disorder Sections. The DIS-5 now includes a separate platform for the substance use disorder sections of Tobacco, Alcohol, and Drug, with a new section for Caffeine. These are all together now in one separate section. The tobacco section is enhanced with e-cigarette use and the drug section has been updated as well. This section also includes ICD-10 (and the ability to code ICD-11) criteria.
  1. Reducing Interviewer Burden. The DIS requires that interviewers review a list of items that had been answered positively when respondents were asked to date the first and most recent symptoms of a disorder and to consider whether symptoms cluster to form an episode. In previous editions of the DIS, interviewers performed this review by flipping through symptom questions and reading underlined phrases to refer to positive symptoms. The computerized version makes this easier to do and facilitates this review of symptom. Also, the streamlined questioning makes the interview shorter, thus, reducing burden.