Poor Separation of Clinical Symptom Profiles by DSM-5 Disorder Criteria

Assessment of mental illness typically relies on a disorder classification system that is considered to be at odds with the vast disorder comorbidity and symptom heterogeneity that exists within and across patients. Patients with the same disorder diagnosis exhibit diverse symptom profiles and comorbidities creating numerous clinical and research challenges. Here we provide a quantitative analysis of the symptom heterogeneity and disorder comorbidity across a sample of 107,349 adult individuals (aged 18–85 years) from 8 English-speaking countries. Data were acquired using the Mental Health Quotient, an anonymous, online, self-report tool that comprehensively evaluates symptom profiles across 10 common mental health disorders. Dissimilarity of symptom profiles within and between disorders was then computed. We found a continuum of symptom prevalence rather than a clear separation of normal and disordered. While 58.7% of those with 5 or more clinically significant symptoms did not map to the diagnostic criteria of any of the 10 DSM-5 disorders studied, those with symptom profiles that mapped to at least one disorder had, on average, 20 clinically significant symptoms. Within this group, the heterogeneity of symptom profiles was almost as high within a disorder label as between 2 disorder labels and not separable from randomly selected groups of individuals with at least one of any of the 10 disorders. Overall, these results quantify the scale of misalignment between clinical symptom profiles and DSM-5 disorder labels and demonstrate that DSM-5 disorder criteria do not separate individuals from random when the complete mental health symptom profile of an individual is considered. Greater emphasis on empirical, disorder agnostic approaches to symptom profiling would help overcome existing challenges with heterogeneity and comorbidity, aiding clinical and research outcomes.

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Phenotypically independent mental health symptom profiles are genetically related

10.1101/2020.03.30.20045591 ◽

2020 ◽

Author(s):

Daniel Roelfs ◽

Dag Alnæs ◽

Oleksandr Frei ◽

Dennis van der Meer ◽

Olav B. Smeland ◽

...

Keyword(s):

Mental Health ◽

Psychiatric Disorders ◽

Genetic Correlations ◽

Classical Case ◽

Case Control ◽

Self Report ◽

Healthy Individuals ◽

Symptom Profiles ◽

Symptom Profile ◽

Cognitive Traits

AbstractImportanceGenome-wide association studies (GWAS) and family-based studies have revealed partly overlapping genetic architectures between various psychiatric disorders. Given clinical overlap between disorders our knowledge of the genetic architectures underlying specific symptom profiles is limited, and the predominant use of classical case-control designs have not allowed the study of variations in mental health independent of diagnosis.ObjectiveTo derive distinct profiles of mental symptoms in healthy individuals and to study how these genetically relate to each other and to common psychiatric disorders.DesignThis is a cross-sectional study using self-report mental health questionnaires and molecular genetic data.SettingWe used population-based data from the UK Biobank.ParticipantsData from individuals with a diagnosed neurological or psychiatric disorder were excluded, allowing us to study variations in mental health in 139,006 healthy individuals, and genotypes in 117,088 healthy individuals with Caucasian ancestry.Main Outcomes and MeasuresWe decomposed self-report mental health questionnaires into twelve distinct symptom profiles using independent component analysis, and performed a GWAS for each of them. Using GWAS summary statistics, we assessed genetic correlations between the symptom profiles, and between symptom profiles and common psychiatric disorders and cognitive traits.ResultsWe found that symptom profiles were genetically correlated with a wide range of psychiatric disorders and cognitive traits (67 out of 108 correlations significant at p < FDR), with strongest effects typically observed between a given symptom profile and a disorder for which the symptom is common (e.g. depression symptoms and major depressive disorder, trauma experience and post-traumatic stress disorder). Strikingly, although the symptom profiles were phenotypically uncorrelated, many of them were genetically correlated with each other (31 out of 66 comparisons significant; p < FDR).Conclusions and RelevanceThis study provides evidence that statistically independent mental health profiles in healthy individuals partly share genetic underpinnings and show genetic overlaps with psychiatric disorders. These findings suggest that shared genetics across psychiatric disorders cannot be exclusively attributed to the overlapping symptomatology between and the heterogeneity within psychiatric disorders, and supports that moving from a classical case-control setting to a continuous mental health spectrum may complement the study of psychiatric genetics.Key pointsQuestionHow to statistically independent mental health profiles genetically correlate with each other, and with psychiatric disorders and cognitive traits?FindingsSymptom profiles capturing different facets of mental health that were phenotypically uncorrelated were nonetheless genetically correlated. The symptom profiles also genetically correlated with psychiatric disorders and cognitive traits and although strongest correlations were typically observed between a given symptom profile and a disorder for which the symptom is common, specificity was overall limited.MeaningThe genetic correlations of phenotypically independent symptom profiles may suggest that the known pleiotropy among common psychiatric disorders cannot be exclusively attributed to the overlapping symptomatology between the disorders.

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ADHD-Related Mental Health Issues of Young Adult Male Prisoners in Pravieniškės Correction House-Open Colony (Lithuania)

American Journal of Men s Health ◽

10.1177/1557988319870974 ◽

2019 ◽

Vol 13 (4) ◽

pp. 155798831987097

Author(s):

Jūratė Kuzmickaitė ◽

Darius Leskauskas ◽

Ona Gylytė

Keyword(s):

Mental Health ◽

Young Adult ◽

Adult Male ◽

Adhd Symptoms ◽

Health Issues ◽

Dsm 5 ◽

Young Adult Male ◽

Mental Health Issues ◽

Clinically Significant ◽

Male Prisoners

The aim of this study was to evaluate mental health issues related to attention-deficit/hyperactivity disorder (ADHD) in young adult male prisoners. The study was performed in the Pravieniškės Correction House-Open Prison Colony and represents the first study on adult ADHD in Lithuania. The sample consisted of 100 young males imprisoned for mild to moderate crimes. ADHD symptoms were assessed using the Adult Self-Report Scale v1.1 (ASRS v1.1) and Wender Utah Rating Scale (WURS) self-rating scales. Related mental health issues were evaluated using the DSM-5 Level 1 Cross-Cutting Symptom Measure, the Personality Inventory for DSM-5, and data from both medical files and offenses-incentives lists. Clinically significant ADHD symptoms were found in 17% of the respondents. Prisoners with ADHD were younger and had shorter incentives lists. Personality traits of negative affect, antagonism, disinhibition, and psychoticism with increased personality dysfunction were more prevalent in the respondents with ADHD. Medical files of prisoners with ADHD more frequently included data on substance abuse, psychiatric diagnoses, and psychopharmacological treatment. None of the respondents had been diagnosed or treated for this disorder. Clinically significant ADHD symptoms were highly prevalent among imprisoned males, but ADHD was not diagnosed or treated correctly. These findings show that the problem of ADHD in young male adults with increased risk for criminal behavior needs recognition by the politicians and professionals responsible for health care in Lithuania in order to better care for prisoners with this psychopathology.

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Online group CBT for symptoms of anxiety and depression among university students: A pragmatic open trial (Preprint)

10.2196/preprints.27400 ◽

2021 ◽

Author(s):

Jason Bantjes ◽

Alan E. Kazdin ◽

Pim Cuijpers ◽

Elsie Breet ◽

Munita Dunn-Coetzee ◽

...

Keyword(s):

Mental Health ◽

University Students ◽

Open Trial ◽

Self Report ◽

Anxiety And Depression ◽

Post Intervention ◽

Satisfaction With Treatment ◽

Clinically Significant ◽

Online Group ◽

Group Cbt

BACKGROUND Both anxiety and depression are common among university students, and university counselling centres are under pressure to develop effective, novel and sustainable interventions that engage and retain students. Group interventions delivered via the internet could be a novel and effective way to promote student mental health. OBJECTIVE We carried out a pragmatic open trial to investigate uptake, retention, treatment response, and level of satisfaction with a remote group CBT intervention designed to reduce symptoms of anxiety and depression delivered online to university students during the COVID pandemic. METHODS Pre- and post-intervention self-report data on anxiety and depression were collected with the GAD-7 and PHQ-9. Satisfaction was assessed post-intervention with the Client Satisfaction with Treatment Questionnaire. RESULTS 175 students (86.1% female, mean age=22.4 years) were enrolled, 90.3% (n=158) of whom initiated treatment. Mean (SD) number of sessions attended was 6.4 (2.8) out of 10. Among participants with clinically significant symptoms at baseline, mean symptom scores decreased significantly for anxiety (t56=11.6, P<.001), depression (t61=7.8, P<.001), and composite anxiety/depression (t60=10.7, P<.001), with large effect sizes (d=1.0-1.5). Remission rates among participants with clinically significant baseline symptoms were 67.7-78.9% and were not associated with baseline symptom severity. High overall levels of satisfaction with treatment were reported. CONCLUSIONS These results serve as a proof of concept for the use of online group CBT to promote the mental health of university students. CLINICALTRIAL This was a pragmatic trial undertaken as part of a rapid response to COVID. As such we did not register this trial.

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Using Participatory Design Methodologies to Co-Design and Culturally Adapt the Spanish Version of the Mental Health eClinic: Qualitative Study

Journal of Medical Internet Research ◽

10.2196/14127 ◽

2019 ◽

Vol 21 (8) ◽

pp. e14127 ◽

Cited By ~ 11

Author(s):

Laura Ospina-Pinillos ◽

Tracey Davenport ◽

Antonio Mendoza Diaz ◽

Alvaro Navarro-Mancilla ◽

Elizabeth M Scott ◽

...

Keyword(s):

Mental Health ◽

Young People ◽

Health Professionals ◽

Help Seeking ◽

Participatory Design ◽

Well Being ◽

Self Report ◽

User Testing ◽

Spanish Speaking ◽

English Speaking

Background The Mental Health eClinic (MHeC) aims to deliver best-practice clinical services to young people experiencing mental health problems by making clinical care accessible, affordable, and available to young people whenever and wherever they need it most. The original MHeC consists of home page with a visible triage system for those requiring urgent help; a online physical and mental health self-report assessment; a results dashboard; a booking and videoconferencing system; and the generation of a personalized well-being plan. Populations who do not speak English and reside in English-speaking countries are less likely to receive mental health care. In Australia, international students have been identified as disadvantaged compared with their peers; have weaker social support networks; and have higher rates of psychological distress. This scenario is acquiring significant relevance as Spanish-speaking migration is rapidly growing in Australia, and the mental health services for culturally and linguistically diverse populations are limited. Having a Spanish version (MHeC-S) of the Mental Health eClinic would greatly benefit these students. Objective We used participatory design methodologies with users (young people aged 16-30 years, supportive others, and health professionals) to (1) conduct workshops with users to co-design and culturally adapt the MHeC; (2) inform the development of the MHeC-S alpha prototype; (3) test the usability of the MHeC-S alpha prototype; (4) translate, culturally adapt, and face-validate the MHeC-S self-report assessment; and (5) collect information to inform its beta prototype. Methods A research and development cycle included several participatory design phases: co-design workshops; knowledge translation; language translation and cultural adaptation; and rapid prototyping and user testing of the MHeC-S alpha prototype. Results We held 2 co-design workshops with 17 users (10 young people, 7 health professionals). A total of 15 participated in the one-on-one user testing sessions (7 young people, 5 health professionals, 3 supportive others). We collected 225 source documents, and thematic analysis resulted in 5 main themes (help-seeking barriers, technology platform, functionality, content, and user interface). A random sample of 106 source documents analyzed by 2 independent raters revealed almost perfect agreement for functionality (kappa=.86; P<.001) and content (kappa=.92; P<.001) and substantial agreement for the user interface (kappa=.785; P<.001). In this random sample, no annotations were coded for help-seeking barriers or the technology platform. Language was identified as the main barrier to getting medical or psychological services, and smartphones were the most-used device to access the internet. Acceptability was adequate for the prototype’s 5 main elements: home page and triage system, self-report assessment, dashboard of results, booking and video visit system, and personalized well-being plan. The data also revealed gaps in the alpha prototype, such as the need for tailored assessment tools and a greater integration with Spanish-speaking services and communities. Spanish-language apps and e-tools, as well as online mental health information, were lacking. Conclusions Through a research and development process, we co-designed and culturally adapted, developed and user tested, and evaluated the MHeC-S. By translating and culturally adapting the MHeC to Spanish, we aimed to increase accessibility and availability of e-mental health care in the developing world, and assist vulnerable populations that have migrated to English-speaking countries.

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Transitioning Transdiagnostic CBT from Face-to-Face to Telephone Delivery During the Coronavirus Pandemic: A Case Study

Clinical Case Studies ◽

10.1177/15346501211018278 ◽

2021 ◽

pp. 153465012110182

Author(s):

Jess Saunders ◽

Chris Allen

Keyword(s):

Mental Health ◽

Mental Health Services ◽

Health Services ◽

Behavioral Therapy ◽

Self Report ◽

Health Conditions ◽

Face To Face ◽

Clinically Significant ◽

Digital Exclusion

The coronavirus pandemic led to worldwide disruption in the delivery of face-to-face mental health services. This impact was marked for individuals with long-term health conditions and comorbid depression and anxiety. Many face-to-face mental health services switched to remote delivery or paused therapeutic input entirely, despite the lack of research on the efficacy of switching between modalities mid-therapy or having breaks in therapy. This paper presents the case of a patient with long-term health conditions who experienced both breaks in therapy and a switch in modalities from face-to-face to telephone delivery. The intervention used was based on transdiagnostic cognitive behavioral therapy and self-report measures were completed at the beginning and end of the twelve sessions. Despite the shift in modalities, the patient experienced clinically significant recovery on all measures, indicating the efficacy of therapy was not greatly affected by the shift in modalities. Long breaks in therapy were linked to deterioration in mental health, although this could be due to the deterioration in physical health that necessitated these breaks. This case highlights the benefits and challenges of a shifting modality of therapy during treatment and in response to a pandemic for a shielding population. From the work presented here, it seems beneficial for services to be able to work across multiple modalities to suit the needs of the patients and ensure continuity of treatment. It also indicates that pauses in therapy may risk deterioration. Further work is needed to prevent digital exclusion of patients.

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Assessing distress in the community: psychometric properties and crosswalk comparison of eight measures of psychological distress

Psychological Medicine ◽

10.1017/s0033291717002835 ◽

2017 ◽

Vol 48 (8) ◽

pp. 1316-1324 ◽

Cited By ~ 19

Author(s):

P. J. Batterham ◽

M. Sunderland ◽

T. Slade ◽

A. L. Calear ◽

N. Carragher

Keyword(s):

Mental Health ◽

Psychological Distress ◽

Mental Health Problems ◽

Multiple Scales ◽

Optimal Performance ◽

Self Report ◽

Hopkins Symptom Checklist ◽

Dsm 5 ◽

Patient Health ◽

Unidimensional Construct

AbstractBackgroundMany measures are available for measuring psychological distress in the community. Limited research has compared these scales to identify the best performing tools. A common metric for distress measures would enable researchers and clinicians to equate scores across different measures. The current study evaluated eight psychological distress scales and developed crosswalks (tables/figures presenting multiple scales on a common metric) to enable scores on these scales to be equated.MethodsAn Australian online adult sample (N = 3620, 80% female) was administered eight psychological distress measures: Patient Health Questionnaire-4, Kessler-10/Kessler-6, Distress Questionnaire-5 (DQ5), Mental Health Inventory-5, Hopkins Symptom Checklist-25 (HSCL-25), Self-Report Questionnaire-20 (SRQ-20) and Distress Thermometer. The performance of each measure in identifying DSM-5 criteria for a range of mental disorders was tested. Scale fit to a unidimensional latent construct was assessed using Confirmatory Factor Analysis (CFA). Finally, crosswalks were developed using Item Response Theory.ResultsThe DQ5 had optimal performance in identifying individuals meeting DSM-5 criteria, with adequate fit to a unidimensional construct. The HSCL-25 and SRQ-20 also had adequate fit but poorer specificity and/or sensitivity than the DQ5 in identifying caseness. The unidimensional CFA of the combined item bank for the eight scales showed acceptable fit, enabling the creation of crosswalk tables.ConclusionsThe DQ5 had optimal performance in identifying risk of mental health problems. The crosswalk tables developed in this study will enable rapid conversion between distress measures, providing more efficient means of data aggregation and a resource to facilitate interpretation of scores from multiple distress scales.

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The physical and mental health problems of refugee and migrant fathers: findings from an Australian population-based study of children and their families

BMJ Open ◽

10.1136/bmjopen-2016-015603 ◽

2017 ◽

Vol 7 (11) ◽

pp. e015603 ◽

Cited By ~ 5

Author(s):

Rebecca Giallo ◽

Elisha Riggs ◽

Claire Lynch ◽

Dannielle Vanpraag ◽

Jane Yelland ◽

...

Keyword(s):

Mental Health ◽

Psychological Distress ◽

Alcohol Use ◽

Mental Health Problems ◽

Forced Migration ◽

Population Based ◽

Self Report ◽

Physical And Mental Health ◽

Population Based Study ◽

English Speaking

ObjectivesThe aim of this study was to report on the physical and mental health of migrant and refugee fathers participating in a population-based study of Australian children and their families.DesignCross-sectional survey data drawn from a population-based longitudinal study when children were aged 4–5 years.SettingPopulation-based study of Australian children and their families.Participants8137 fathers participated in the study when their children were aged 4–5 years. There were 131 (1.6%) fathers of likely refugee background, 872 (10.7%) fathers who migrated from English-speaking countries, 1005 (12.4%) fathers who migrated from non-English-speaking countries and 6129 (75.3%) Australian-born fathers.Primary outcome measuresFathers’ psychological distress was assessed using the self-report Kessler-6. Information pertaining to physical health conditions, global or overall health, alcohol and tobacco use, and body mass index status was obtained.ResultsCompared with Australian-born fathers, fathers of likely refugee background (adjusted OR(aOR) 3.17, 95% CI 2.13 to 4.74) and fathers from non-English-speaking countries (aOR 1.79, 95%CI 1.51 to 2.13) had higher odds of psychological distress. Refugee fathers were more likely to report fair to poor overall health (aOR 1.95, 95% CI 1.06 to 3.60) and being underweight (aOR 3.49, 95% CI 1.57 to 7.74) compared with Australian-born fathers. Refugee fathers and those from non-English-speaking countries were less likely to report light (aOR 0.25, 95% CI 0.15 to 0.43, and aOR 0.30, 95% CI 0.24 to 0.37, respectively) and moderate to harmful alcohol use (aOR 0.04, 95% CI 0.10 to 0.17, and aOR 0.14, 95% CI 0.10 to 0.19, respectively) than Australian-born fathers. Finally, fathers from non-English-speaking and English-speaking countries were less likely to be overweight (aOR 0.62, 95% CI 0.51 to 0.75, and aOR 0.84, 95% CI 0.68 to 1.03, respectively) and obese (aOR 0.43, 95% CI 0.32 to 0.58, and aOR 0.77, 95% CI 0.61 to 0.98, respectively) than Australian-born fathers.ConclusionFathers of refugee background experience poorer mental health and poorer general health than Australian-born fathers. Fathers who have migrated from non-English-speaking countries also report greater psychological distress than Australian-born fathers. This underscores the need for primary healthcare services to tailor efforts to reduce disparities in health outcomes for refugee populations that may be vulnerable due to circumstances and sequelae of forced migration and to recognise the additional psychological stresses that may accompany fatherhood following migration from non-English-speaking countries. It is important to note that refugee and migrant fathers report less alcohol use and are less likely to be overweight and obese than Australian-born fathers.

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Using participatory design methodologies to co-design and culturally adapt the Spanish version of the Mental Health eClinic (Preprint)

10.2196/preprints.14127 ◽

2019 ◽

Author(s):

Laura Ospina-Pinillos ◽

Tracey Davenport ◽

Antonio Mendoza Diaz ◽

Alvaro Andres Navarro-Mancilla ◽

Elizabeth M Scott ◽

...

Keyword(s):

Mental Health ◽

Young People ◽

Health Professionals ◽

Help Seeking ◽

Participatory Design ◽

Self Report ◽

User Testing ◽

Technology Platform ◽

Spanish Speaking ◽

English Speaking

BACKGROUND Populations who do not speak English and currently reside in English-speaking countries are less likely to receive mental health care. In Australia, international students have been identified as disadvantaged compared with their peers; have weaker social support networks; and have higher rates of psychological distress. This scenario is acquiring significant relevance as Spanish-speaking migration is rapidly growing in Australia, and the mental health services for culturally and linguistically-diverse populations are limited. Having a Spanish version of the Mental Health eClinic (MHeC-S) would greatly benefit these students. OBJECTIVE Using participatory design (PD) methodologies with users (young people aged 16 to 30 years, supportive others and health professionals) the aims of this study were to: i) conduct workshops with users to co-design and culturally-adapt the MHeC; ii) inform the development of the MHeC-S alpha prototype; iii) perform usability testing of the MHeC-S alpha prototype; iv) translate, culturally-adapt and face-validate the MHeC-S self-report assessment; and v) collect information to inform its beta prototype. METHODS A research and development (R&D) cycle included several iterative PD phases: co-design workshops; knowledge translation; language translation and cultural adaptation; rapid prototyping and user testing of the MHeC-S alpha prototype. RESULTS Two co-design workshops were held with 17 users (young people n=10, health professionals n=7). A total of 15 participated in the one-on-one user testing sessions (young people n=7, health professionals n=5, supportive others n=3). 225 source documents were collected and thematic analysis resulted in five main themes (help-seeking barriers, technology platform, functionality, content, user interface). A random sample of 106 source documents were analyzed by two independent raters revealing an ‘almost perfect’ agreement for the functionality (kappa=0.86; P<0.001) and content (kappa=0.92; P<0.001); and, a ‘substantial’ agreement for the user interface (kappa=0.785; P<0.001). In this random sample, no annotations were coded for help-seeking barriers or the technology platform. Language was identified as the main barrier to get medical or psychological services and smartphones were the most used device to access the Internet. There was adequate acceptability of the prototype’s five main elements: home page and triage system, self-report assessment, dashboard of results, booking and video visit system and personalized well-being plan. The data also revealed gaps in the current alpha prototype, such as the need for tailored assessment tools and a greater integration with Spanish-speaking services and communities; and, a lack of Spanish language apps and etools as well as online mental health information was noted. CONCLUSIONS Through an iterative process of R&D, the MHeC-S was co-designed and culturally-adapted, developed and user-tested, as well as evaluated. By translating and culturally-adapting the MHeC to Spanish, we aimed to increase accessibility and availability of (e)mental health care to the developing world, and assist vulnerable populations that have migrated to English-speaking countries. CLINICALTRIAL The University of Sydney’s Human Research Ethics Committee approved the study Protocol No. 2014/689 and Protocol No. 2016/487

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Conducting Universal Complete Mental Health Screening via Student Self-Report

Contemporary School Psychology ◽

10.1007/s40688-015-0062-x ◽

2015 ◽

Vol 19 (4) ◽

pp. 253-267 ◽

Cited By ~ 20

Author(s):

Stephanie A. Moore ◽

Oscar Widales-Benitez ◽

Katherine W. Carnazzo ◽

Eui Kyung Kim ◽

Kathryn Moffa ◽

...

Keyword(s):

Mental Health ◽

Health Screening ◽

Mental Health Screening ◽

Self Report ◽

Complete Mental Health

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Rapid and Accurate Behavioral Health Diagnostic Screening: Initial Validation Study of a Web-Based, Self-Report Tool (the SAGE-SR) (Preprint)

10.2196/preprints.9428 ◽

2017 ◽

Author(s):

Benjamin Brodey ◽

Susan E Purcell ◽

Karen Rhea ◽

Philip Maier ◽

Michael First ◽

...

Keyword(s):

Mental Health ◽

Expert Panel ◽

Mental Health Center ◽

Self Report ◽

Cognitive Interviewing ◽

Web Based ◽

Diagnostic Screening ◽

Retest Reliability ◽

Dsm 5 ◽

Test Retest Reliability

BACKGROUND The Structured Clinical Interview for DSM (SCID) is considered the gold standard assessment for accurate, reliable psychiatric diagnoses; however, because of its length, complexity, and training required, the SCID is rarely used outside of research. OBJECTIVE This paper aims to describe the development and initial validation of a Web-based, self-report screening instrument (the Screening Assessment for Guiding Evaluation-Self-Report, SAGE-SR) based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and the SCID-5-Clinician Version (CV) intended to make accurate, broad-based behavioral health diagnostic screening more accessible within clinical care. METHODS First, study staff drafted approximately 1200 self-report items representing individual granular symptoms in the diagnostic criteria for the 8 primary SCID-CV modules. An expert panel iteratively reviewed, critiqued, and revised items. The resulting items were iteratively administered and revised through 3 rounds of cognitive interviewing with community mental health center participants. In the first 2 rounds, the SCID was also administered to participants to directly compare their Likert self-report and SCID responses. A second expert panel evaluated the final pool of items from cognitive interviewing and criteria in the DSM-5 to construct the SAGE-SR, a computerized adaptive instrument that uses branching logic from a screener section to administer appropriate follow-up questions to refine the differential diagnoses. The SAGE-SR was administered to healthy controls and outpatient mental health clinic clients to assess test duration and test-retest reliability. Cutoff scores for screening into follow-up diagnostic sections and criteria for inclusion of diagnoses in the differential diagnosis were evaluated. RESULTS The expert panel reduced the initial 1200 test items to 664 items that panel members agreed collectively represented the SCID items from the 8 targeted modules and DSM criteria for the covered diagnoses. These 664 items were iteratively submitted to 3 rounds of cognitive interviewing with 50 community mental health center participants; the expert panel reviewed session summaries and agreed on a final set of 661 clear and concise self-report items representing the desired criteria in the DSM-5. The SAGE-SR constructed from this item pool took an average of 14 min to complete in a nonclinical sample versus 24 min in a clinical sample. Responses to individual items can be combined to generate DSM criteria endorsements and differential diagnoses, as well as provide indices of individual symptom severity. Preliminary measures of test-retest reliability in a small, nonclinical sample were promising, with good to excellent reliability for screener items in 11 of 13 diagnostic screening modules (intraclass correlation coefficient [ICC] or kappa coefficients ranging from .60 to .90), with mania achieving fair test-retest reliability (ICC=.50) and other substance use endorsed too infrequently for analysis. CONCLUSIONS The SAGE-SR is a computerized adaptive self-report instrument designed to provide rigorous differential diagnostic information to clinicians.

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