Subjects
Of 342 eligible patients, 285 (83.33%) completed a test and a retest interview. Of these 285 patients, 54.04% (N=154) were male. About half (51.93%, N=148) were white, 31.58% (N=90) were African American, 12.28% (N=35) were Hispanic, and 2.21% (N=6) were of other ethnicities. The subjects’ mean age was 36.28 years (SD=8.77), almost one-half (47.02%, N=134) were unemployed, 74.74% (N=213) had at least 12 years of education, and 13.70% (N=39) were married or cohabiting. Treatment settings included outpatient substance abuse/dual-diagnosis (43.2%, N=123), outpatient mental health (35.4%, N=101), and inpatient rehabilitation or dual-diagnosis (21.4%, N=61) settings. When we compared the subjects who completed only one interview (N=17) to those who completed both interviews (N=285), no significant differences were found for age, race, gender, employment, marital status, education, or a lifetime diagnosis of substance abuse/dependence or major depressive disorder (primary or substance-induced). No information was available for those who did not participate in at least one interview, but the good response rate (83%) precluded substantial bias.
Measure
The PRISM-IV is a semistructured interview. Initial PRISM-IV probes are structured and asked as written; follow-up probes are also provided to ascertain more information. Unlike fully structured interviews where rereading the written probe is the only authorized clarification, the PRISM-IV also allows some unstructured interviewer follow-up probing. Interviewers are trained to use the follow-up probes provided or to add their own probes when necessary, using guidelines in the interview.
The PRISM-IV covers the following diagnoses for current and lifetime time frames: abuse and dependence (by substance), major depressive disorder, dysthymia, cyclothymia, mania, hypomania, schizophrenia, schizophreniform disorder, schizoaffective disorder, mood disorder with psychotic features, delusional disorder, brief psychotic disorder, psychotic disorder due to a medical condition, psychotic disorder not otherwise specified, specific phobia, social phobia, panic disorder, agoraphobia, generalized anxiety disorder, obsessive-compulsive disorder, posttraumatic stress disorder (PTSD), anorexia, bulimia, antisocial personality disorder, and borderline personality disorder. Psychiatric syndromes due to a medical condition are noted. Diagnostic modules can be selected to suit specific research needs. Substance use disorders that are unimportant to the research question can be omitted.
The PRISM-IV also provides continuous measures, including age at onset of disorder, and severity measures based on symptom counts for some disorders, such as major depressive disorder and substance dependence. Onset of substance dependence is established on the basis of the time at which the subject first met the full criteria, i.e., experienced three or more symptoms within the same year. If onset occurred in the last 12 months, onset is identified as having occurred in the month when three or more symptoms first co-occurred. Onset of other psychiatric disorders is the age when the full criteria were initially met (e.g., onset of major depressive disorder is the age when the subject had five or more symptoms and impairment or distress). Each module begins with low-threshold screening questions and skip-outs.
In the PRISM-IV, the sections on substance use
precede other diagnostic sections so that the interviewer ascertains the substance use history before assessing primary and substance-induced psychiatric episodes. Periods of heavy use or chronic intoxication (4 or more days/week for a month, or binge use) and extended periods of abstinence are identified to assist later comorbidity assessment. All four abuse and seven dependence criteria are rated for each substance used to avoid underdiagnosing dependence
(15) .
Primary disorders are diagnosed when symptoms persist at least 4 weeks in the absence of heavy substance use or when symptoms precede the onset of heavy use. For a PRISM-IV substance-induced diagnosis, 1) a primary episode must be ruled out and 2) the symptoms must exceed the expected effects of intoxication or withdrawal. The PRISM-IV provides guidelines that specify these DSM-IV intoxication and withdrawal effects. Because specific diagnostic criteria are necessary to obtain a reliable diagnosis
(16), the PRISM-IV also addresses the lack of duration and threshold criteria for substance-induced disorders in DSM-IV by assigning substance-induced diagnoses only when an episode meets the duration and symptom requirements for a corresponding primary DSM-IV diagnoses. For example, substance-induced major depressive disorder must have a duration of at least 2 weeks, and five of the nine depression symptoms, including depressed mood or anhedonia, must be present.
Depression is common among substance abusers
(17,
18), but diagnosing major depressive disorder in substance abusers has been problematic
(19 –
21) . Therefore, when primary major depressive disorder has been ruled out by the history, the PRISM-IV depression module addresses substance-induced major depressive disorder, giving special attention to depressive symptoms also listed as DSM-IV intoxication/withdrawal effects. To assess these symptoms, the subject’s own substance-using, nondepressed experience is used as a reference period (commonly a period of substance use preceding the onset of depressed mood). Symptoms that do not change in presence or intensity between nondepressed and depressed periods of consistently heavy substance use (e.g., insomnia in a patient with alcoholism) are not counted as symptoms of substance-induced major depressive disorder. However, during periods of heavy substance use, symptoms that begin or substantially increase in intensity with the onset of depressed mood are counted toward a diagnosis of substance-induced major depressive disorder.
Partial remission is available as a time-frame option for some PRISM-IV categories. Relative to current disorders, the PRISM-IV default for partial remission is to consider it as past, although this definition can be adjusted to the needs of individual studies. Specifically, patients with past alcohol/drug dependence and one or two current symptoms are considered to be in partial remission. A major depressive episode that persists at a subthreshold level (i.e., fewer than five symptoms) for at least 2 months is considered to be in partial remission. Patients with psychotic disorders who experienced an active phase are assessed for current residual symptoms. If functioning remains markedly below the functioning level prior to onset of psychosis or if the subject continues to be dependent on social services, the residual phase is coded as “current.” For mood disorder with psychotic features, (nonbizarre) delusional disorder, and brief psychotic episode, there is no distinction between active and residual symptoms. If any psychotic symptoms are present within the last 2 months, the disorder is considered “current”; otherwise it is past. For anxiety and eating disorders, “current” is defined as within the last 2 months, and partial remission is not assessed. Antisocial personality disorder and borderline personality disorder are considered current if full criteria were ever met and any symptoms are present in the last 12 months. The diagnostic programs include three time frames: past, within the past 12 months, and within the past 2 months.