Abstract
Alexander C. McFarlane, Adelaide University, Adelaide, Australia:
I read with interest the article, ‘The comparison of the CIDI with clinical assessment in diagnosing mood and anxiety disorders’ [1].
In particular, I noted the discrepancy between the clinician assessment of posttraumatic stress disorder (PTSD) and a standardised diagnostic assessment. Namely, that the instrument variably using DSM-IV (base rate of 11.1%% and ICD-10, 10.7%%) as against a clinician diagnosis of 1.9%% indicates the problem of clinician-based diagnosis of this disorder. Compared with other disorders, the rates of under diagnosis by the clinicians were in the order of four fault less. The introduction indicates that the clinicians conducting the interview were ‘experienced psychiatrists and clinical psychologists’. The findings of this study are very similar to those conducted elsewhere, namely, that PTSD is a significantly under diagnosed disorder. This has major implications for the public face of psychiatry and psychology.
In medico-legal settings, where clinical assessments are compared and contrasted, there are often widely divergent views offered by clinicians. How can the courts begin to distinguish between these clinical options when it appears that even in research settings there is such divergences between clinical assessments and what was chosen as the gold standard in this setting, namely, the CIDI?
Following the McLean versus Commonwealth case, the application of DSM-IV criteria in legal settings was given a particular mandate in the Australian courts. The CIDI is specific in the way that it examines these phenomena in turn and then applies an algarithm. It is highly unlikely that this can be done in an hour-long interview as indicated in this article, where the full gamit of a psychiatric history is covered.
In an era when quality assurance and evidence-based medicine have gained increasing status, this surely points to the fact that in most clinical settings the significance and relevance of posttraumatic stress disorder is grossly under rated and the absence of any discussion of this issue in this article raises questions as to whether in the hands of clinicians an effective public policy about the significance of trauma in psychiatric morbidity will be effectively developed as lack of recognition of their problem continues, despite calls to the opposite [2].
The article in this edition of the journal on the Prevalence of Psychiatric Disorders in New Zealand Prisons, indicates that PTSD is the most common disorder in both men and women in the last month. Surely there is no population who would greater demonstrate social costs and impairment consequent upon a disorder. This was again diagnosed using the CIDI auto but there is very little comment on this issue. Given the relationship between PTSD and substance abuse [3]. Elsevier Sciences, USA and psychotic disorders, one is left wondering when the broader realm of psychiatry will grasp the significance of these issues and re-focus the resources within the mental health system to what is a major social issue with many potential opportunities for effective intervention.