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Measuring Mood Spectrum: Comparison of interview (SCI-MOODS) and self-report (MOODS-SR) instruments
Measuring Mood Spectrum: Comparison of Interview (SCI-MOODS) and Self-Report (MOODS-SR) Instruments Liliana Dell’Osso, Antonella Armani, Paola Rucci, Ellen Frank, Andrea Fagiolini, Giorgio Corretti, M. Katherine Shear, Victoria J. Grochocinski, Jack D. Maser, Jean Endicott, and Giovanni B. Cassano Spectrum phenomena include, in addition to the typical DSM core symptoms, isolated or atypical symptoms, often of low severity, as well as trait-like behavioral features that arise as a result of coping with the psychopathology. We have demonstrated the psychometric properties of five Structured Clinical Interviews for the assessment of specific mood and anxiety spectrum conditions, including the Structured Clinical Interview for Mood Spectrum (SCI-MOODS). The
present report describes the reliability of the selfreport version (MOODS-SR) of the SCI-MOODS in a sample of 21 patients with a mood disorder and 20 control subjects. Agreement between the self-report and the interview formats was substantial. Intraclass correlation coefficients (ICC) ranged from 0.88 to 0.97. Our findings provide support for the reliability of the MOODS-SR questionnaire. Copyright © 2002 by W.B. Saunders Company
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discriminates between patients and controls (mean domain and total scores were significantly higher in the former, all t tests being significant at P ⬍ .001). Moreover, while the manic domain scores were higher in bipolar than in unipolar patients (t tests significant at P ⬍ .001), the depressive domain scores did not differ between these two groups, thereby supporting the content validity of the instrument. The internal consistency (Cronbach alpha) for the seven domains ranged between 0.72 and 0.92. We have since developed the MOODS-SR, a self-report version of the SCI-MOODS that precisely matches the interview content. Here, we report on the reliability of the new self-report instrument.
GROWING body of evidence indicates the clinical relevance of the subthreshold or atypical presentations of mood and anxiety disorder phenomena.1-9 This evidence suggests the potential usefulness of a thorough dimensional assessment of the psychopathological continuum that includes and gives importance to all the manifestations of a disorder, including prodromal, typical, atypical, residual, and trait-like symptoms. Our experience suggests that a spectrum approach is useful in many clinical and research contexts, including disorder or recurrence prevention, treatment selection, outcome measurement, and subtyping for research purposes.5,6,8-10 The Structured Clinical Interview for Mood Spectrum (SCI-MOODS) is organized into seven symptom domains. It was designed to evaluate the lifetime presence/absence of the full range of features of mood psychopathology that a clinician might observe: DSM-IV core symptoms of depression and mania, atypical symptoms, subthreshold manifestations, and behavioral traits that arise as a means of coping with mood symptoms. All of these manifestations are commonly seen in clinical populations, but, except for the core or criterion symptoms, are not mentioned in the current psychiatric classifications. The psychometric properties of the SCIMOODS have been reported elsewhere11; however, we summarize our findings briefly here. In our original validation study, conducted on a large sample (N ⫽ 491) of mixed participants including university students (n ⫽ 141), gastrointestinal patients (n ⫽ 116), and patients with unipolar depression (n ⫽ 112) or bipolar disorder (n⫽122) in remission, we demonstrated that the instrument
METHOD
Subjects Forty-one subjects were recruited over a 6-month period at the Department of Psychiatry in the University of Pisa; 21 were outpatients with a mood disorder in remission and 20 were control subjects. Patients with mood disorder included six in-
From the Department of Psychiatry, Neurobiology, Pharmacology, Biotechnology, University of Pisa, Pisa, Italy; Department of Psychiatry, University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic, Pittsburgh, PA; University of California, San Diego, CA; Columbia University, New York, NY; and the New York State Psychiatric Institute, New York, NY. Supported in part by National Institute of Mental Health Grants No. MH-29618 and MH-30915. Address reprint requests Liliana Dell’Osso, M.D., Department of Psychiatry at DPNFB, Via Roma 67, 56100 Pisa, Italy. Copyright © 2002 by W.B. Saunders Company 0010-440X/02/4301-0010$35.00/0 doi:10.1053/comp.2002.29852
Comprehensive Psychiatry, Vol. 43, No. 1 ( January/February), 2002: pp 69-73
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dividuals with recurrent depression, eight with bipolar I disorder, and seven with bipolar II disorder. Control subjects included nine university students and 11 gastrointestinal outpatients. The percentage of females in the overall sample was 65.9% and did not differ significantly across groups. Mean age was 36.34 ⫾ 13.28 (SD), with a range of 18 to 62 years. While the mean age was similar in the groups of psychiatric patients and gastrointestinal patients, these individuals were older than students. Subjects were assessed at baseline with the Structured Clinical Interview for DSM-IV (SCID-IV). Subjects in the control group did not meet criteria for any axis I mood disorder. Other exclusion criteria in both groups were organic mental disorders, current psychosis, substance abuse in the previous 3 months, and life-threatening physical illness. The study was approved by the Ethical Committee of the University of Pisa. After a complete description of the study to the subjects, written informed consent was obtained. Half of the sample (21 subjects) received the MOODS-SR first and the SCI-MOODS after 3 to 7 days; for the other 20 subjects, the order of administration was reversed.
Instruments Structured Diagnostic Interview. The SCID-IV12 was used to determine eligibility for entry into the study. Independent evaluators trained and certified in use of the SCID conducted the interviews. The SCI-MOODS was administered by two psychiatric residents (A.A. and G.C.), trained and certified for the use of the interview. SCI-MOODS and MOODS-SR. Both interview and selfreport instruments are composed of 140 dichotomous items grouped into seven domains: mood-depressed, mood-manic, energy-depressed, energy-manic, cognition-depressed, cognition-manic, and rhythmicity and vegetative functions. The mood-manic domain is provided in the Appendix as an example of the structure of the two instruments. SCI-MOODS was created by capitalizing on the long-standing clinical experience of Italian and American psychiatrists and psychologists, including several of the authors (G.B.C., E.F., M.K.S., L.D., J.E., J.DM., A.F.), who met periodically to select a pool of items, discuss their face validity, and arrange the sequence of items according to relevant “domains” defined a priori. Within each domain, we began by enumerating the criterion symptoms according to DSM, then added associated features as described in the DSM, followed by atypical manifestations and temperamental features they had observed in their clinical practice and research experience with mood disorders patients. The “mood” domains explore mood lability and associated changes in interest directed toward family, friends, romantic relationships, work, hobbies, and sports. The “energy” domains explore the presence of periods of time and situations with significant change in energy levels. The “cognition” domains explore changes in cognition associated with energy or mood dysregulation. “Rhythmicity and vegetative functions” are evaluated by exploring changes in energy, physical well-being, and mental and physical efficiency, related to the weather, the seasons, the changes in eating, sleep and sexual activities. The
DELL’OSSO ET AL
instruments include typical items, that are mentioned in the diagnostic criteria for major depression or for mania (e.g., item #29 in the Appendix), atypical items (e.g., items #30, 43), items related to temperament (e.g., item #38), “subthreshold” items (e.g., item #31), and behaviors reflecting adjustment to the disorder (item #46).
Statistical Analyses Sample size for the present study was designed to test the hypothesis that the reliability of domains, which are quantitative variables, was substantial (⬎0.80) versus the null hypothesis that it was moderate (ⱕ0.80).13 Agreement between the scores of corresponding domains of the MOODS-SR and the SCI-MOODS was analyzed using the intraclass correlation coefficient (ICC). According to Shrout’s revision of Landis and Koch criteria,14 ICC values between 0.0 and 0.10 indicate virtually no reliability, between 0.11 and 0.40 slight reliability, between 0.41 and 0.60 fair reliability, and from 0.61 to 0.80 moderate and greater than 0.80 substantial reliability. The agreement between the two versions at the item response level was assessed using Cohen’s kappa.15
RESULTS
Mean scores of domains for the self-report and the interview format are reported in Table 1 for patients and controls. The scores in the two formats were virtually overlapping, although on average two more items were endorsed at the interview. Total scores of the self-report and the interview formats were, respectively, 22.2 and 30.0 in gastrintestinal patients, 49.3 and 49.9 in students, 100.5 and 99.5 in bipolar I patients, 66.7 and 70.1 in bipolar II patients, and 97.2 and 97.7 in patients with recurrent depression. The intraclass correlation coefficient for the total score in the overall sample was 0.97 (95% confidence interval, 0.94 to 0.98), denoting substantial agreement between the self-report and the interview version. The ICCs for single subdomains ranged from 0.88 to 0.96, always exceeding the threshold of 0.80 (Table 2). To explore possible areas of disagreement between the SCI-MOODS and the MOODS-SR, we computed Cohen’s kappa for each individual item. Kappas ranged between 0.30 and 1 (mean value, 0.71), suggesting that, on average, agreement was moderate at the item level. Items in the lower range of kappa were item #20 (“became depressed as a result of using substances/drugs”) and item #56 (“mood became elevated when taking medications”), where subjects tended to acknowledge more symptoms related to substances/drugs when they filled out the self-report.
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Table 1. Mean ⴞ SD of the Subdomain Scores in the Self-Report (MOODS-SR) and Interview (SCI-MOODS) Formats in Patients and Controls (N ⴝ 41)
Mood depressive Mood manic Energy depressive Energy manic Cognitive depressive Cognitive manic Rhythmicity Total score
Patients With Unipolar Depression (n ⫽ 6)
Gastrointestinal Patients (n ⫽ 11)
Students (n ⫽ 9)
Patients With Bipolar I Disorder (n ⫽ 8)
Patients With Bipolar II Disorder (n ⫽ 7)
MOODSSR
SCIMOODS
MOODSSR
SCIMOODS
MOODSSR
SCIMOODS
MOODSSR
SCIMOODS
MOODSSR
SCIMOODS
10.1 ⫾ 8.7 9.1 ⫾ 6.8
9.8 ⫾ 8.3 8.8 ⫾ 7.0
3.3 ⫾ 2.2 5.8 ⫾ 4.7
5.3 ⫾ 4.7 5.6 ⫾ 3.0
20.7 ⫾ 5.1 15.5 ⫾ 6.3
19.5 ⫾ 5.2 15.5 ⫾ 5.7
20.0 ⫾ 2.1 17.2 ⫾ 4.4
20.0 ⫾ 2.8 17.2 ⫾ 6.7
12.1 ⫾ 2.5 13.4 ⫾ 4.4
12.1 ⫾ 2.9 12.6 ⫾ 4.2
3.7 ⫾ 3.6 3.6 ⫾ 3.8
3.7 ⫾ 3.5 3.8 ⫾ 4.0
0.64 ⫾ 0.67 1.6 ⫾ 1.8
1.6 ⫾ 1.4 2.1 ⫾ 1.7
8.2 ⫾ 1.2 7.3 ⫾ 2.7
8.8 ⫾ 1.1 7.3 ⫾ 2.5
7.6 ⫾ 1.4 7.4 ⫾ 2.2
7.9 ⫾ 1.2 7.2 ⫾ 2.5
4.1 ⫾ 2.9 4.3 ⫾ 1.9
5.3 ⫾ 2.0 5.4 ⫾ 1.7
8.2 ⫾ 7.4
7.9 ⫾ 7.7
2.3 ⫾ 1.5
4.2 ⫾ 3.0
21.0 ⫾ 5.4
21.7 ⫾ 5.1
22.0 ⫾ 3.6
21.6 ⫾ 3.9
12.3 ⫾ 4.3
12.3 ⫾ 3.9
3.6 ⫾ 3.5 11.1 ⫾ 9.1 49.3 ⫾ 40.5
3.9 ⫾ 4.0 12.1 ⫾ 9.1 49.9 ⫾ 40.9
2.3 ⫾ 2.0 6.3 ⫾ 5.1 22.2 ⫾ 11.6
3.3 ⫾ 2.9 7.9 ⫾ 5.6 30.0 ⫾ 16.6
7.7 ⫾ 2.9 16.8 ⫾ 7.2 97.1 ⫾ 21.1
8.2 ⫾ 4.7 16.7 ⫾ 7.0 97.7 ⫾ 22.7
11.7 ⫾ 4.0 14.5 ⫾ 5.2 100.5 ⫾ 11.9
11.1 ⫾ 4.2 14.4 ⫾ 5.8 99.5 ⫾ 19.3
6.3 ⫾ 3.4 14.1 ⫾ 2.9 66.7 ⫾ 7.8
6.4 ⫾ 3.4 16.0 ⫾ 3.6 70.1 ⫾ 11.7
DISCUSSION
In the present study we found substantial agreement between total scores on a self-administered and an interviewer administered version of an assessment of mood spectrum symptoms. Agreement was excellent both for total scores and for scores on the seven domains of the instrument. These domains were constructed largely for conceptual and organizational purposes. It remains to be demonstrated, in a much larger study population, that these seven domains represent distinct factors. Indeed, it may be the case that the structure of the MOODS-SR is comprised of only two empirical factors—depression and mania. The overall Spectrum Project is a collaborative research effort aimed at the development of a systematic approach to the assessment and treatment of dimensionally classified psychopathological conditions. The spectrum approach is much less restrictive than DSM-IV or ICD-10 categorical systems and considers as clinically relevant and potentially incapacitating not only the syndromally Table 2. Intraclass Correlation Coefficients and 95% Confidence Intervals for the Domains and Subdomains of the SCI-MOODS and MOODS-SR
Mood depressive Mood manic Energy depressive Energy manic Cognitive depressive Cognitive manic Rhythmicity Total score
ICC
95% CI
0.93 0.94 0.91 0.88 0.96 0.90 0.89 0.97
0.87-0.96 0.90-0.97 0.84-0.95 0.79-0.93 0.94-0.98 0.82-0.94 0.80-0.94 0.94-0.98
defined disorders but also their prodromal, atypical, and attenuated presentations. We have developed and validated five psychometrically sound instruments10,11,16,17 for the assessment of mood, panic-agoraphobic, obsessive-compulsive, social phobic, and eating disorder spectra. In a continuing effort to convert interview-based instruments to self-report instruments, we have developed and tested a self-report version of the panicagoraphobic spectrum,9 the obsessive-compulsive spectrum,18 the social phobic spectrum,18 and a selfreport instrument for the overall assessment of all the five spectrum conditions.19 Self-rating instruments have obvious advantages: economy, no extensive rater training, and absence of observer bias. The correlation between the self-report and the interview format of the MOODS was 0.97, a value comparable to 0.91 reported by Rush et al.,20 who compared the clinician and the self-report formats of the Inventory of Depressive Symptoms (IDS), an instrument measuring depressive symptoms. We also found a high correspondence between the MOODS-SR and the SCI-MOODS in the item-byitem comparison, except for two items assessing whether depressive/manic symptoms occur when taking drugs or substances. In these two instances, subjects attributed their mood changes to substances/drugs more often in the self-report than in the interview process. It is quite possible that these items explore “critical” areas where subjects are more likely to acknowledge a problem in the anonymity of the self-report experience. All patients found the self-rating procedure relevant to their personal experience of illness and none found
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it difficult. Administration of the interview took about 53 minutes and that of the self-report about 40 minutes. Despite the potential advantages of using the selfreport format, its (life)time frame limits its utility in clinical trials in which assessment of change is relevant. We have thus developed a “1-month” version in order to assess changes in the mood symptomatology. Future studies will examine the sensitivity to change of
this alternate version vs. other standard measures of mood symptoms. Additionally, the length of the instrument is a potential problem when repeated assessments are needed. To this end, using a data reduction technique we have identified 14 “best” items.19 The performance of these 14 items as a stand-alone questionnaire relative to the full MOODS-SR is being tested in a larger ongoing study.
APPENDIX Structure of the MOODS-SR: The “Mood-Manic” Subdomain In the course of your life (including when you were a child), have you ever had periods of at least 3-5 days in which 29. . . .you felt persistently good or high? 30. . . .you (or others) found that your sense of humor and irony were very sharp 31. . . .even the smallest thing could make you enthusiastic? 32. . . .you liked to make puns or plays on words? 33. . . .you liked to make a lot of jokes (even ones that might have been inappropriate or out of place)? 34. . . .you were intrusive, insulting or tactless, or others thought that you were? 35. . . .you found it very pleasurable and easy to buy things, even things you didn’t need? 36. . . .you gave lots of presents, even when you really couldn’t afford them? 37. . . .you were warm, extroverted and sociable and it was very easy to introduce yourself to others or to make new friends? 38. . . .you were the kind of person to whom others were attacted because of your confidence, energy and ethusiasm? 39. . . .you did a lot of entertaining either at home or in restaurants? 40. . . .you enjoyed being the center of attention or were particularly seductive or flirtatious, as if you were playing a role? 41. . . .you had a particularly intense romantic life? 42. . . .Are you the kind of person who always had an intense romantic life? 43. . . .you wore clothing or a hairstyle that was dramatic, extravagant, very high fashion or very unusual? 44. . . .you were full of plans or got involved in many projects, jumping from one activity to another? 45. . . .you had difficulty saying NO to business or social opportunities, even when you knew you did not have time for them? 46. . . .you frequently (that is, more frequently than is common for your friends or acquaintances) changed . . . a) your job? b) your place of residence? c) your friends? d) your favorite sports or hobbies? 47. . . .you found it very pleasurable and exciting to get involved in dangerous, risky, challenging or emotionally intense activities? 48. . . .you tended to do the opposite of what people wanted you to do or to play the devil’s advocate? 49. . . .your mood changed rapidly from happy to sad and back again? 50. . . .you felt like crying and laughing at the same time? 51. . . .you were very irritable, for example: a) even the smallest thing could make you very irritable? b) you found that you were particularly critical or sarcastic? c) you had great difficulty seeing other’s points of view? d) you were unusually argumentative or showed unusual hostility? 52. . . .you had trouble controlling your temper, for example: a) you felt that you really needed to even the score? b) you found yourself shouting at people or starting arguments or fights even over minor matters? 53. . . .your mood became irritable or elevated when you had a medical problem such as the flu or a cold? 54. . . .your mood became irritable or elevated when you took medications (that were not prescribed to change one’s mood), such as antibiotics, contraceptives, or steroids? I have never taken such medications. 55. . . .your mood became irritable or elevated when you were abusing (and clearly in relation to) alcohol, sedatives, hypnotics, anxiolytics, other substances, or within a month of withdrawal? I have never taken such substances. 56. . . .your mood became irritable or elevated when you increased your use of alcohol, sedatives, nicotine, caffeine, stimulants and similar substances when you were irritable or high? I have never taken such substances. 57. . . .If you answered YES to any of the questions from 29 to 56, were you seriously limited, preoccupied or troubled by what was happening to you?
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REFERENCES 1. Judd LL, Rapaport MH, Paulus MP, Brown JL. Subsyndromal symptomatic depression: a new mood disorder? J Clin Psychiatry 1994;55,18S-28S. 2. Akiskal HS, Judd LL, Gillin JC, Lemmi H. Subthreshold depressions: clinical and polysomnigraphic validation of dysthimic, residual and masked forms. J Affect Disord 1997;45: 53-63. 3. Angst J, Dobler-Mikola A. The Zurich Study II. The continuum from normal to pathological depressive mood swings. Eur Arch Psychiatry Neurol 1984;234:21-29. 4. Coryell W: Do psychotic, minor and intermittent depressive disorders exist on a continuum? J Affect Disord 1997;45: 75-83. 5. Cassano GB, Michelini S, Shear MK, Coli E, Maser J, Frank E. The panic-agoraphobic spectrum: a descriptive approach to the assessment and treatment of subtle symptoms. Am J Psychiatry 1997;154(Suppl 6):27-38. 6. Frank E, Shear MK, Rucci P, Cyranowski J, Endicott J, Fagiolini A, et al. Influence of panic-agoraphobic spectrum symptomatology on treatment response in patients with recurrent major depression. Am J Psychiatry 2000;157:1101-1107. 7. Feske U, Frank E, Mallinger AG, Houck PR, Fagiolini A, Shear MK, et al. Anxiety as a correlate of response to the acute treatment of bipolar 1 disorder. Am J Psychiatry 2000;157:956962. 8. Frank E, Cyranowski JM, Rucci P, Shear MK, Fagiolini A, Thase ME, et al. Clinical significance of lifetime panic spectrum symptoms in the treatment of bipolar I disorder. Arch Gen Psychiatry. In Press. 9. Shear MK, Frank E, Rucci P, Fagiolini A, Grochocinski VJ, Houck P, et al. Panic-agoraphobic spectrum: reliability and validity of assessment instruments. J Psychiatr Res 2001;35:5966. 10. Cassano GB, Dell’Osso L, Frank E, Miniati M, Fagiolini A, Shear MK, et al. Bipolar spectrum: A clinical reality in source of diagnostic criteria and an assessment methodology. J Affect Disord 1999;54:319-328.
11. Fagiolini A, Dell’Osso L, Pini S, Shear MK, Maser JD, Armani A, et al. Validity and reliability of a new instrument for assessing mood symptomatology: the Structured Clinical Interview for Mood Spectrum (SCI-MOODS). Int J Meth Psychiatr Res 1999;8:75-86. 12. First MB, Spitzer RL, Gibbon M, Williams JBW. Structured Clinical Interview for DSM-IV Axis I Disorders–Patient Edition (SCID-I/P version 2.0). New York, NY: Biometrics Research Department, New York State Psychiatric Institute, 1995. 13. Donner A, Eliasziw M. Sample size requirements for reliability studies. Stat Med 1987;441-448. 14. Shrout PE, Fleiss JL. Intraclass correlations: uses in assessing rater reliability. Psychol Bull 1979;86:420-428. 15. Cohen J: A coefficient of agreement for nominal scales. Educ Psychol Measure 1960;20:37-64. 16. Dell’Osso L, Cassano GB, Sarno N, Milanfranchi A, Pfanner C, Gemignanni A, et al. Validity and reliability of the Structured Clinical Interview for the Obsessive-Compulsive Spectrum (SCI-OBS) and the Structured Clinical Interview for Social Phobia Spectrum (SCI-SHY). Int J Meth Psychiatr Res 2000;9:11-24. 17. Mauri M, Borri C, Baldassari S, Benvenuti A, Cassano GB, Rucci P, et al.. Acceptability and psychometric properties of the Structured Clinical Interview for Anorexic-Bulimic Spectrum (SCI-ABS). Int J Meth Psychiatr Res 2000;9:68-78. 18. Dell’Osso L, Cassano GB, Saettoni M, Sarno N, Endicott J, Maser JD, et al. Measuring social anxiety and obsessivecompulsive spectra: comparison of interviews and self-report instruments. Compr Psychiatry. In Press. 19. Rucci P, Frank E, Fagiolini A, Kupfer DJ, Shear MK, Dell’Osso L, et al. Development of the general 5-spectrum measure (GSM-V). Depress Anxiety. Submitted. 20. Rush JA, Carmody T, Reimitz PE. The Inventory of Depressive Symptomatology (IDS): Clinician (IDS-C) and Self-Report (IDS-SR) ratings of depressive symptoms. Int J Meth Psychiatr Res 2000;9:45-59.
present report describes the reliability of the selfreport version (MOODS-SR) of the SCI-MOODS in a sample of 21 patients with a mood disorder and 20 control subjects. Agreement between the self-report and the interview formats was substantial. Intraclass correlation coefficients (ICC) ranged from 0.88 to 0.97. Our findings provide support for the reliability of the MOODS-SR questionnaire. Copyright © 2002 by W.B. Saunders Company
A
discriminates between patients and controls (mean domain and total scores were significantly higher in the former, all t tests being significant at P ⬍ .001). Moreover, while the manic domain scores were higher in bipolar than in unipolar patients (t tests significant at P ⬍ .001), the depressive domain scores did not differ between these two groups, thereby supporting the content validity of the instrument. The internal consistency (Cronbach alpha) for the seven domains ranged between 0.72 and 0.92. We have since developed the MOODS-SR, a self-report version of the SCI-MOODS that precisely matches the interview content. Here, we report on the reliability of the new self-report instrument.
GROWING body of evidence indicates the clinical relevance of the subthreshold or atypical presentations of mood and anxiety disorder phenomena.1-9 This evidence suggests the potential usefulness of a thorough dimensional assessment of the psychopathological continuum that includes and gives importance to all the manifestations of a disorder, including prodromal, typical, atypical, residual, and trait-like symptoms. Our experience suggests that a spectrum approach is useful in many clinical and research contexts, including disorder or recurrence prevention, treatment selection, outcome measurement, and subtyping for research purposes.5,6,8-10 The Structured Clinical Interview for Mood Spectrum (SCI-MOODS) is organized into seven symptom domains. It was designed to evaluate the lifetime presence/absence of the full range of features of mood psychopathology that a clinician might observe: DSM-IV core symptoms of depression and mania, atypical symptoms, subthreshold manifestations, and behavioral traits that arise as a means of coping with mood symptoms. All of these manifestations are commonly seen in clinical populations, but, except for the core or criterion symptoms, are not mentioned in the current psychiatric classifications. The psychometric properties of the SCIMOODS have been reported elsewhere11; however, we summarize our findings briefly here. In our original validation study, conducted on a large sample (N ⫽ 491) of mixed participants including university students (n ⫽ 141), gastrointestinal patients (n ⫽ 116), and patients with unipolar depression (n ⫽ 112) or bipolar disorder (n⫽122) in remission, we demonstrated that the instrument
METHOD
Subjects Forty-one subjects were recruited over a 6-month period at the Department of Psychiatry in the University of Pisa; 21 were outpatients with a mood disorder in remission and 20 were control subjects. Patients with mood disorder included six in-
From the Department of Psychiatry, Neurobiology, Pharmacology, Biotechnology, University of Pisa, Pisa, Italy; Department of Psychiatry, University of Pittsburgh School of Medicine, Western Psychiatric Institute and Clinic, Pittsburgh, PA; University of California, San Diego, CA; Columbia University, New York, NY; and the New York State Psychiatric Institute, New York, NY. Supported in part by National Institute of Mental Health Grants No. MH-29618 and MH-30915. Address reprint requests Liliana Dell’Osso, M.D., Department of Psychiatry at DPNFB, Via Roma 67, 56100 Pisa, Italy. Copyright © 2002 by W.B. Saunders Company 0010-440X/02/4301-0010$35.00/0 doi:10.1053/comp.2002.29852
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dividuals with recurrent depression, eight with bipolar I disorder, and seven with bipolar II disorder. Control subjects included nine university students and 11 gastrointestinal outpatients. The percentage of females in the overall sample was 65.9% and did not differ significantly across groups. Mean age was 36.34 ⫾ 13.28 (SD), with a range of 18 to 62 years. While the mean age was similar in the groups of psychiatric patients and gastrointestinal patients, these individuals were older than students. Subjects were assessed at baseline with the Structured Clinical Interview for DSM-IV (SCID-IV). Subjects in the control group did not meet criteria for any axis I mood disorder. Other exclusion criteria in both groups were organic mental disorders, current psychosis, substance abuse in the previous 3 months, and life-threatening physical illness. The study was approved by the Ethical Committee of the University of Pisa. After a complete description of the study to the subjects, written informed consent was obtained. Half of the sample (21 subjects) received the MOODS-SR first and the SCI-MOODS after 3 to 7 days; for the other 20 subjects, the order of administration was reversed.
Instruments Structured Diagnostic Interview. The SCID-IV12 was used to determine eligibility for entry into the study. Independent evaluators trained and certified in use of the SCID conducted the interviews. The SCI-MOODS was administered by two psychiatric residents (A.A. and G.C.), trained and certified for the use of the interview. SCI-MOODS and MOODS-SR. Both interview and selfreport instruments are composed of 140 dichotomous items grouped into seven domains: mood-depressed, mood-manic, energy-depressed, energy-manic, cognition-depressed, cognition-manic, and rhythmicity and vegetative functions. The mood-manic domain is provided in the Appendix as an example of the structure of the two instruments. SCI-MOODS was created by capitalizing on the long-standing clinical experience of Italian and American psychiatrists and psychologists, including several of the authors (G.B.C., E.F., M.K.S., L.D., J.E., J.DM., A.F.), who met periodically to select a pool of items, discuss their face validity, and arrange the sequence of items according to relevant “domains” defined a priori. Within each domain, we began by enumerating the criterion symptoms according to DSM, then added associated features as described in the DSM, followed by atypical manifestations and temperamental features they had observed in their clinical practice and research experience with mood disorders patients. The “mood” domains explore mood lability and associated changes in interest directed toward family, friends, romantic relationships, work, hobbies, and sports. The “energy” domains explore the presence of periods of time and situations with significant change in energy levels. The “cognition” domains explore changes in cognition associated with energy or mood dysregulation. “Rhythmicity and vegetative functions” are evaluated by exploring changes in energy, physical well-being, and mental and physical efficiency, related to the weather, the seasons, the changes in eating, sleep and sexual activities. The
DELL’OSSO ET AL
instruments include typical items, that are mentioned in the diagnostic criteria for major depression or for mania (e.g., item #29 in the Appendix), atypical items (e.g., items #30, 43), items related to temperament (e.g., item #38), “subthreshold” items (e.g., item #31), and behaviors reflecting adjustment to the disorder (item #46).
Statistical Analyses Sample size for the present study was designed to test the hypothesis that the reliability of domains, which are quantitative variables, was substantial (⬎0.80) versus the null hypothesis that it was moderate (ⱕ0.80).13 Agreement between the scores of corresponding domains of the MOODS-SR and the SCI-MOODS was analyzed using the intraclass correlation coefficient (ICC). According to Shrout’s revision of Landis and Koch criteria,14 ICC values between 0.0 and 0.10 indicate virtually no reliability, between 0.11 and 0.40 slight reliability, between 0.41 and 0.60 fair reliability, and from 0.61 to 0.80 moderate and greater than 0.80 substantial reliability. The agreement between the two versions at the item response level was assessed using Cohen’s kappa.15
RESULTS
Mean scores of domains for the self-report and the interview format are reported in Table 1 for patients and controls. The scores in the two formats were virtually overlapping, although on average two more items were endorsed at the interview. Total scores of the self-report and the interview formats were, respectively, 22.2 and 30.0 in gastrintestinal patients, 49.3 and 49.9 in students, 100.5 and 99.5 in bipolar I patients, 66.7 and 70.1 in bipolar II patients, and 97.2 and 97.7 in patients with recurrent depression. The intraclass correlation coefficient for the total score in the overall sample was 0.97 (95% confidence interval, 0.94 to 0.98), denoting substantial agreement between the self-report and the interview version. The ICCs for single subdomains ranged from 0.88 to 0.96, always exceeding the threshold of 0.80 (Table 2). To explore possible areas of disagreement between the SCI-MOODS and the MOODS-SR, we computed Cohen’s kappa for each individual item. Kappas ranged between 0.30 and 1 (mean value, 0.71), suggesting that, on average, agreement was moderate at the item level. Items in the lower range of kappa were item #20 (“became depressed as a result of using substances/drugs”) and item #56 (“mood became elevated when taking medications”), where subjects tended to acknowledge more symptoms related to substances/drugs when they filled out the self-report.
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Table 1. Mean ⴞ SD of the Subdomain Scores in the Self-Report (MOODS-SR) and Interview (SCI-MOODS) Formats in Patients and Controls (N ⴝ 41)
Mood depressive Mood manic Energy depressive Energy manic Cognitive depressive Cognitive manic Rhythmicity Total score
Patients With Unipolar Depression (n ⫽ 6)
Gastrointestinal Patients (n ⫽ 11)
Students (n ⫽ 9)
Patients With Bipolar I Disorder (n ⫽ 8)
Patients With Bipolar II Disorder (n ⫽ 7)
MOODSSR
SCIMOODS
MOODSSR
SCIMOODS
MOODSSR
SCIMOODS
MOODSSR
SCIMOODS
MOODSSR
SCIMOODS
10.1 ⫾ 8.7 9.1 ⫾ 6.8
9.8 ⫾ 8.3 8.8 ⫾ 7.0
3.3 ⫾ 2.2 5.8 ⫾ 4.7
5.3 ⫾ 4.7 5.6 ⫾ 3.0
20.7 ⫾ 5.1 15.5 ⫾ 6.3
19.5 ⫾ 5.2 15.5 ⫾ 5.7
20.0 ⫾ 2.1 17.2 ⫾ 4.4
20.0 ⫾ 2.8 17.2 ⫾ 6.7
12.1 ⫾ 2.5 13.4 ⫾ 4.4
12.1 ⫾ 2.9 12.6 ⫾ 4.2
3.7 ⫾ 3.6 3.6 ⫾ 3.8
3.7 ⫾ 3.5 3.8 ⫾ 4.0
0.64 ⫾ 0.67 1.6 ⫾ 1.8
1.6 ⫾ 1.4 2.1 ⫾ 1.7
8.2 ⫾ 1.2 7.3 ⫾ 2.7
8.8 ⫾ 1.1 7.3 ⫾ 2.5
7.6 ⫾ 1.4 7.4 ⫾ 2.2
7.9 ⫾ 1.2 7.2 ⫾ 2.5
4.1 ⫾ 2.9 4.3 ⫾ 1.9
5.3 ⫾ 2.0 5.4 ⫾ 1.7
8.2 ⫾ 7.4
7.9 ⫾ 7.7
2.3 ⫾ 1.5
4.2 ⫾ 3.0
21.0 ⫾ 5.4
21.7 ⫾ 5.1
22.0 ⫾ 3.6
21.6 ⫾ 3.9
12.3 ⫾ 4.3
12.3 ⫾ 3.9
3.6 ⫾ 3.5 11.1 ⫾ 9.1 49.3 ⫾ 40.5
3.9 ⫾ 4.0 12.1 ⫾ 9.1 49.9 ⫾ 40.9
2.3 ⫾ 2.0 6.3 ⫾ 5.1 22.2 ⫾ 11.6
3.3 ⫾ 2.9 7.9 ⫾ 5.6 30.0 ⫾ 16.6
7.7 ⫾ 2.9 16.8 ⫾ 7.2 97.1 ⫾ 21.1
8.2 ⫾ 4.7 16.7 ⫾ 7.0 97.7 ⫾ 22.7
11.7 ⫾ 4.0 14.5 ⫾ 5.2 100.5 ⫾ 11.9
11.1 ⫾ 4.2 14.4 ⫾ 5.8 99.5 ⫾ 19.3
6.3 ⫾ 3.4 14.1 ⫾ 2.9 66.7 ⫾ 7.8
6.4 ⫾ 3.4 16.0 ⫾ 3.6 70.1 ⫾ 11.7
DISCUSSION
In the present study we found substantial agreement between total scores on a self-administered and an interviewer administered version of an assessment of mood spectrum symptoms. Agreement was excellent both for total scores and for scores on the seven domains of the instrument. These domains were constructed largely for conceptual and organizational purposes. It remains to be demonstrated, in a much larger study population, that these seven domains represent distinct factors. Indeed, it may be the case that the structure of the MOODS-SR is comprised of only two empirical factors—depression and mania. The overall Spectrum Project is a collaborative research effort aimed at the development of a systematic approach to the assessment and treatment of dimensionally classified psychopathological conditions. The spectrum approach is much less restrictive than DSM-IV or ICD-10 categorical systems and considers as clinically relevant and potentially incapacitating not only the syndromally Table 2. Intraclass Correlation Coefficients and 95% Confidence Intervals for the Domains and Subdomains of the SCI-MOODS and MOODS-SR
Mood depressive Mood manic Energy depressive Energy manic Cognitive depressive Cognitive manic Rhythmicity Total score
ICC
95% CI
0.93 0.94 0.91 0.88 0.96 0.90 0.89 0.97
0.87-0.96 0.90-0.97 0.84-0.95 0.79-0.93 0.94-0.98 0.82-0.94 0.80-0.94 0.94-0.98
defined disorders but also their prodromal, atypical, and attenuated presentations. We have developed and validated five psychometrically sound instruments10,11,16,17 for the assessment of mood, panic-agoraphobic, obsessive-compulsive, social phobic, and eating disorder spectra. In a continuing effort to convert interview-based instruments to self-report instruments, we have developed and tested a self-report version of the panicagoraphobic spectrum,9 the obsessive-compulsive spectrum,18 the social phobic spectrum,18 and a selfreport instrument for the overall assessment of all the five spectrum conditions.19 Self-rating instruments have obvious advantages: economy, no extensive rater training, and absence of observer bias. The correlation between the self-report and the interview format of the MOODS was 0.97, a value comparable to 0.91 reported by Rush et al.,20 who compared the clinician and the self-report formats of the Inventory of Depressive Symptoms (IDS), an instrument measuring depressive symptoms. We also found a high correspondence between the MOODS-SR and the SCI-MOODS in the item-byitem comparison, except for two items assessing whether depressive/manic symptoms occur when taking drugs or substances. In these two instances, subjects attributed their mood changes to substances/drugs more often in the self-report than in the interview process. It is quite possible that these items explore “critical” areas where subjects are more likely to acknowledge a problem in the anonymity of the self-report experience. All patients found the self-rating procedure relevant to their personal experience of illness and none found
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it difficult. Administration of the interview took about 53 minutes and that of the self-report about 40 minutes. Despite the potential advantages of using the selfreport format, its (life)time frame limits its utility in clinical trials in which assessment of change is relevant. We have thus developed a “1-month” version in order to assess changes in the mood symptomatology. Future studies will examine the sensitivity to change of
this alternate version vs. other standard measures of mood symptoms. Additionally, the length of the instrument is a potential problem when repeated assessments are needed. To this end, using a data reduction technique we have identified 14 “best” items.19 The performance of these 14 items as a stand-alone questionnaire relative to the full MOODS-SR is being tested in a larger ongoing study.
APPENDIX Structure of the MOODS-SR: The “Mood-Manic” Subdomain In the course of your life (including when you were a child), have you ever had periods of at least 3-5 days in which 29. . . .you felt persistently good or high? 30. . . .you (or others) found that your sense of humor and irony were very sharp 31. . . .even the smallest thing could make you enthusiastic? 32. . . .you liked to make puns or plays on words? 33. . . .you liked to make a lot of jokes (even ones that might have been inappropriate or out of place)? 34. . . .you were intrusive, insulting or tactless, or others thought that you were? 35. . . .you found it very pleasurable and easy to buy things, even things you didn’t need? 36. . . .you gave lots of presents, even when you really couldn’t afford them? 37. . . .you were warm, extroverted and sociable and it was very easy to introduce yourself to others or to make new friends? 38. . . .you were the kind of person to whom others were attacted because of your confidence, energy and ethusiasm? 39. . . .you did a lot of entertaining either at home or in restaurants? 40. . . .you enjoyed being the center of attention or were particularly seductive or flirtatious, as if you were playing a role? 41. . . .you had a particularly intense romantic life? 42. . . .Are you the kind of person who always had an intense romantic life? 43. . . .you wore clothing or a hairstyle that was dramatic, extravagant, very high fashion or very unusual? 44. . . .you were full of plans or got involved in many projects, jumping from one activity to another? 45. . . .you had difficulty saying NO to business or social opportunities, even when you knew you did not have time for them? 46. . . .you frequently (that is, more frequently than is common for your friends or acquaintances) changed . . . a) your job? b) your place of residence? c) your friends? d) your favorite sports or hobbies? 47. . . .you found it very pleasurable and exciting to get involved in dangerous, risky, challenging or emotionally intense activities? 48. . . .you tended to do the opposite of what people wanted you to do or to play the devil’s advocate? 49. . . .your mood changed rapidly from happy to sad and back again? 50. . . .you felt like crying and laughing at the same time? 51. . . .you were very irritable, for example: a) even the smallest thing could make you very irritable? b) you found that you were particularly critical or sarcastic? c) you had great difficulty seeing other’s points of view? d) you were unusually argumentative or showed unusual hostility? 52. . . .you had trouble controlling your temper, for example: a) you felt that you really needed to even the score? b) you found yourself shouting at people or starting arguments or fights even over minor matters? 53. . . .your mood became irritable or elevated when you had a medical problem such as the flu or a cold? 54. . . .your mood became irritable or elevated when you took medications (that were not prescribed to change one’s mood), such as antibiotics, contraceptives, or steroids? I have never taken such medications. 55. . . .your mood became irritable or elevated when you were abusing (and clearly in relation to) alcohol, sedatives, hypnotics, anxiolytics, other substances, or within a month of withdrawal? I have never taken such substances. 56. . . .your mood became irritable or elevated when you increased your use of alcohol, sedatives, nicotine, caffeine, stimulants and similar substances when you were irritable or high? I have never taken such substances. 57. . . .If you answered YES to any of the questions from 29 to 56, were you seriously limited, preoccupied or troubled by what was happening to you?
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