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  • Publications and Abstracts

  • Following is a listing of recently published research and related abstracts. A listing of additional research previously published is also available.

    1. McDermut,  W., Fuller, J.R., DiGiuseppe, R., Chelminski, I.,  Zimmerman, M.
    Trait anger and Axis I comorbidity: Implications for Rational Emotive Behavior
    Therapy.
    Journal of Rational Emotive & Cognitive Behavior Therapy. 2009, 27, 79-82.

    2. Gaudiano, B.A., Zimmerman, M. Journal of Clinical Psychiatry 2010, 71, 442-450
    Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Butler Hospital, Psychosocial Research Program, Providence, RI 02906, USA. Brandon_Gaudiano@brown.edu
    Does comorbid posttraumatic stress disorder affect the severity and course of psychotic
    major depression?

    Abstract: BACKGROUND: Major depressive disorder (MDD) and posttraumatic stress disorder (PTSD) are commonly comorbid conditions that result in greater severity, chronicity, and impairment compared with either disorder alone. However, previous research has not systematically explored the potential effects of the psychotic subtyping of MDD and comorbid PTSD.
    METHOD: The sample in this retrospective case-control study conducted from December 1995 to August 2006 consisted of psychiatric outpatients with DSM-IV- diagnosed psychotic MDD with PTSD, psychotic MDD without PTSD, or nonpsychotic MDD with PTSD presenting for clinic intake. Clinical indices of severity, impairment, and history of illness were assessed by trained diagnosticians using the Structured Clinical Interview for DSM-IV Axis I Disorders supplemented by items from the Schedule for Affective Disorders and Schizophrenia. RESULTS: In terms of current severity and impairment, the psychotic MDD with PTSD (n = 34) and psychotic MDD only (n = 26) groups were similar to each other, and both tended to be more severe than the nonpsychotic MDD with PTSD group (n = 263). In terms of history of illness, the psychotic MDD with PTSD group tended to show greater severity and impairment relative to either the psychotic MDD only or nonpsychotic MDD with PTSD groups. Furthermore, the psychotic MDD with PTSD patients had an earlier time to depression onset than patients with either psychotic MDD alone or nonpsychotic MDD with PTSD, which appeared to contribute to the poorer history of illness demonstrated in the former group. CONCLUSIONS: Future research should explore the possibility of a subtype of psychotic depression that is associated with PTSD, resulting in a poorer course of illness. The current findings highlight the need for pharmacologic and psychotherapeutic approaches that can be better tailored to psychotic MDD patients with PTSD comorbidity.

    3. J Clin Psychiatry. 2010 Mar;71(3):235-8. Epub 2010 Jan 26. Psychiatrists' and nonpsychiatrist physicians' reported use of the DSM-IV criteria for major depressive disorder.Zimmerman M, Galione J. Bayside Medical Center, 235 Plain Street, Providence, RI 02905, USA. mzimmerman@lifespan.org

    Abstract: OBJECTIVE: Several studies of nonpsychiatrist physicians suggest that there are deficits in the knowledge and application of the diagnostic criteria for major depressive disorder (MDD). This research raises questions about the clinical utility of the MDD criteria. The goal of the present study was to determine psychiatrists' reported use of the DSM-IV criteria for MDD to diagnose depression and to compare their use to the use by nonpsychiatrist physicians. METHOD: The subjects were 291 psychiatrists and 40 nonpsychiatrist physicians who attended a continuing medical education conference in 2006 or 2007 on the treatment and management of depression. Prior to a lecture, the subjects completed a questionnaire that included a question regarding how frequently the DSM-IV diagnostic criteria for MDD are used when diagnosing depression. RESULTS: Nearly one-quarter of the psychiatrists indicated that they usually did not use the DSM-IV MDD criteria when diagnosing depression, and nearly half of the nonpsychiatrist physicians indicated that they rarely used the DSM-IV MDD criteria to diagnose depression. CONCLUSIONS: A substantial minority of psychiatrists and the majority of nonpsychiatrist physicians reported that they often do not use the DSM-IV MDD criteria when diagnosing depression. These findings raise questions about the clinical utility of the MDD criteria. These results, along with other studies demonstrating problems with recalling the MDD criteria, suggest that clinical utility should be considered in discussions of revising these criteria for DSM-V.


    4. J Clin Psychiatry. 2010 Apr;71(4):484-90. Underrecognition of clinically significant side effects in depressed outpatients.Zimmerman M, Galione JN, Attiullah N, Friedman M, Toba C, Boerescu DA, Ragheb M. Bayside Medical Center, 235 Plain Street, Providence, RI 02905, USA. mzimmerman@lifespan.org

    Abstract: OBJECTIVE: The presence of medication side effects is one of the most frequent reasons depressed patients discontinue medication, and premature discontinuation of medication is associated with poorer outcome in the treatment of depression. Despite the clinical importance of detecting side effects, few studies have examined the adequacy of their detection and documentation by clinicians. We are not aware of any studies comparing psychiatrists' clinical assessments to a standardized side effects checklist in depressed patients receiving ongoing treatment in clinical practice. The goal of the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project was to test the hypothesis that fewer side effects would be recorded by psychiatrists in their patients' charts compared to the number reported by patients on a side effects checklist. METHOD: Three hundred depressed outpatients (diagnosed according to DSM-IV criteria) in ongoing treatment completed a self-administered version of the Toronto Side Effects Scale (TSES). The patients rated the frequency of each of the 31 side effects and the degree of trouble caused by them. A research assistant reviewed patients' charts to extract side effects information recorded by the treating psychiatrist. The study was conducted from June 2008 to July 2008. RESULTS: The mean number of side effects reported by the patients on the TSES was 20 times higher than the number recorded by the psychiatrists (P < .01). When the self- reported side effects were limited to frequently occurring or very bothersome side effects, the rate was still 2 to 3 times higher (P < .01).
    CONCLUSIONS: Psychiatrists may not be aware of most side effects experienced by psychiatric outpatients receiving ongoing pharmacologic treatment for depression.

    5. Addict Behav. 2009 Jun-Jul;34(6-7):587-92. Epub 2009 Apr 1. Diagnosing alcohol abuse in alcohol dependent individuals: diagnostic and clinical implications.Ray LA, Hutchison KE, Leventhal AM, Miranda R Jr, Francione C, Chelminski I, Young D, Zimmerman M. Department of Psychology, University of California, Los Angeles, 1285 Franz Hall, Box 951563, Los Angeles, CA 90095-1563, United States. lararay@psych.ucla.edu

    Abstract: In DMS-IV, the diagnosis of alcohol abuse is precluded by the diagnosis of alcohol dependence. The goal of this study was to examine the diagnostic and clinical implications of diagnosing alcohol abuse among alcohol dependent individuals. Treatment-seeking psychiatric outpatients with a lifetime history of alcohol dependence (n=544), some of whom (n=45) did not meet lifetime criteria for alcohol abuse completed in-depth, face-to-face, semi-structured clinical assessments of DSM-IV axis I and axis II psychopathology. Alcohol dependent patients who did not meet criteria for alcohol abuse were significantly more likely to be female, have a later age of onset for alcohol dependence, have fewer dependence symptoms, and have a lower rate of positive family history for alcoholism, and were less likely to report a lifetime history of DSM-IV drug use disorders and PTSD. These findings suggest that diagnosing alcohol abuse among alcohol dependent patients may be clinically useful as an index of severity and higher likelihood of comorbid drug abuse and dependence. Future studies are needed to establish whether these differences are clinically significant in terms of the course of the disorder and response to treatment.


    6. Compr Psychiatry. 2010 Mar-Apr;51(2):99-105. Epub 2009 Jul 9. Clinical characteristics of depressed outpatients previously overdiagnosed with bipolar disorder.Zimmerman M, Ruggero CJ, Chelminski I, Young D. Department of Psychiatry and Human Behavior, Brown University School of Medicine, Providence, RI 02905, USA. mzimmerman@lifespan.org

    Abstract: The diagnosis of bipolar disorder in depressed patients requires the ascertainment of prior episodes of mania and hypomania. Several research reports and commentaries have suggested that bipolar disorder is underrecognized and that many patients with nonbipolar major depressive disorder have, in fact, bipolar disorder. In a previous article from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we reported the opposite phenomenon-that bipolar disorder is often overdiagnosed in psychiatric outpatients. An important question that has not been previously examined is whether there is a particular clinical or demographic profile associated with bipolar disorder overdiagnosis among depressed patients. Forty psychiatric outpatients with current major depressive disorder reported having been previously diagnosed with bipolar disorder, which was not confirmed when interviewed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (SCID). Psychiatric diagnoses, clinical and demographic variables were compared in these 40 patients and 233 depressed patients who were not diagnosed with bipolar disorder. Patients were interviewed by a highly trained diagnostic rater who administered the SCID for DSM-IV Axis I disorders, the Structured Interview for DSM-IV Personality for DSM-IV Axis II disorders, and the Schedule for Affective Disorders and Schizophrenia for clinical features of depression. The depressed patients who were overdiagnosed with bipolar disorder were diagnosed with a significantly higher number of Axis I disorders and were more likely to be diagnosed with specific phobia, posttraumatic stress disorder, and drug abuse/dependence. The patients overdiagnosed with bipolar disorder were also significantly more likely to be diagnosed with a current personality disorder and were more chronically ill with greater psychosocial impairment. Thus, the results suggest that depressed outpatients who had previously been overdiagnosed with bipolar disorder were more chronically and severely ill than depressed outpatients who had not been overdiagnosed.


    7. J Clin Psychiatry. 2010 Sep;71(9):1212-7. Epub 2010 Mar 23. Screening for bipolar disorder and finding borderline personality disorder.Zimmerman M, Galione JN, Ruggero CJ, Chelminski I, Young D, Dalrymple K, McGlinchey JB. Department of Psychiatry and Human Behavior, Brown Medical School, Department of Psychiatry Rhode Island Hospital, Providence, USA. mzimmerman@lifespan.org

    Abstract: OBJECTIVE: Bipolar disorder and borderline personality disorder share some clinical features and have similar correlates. It is, therefore, not surprising that differential diagnosis is sometimes difficult. The Mood Disorder Questionnaire (MDQ) is the most widely used screening scale for bipolar disorder. Prior studies found a high false-positive rate on the MDQ in a heterogeneous sample of psychiatric patients and primary care patients with a history of trauma. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we examined whether psychiatric outpatients without bipolar disorder who screened positive on the MDQ would be significantly more often diagnosed with borderline personality disorder than patients who did not screen positive. METHOD: The study was conducted from September 2005 to November 2008. Five hundred thirty-four psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV and Structured Interview for DSM-IV Personality Disorders and asked to complete the MDQ. Missing data on the MDQ reduced the sample size to 480. Approximately 10% of the study sample were diagnosed with a lifetime history of bipolar disorder (n = 52) and excluded from the initial analyses. RESULTS: Borderline personality disorder was 4 times more frequently diagnosed in the MDQ positive group than the MDQ negative group (21.5% vs 4.1%, P < .001). The results were essentially the same when the analysis was restricted to patients with a current diagnosis of major depressive disorder (27.6% vs 6.9%, P = .001). Of the 98 patients who screened positive on the MDQ in the entire sample of patients, including those diagnosed with bipolar disorder, 23.5% (n = 23) were diagnosed with bipolar disorder, and 27.6% (n = 27) were diagnosed with borderline personality disorder. CONCLUSIONS: Positive results on the MDQ were as likely to indicate that a patient has borderline personality disorder as bipolar disorder. The clinical utility of the MDQ in routine clinical practice is uncertain.


    8. Psychol Med. 2010 Mar;40(3):451-7. Epub 2009 Jul 23. A simpler definition of major depressive disorder.Zimmerman M, Galione JN, Chelminski I, McGlinchey JB, Young D, Dalrymple K, Ruggero CJ, Witt CF. Department of Psychiatry and Human Behavior, Brown Medical School, Providence and Rhode Island Hospital, Providence, RI, USA. mzimmerman@lifespan.org

    Abstract: BACKGROUND: The DSM-IV symptom criteria for major depressive disorder (MDD) are somewhat lengthy, with many studies showing that treatment providers have difficulty recalling all nine symptoms. Moreover, the criteria include somatic symptoms that are difficult to apply in patients with medical illnesses. In a previous report, we developed a briefer definition of MDD that was composed of the mood and cognitive symptoms of the DSM-IV criteria, and found high levels of agreement between the simplified and full DSM-IV definitions. The goal of the present study was to replicate these findings in another large sample of psychiatric out-patients and to extend the findings to other patient samples. METHOD: We interviewed 1100 psychiatric out-patients and 210 pathological gamblers presenting for treatment and 1200 candidates for bariatric surgery. All patients were interviewed by a diagnostic rater who administered a semi-structured interview. We inquired about all symptoms of depression for all patients. RESULTS: In all three samples high levels of agreement were found between the DSM- IV and the simpler definition of MDD. Summing across all 2510 patients, the level of agreement between the two definitions was 95.5% and the kappa coefficient was 0.87. CONCLUSIONS: After eliminating the four somatic criteria from the DSM-IV definition of MDD, a high level of concordance was found between this simpler definition and the original DSM-IV classification. This new definition offers two advantages over the current DSM-IV definition--it is briefer and it is easier to apply with medically ill patients because it is free of somatic symptoms.


    9. Bipolar Disord. 2009 Nov;11(7):759-65. Performance of the mood disorders questionnaire in a psychiatric outpatient setting.Zimmerman M, Galione JN, Ruggero CJ, Chelminski I, McGlinchey JB, Dalrymple K, Young D. Department of Psychiatry and Human Behavior, Brown University School of Medicine, Providence, RI 02905, USA. mzimmerman@lifespan.org

    Abstract: OBJECTIVES: The Mood Disorders Questionnaire (MDQ) has been the most widely studied screening questionnaire for bipolar disorder, though few studies have examined its performance in a heterogeneous sample of psychiatric outpatients. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we examined the operating characteristics of the MDQ in a large sample of psychiatric outpatients presenting for treatment. METHODS: A total of 534 psychiatric outpatients were interviewed with the Structured Clinical Interview for DSM-IV and asked to complete the MDQ. Missing data on the MDQ reduced the number of patients to 480, 10.4% (n = 52) of whom were diagnosed with bipolar disorder. RESULTS: Based on the scoring guidelines recommended by the developers of the MDQ, the sensitivity of the scale was only 63.5% for the entire group of bipolar patients. The specificity of the scale was 84.8%, and the positive and negative predictive values were 33.7% and 95.0%, respectively. When impairment was not required to define a case on the MDQ, then sensitivity increased to 75.0%, specificity dropped to 78.5%, positive predictive value was 29.8%, and negative predictive value was 96.3%. CONCLUSIONS: In a large sample of psychiatric outpatients, we found that the MDQ, when scored according to the developers' recommendations, had inadequate sensitivity as a screening measure. After the threshold to determine MDQ caseness was lowered by not requiring moderate or severe impairment, the sensitivity of the scale increased, but specificity decreased, and positive predictive value remained below 30%. These results raise questions regarding the MDQ's utility in routine clinical practice.


    10. J Pers Disord. 2010 Dec;24(6):763-72. A comparison of depressed patients with and without borderline personality disorder: implications for interpreting studies of the validity of the bipolar spectrum.Galione J, Zimmerman M. Department of Psychiatry and Human Behavior, Brown University School of Medicine, Rhode Island Hospital, Providence, RI, USA.

    Abstract: The nosological status of borderline personality disorder as it relates to the bipolar disorder spectrum has been controversial. Studies have supported, in part, the validity of the bipolar spectrum by demonstrating that these patients, compared to patients with nonbipolar depression, are characterized by earlier age of onset of depression, recurrent depressive episodes, comorbid anxiety and substance use disorders and increased suicidality. However, all of these factors have likewise been found to distinguish depressed patients with and without borderline personality disorder. A family history of bipolar disorder is one of the few disorder specific validators. In the present study from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compared the demographic and clinical characteristics of depressed patients with and without borderline personality disorder. We hypothesized that many of the factors used to validate the bipolar spectrum will also distinguish depressed patients with and without borderline personality disorder except, however, a family history of bipolar disorder. Two thousand nine hundred psychiatric outpatients at Rhode Island Hospital were evaluated with the Structured Clinical Interview for DSM-IV (SCID) and Structured Interview for DSM-IV Personality Disorders (SIDP-IV). Family history information regarding first-degree relatives was obtained from the patient using the Family History Research Diagnostic Criteria. One hundred and one patients with borderline personality disorder plus major depressive disorder were compared to 947 patients with major depressive disorder alone on the prevalence of bipolar disorder validators. Compared to depressed patients without borderline personality disorder, depressed patients with borderline personality disorder had a younger age of onset, more depressive episodes, a greater likelihood of experiencing atypical symptoms and had a higher prevalence of comorbid anxiety disorders, substance use disorders, and number of previous suicide attempts. The depressed patients with borderline personality disorder did not significantly differ from the patients without borderline personality disorder on morbid risk for bipolar disorder in first degree relatives. In addition, patients with a diagnosis of bipolar disorder had a significantly higher morbid risk of bipolar disorder in first degree relatives than the borderline personality disorder group. The findings indicate that many factors used to validate the bipolar spectrum are not disorder specific. These results raise questions about studies of the validity of the broad bipolar spectrum that do not assess borderline personality disorder. Our results do not support inclusion of borderline personality disorder as part of the bipolar spectrum.


    11. Compr Psychiatry. 2010 Jul-Aug;51(4):340-6. Epub 2009 Dec 21.Adifferent approach toward screening for bipolar disorder: the prototype matching method.Zimmerman M, Galione JN, Ruggero CJ, Chelminski I, Young D. Department of Psychiatry and Human Behavior, Brown University School of Medicine, Providence, RI 02905, USA. mzimmerman@lifespan.org

    Abstract: Most screening scales for psychiatric disorders consist of a series of questions about the signs and symptoms of the disorder of interest, and to determine whether a patient screens positive, the scores of the individual items are summed and the total score is compared with an empirically derived threshold. A problem with the score summation approach toward case identification on screening scales is that different studies may find that different thresholds are optimal for distinguishing cases from noncases. An alternative approach toward screening is the prototype matching approach, in which respondents are asked to indicate how well their clinical history matches the described prototype. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we compared the symptom summation and prototype matching approaches toward screening for bipolar disorder in a large sample of psychiatric outpatients. Nine hundred sixty-one psychiatric outpatients were interviewed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition and completed the Bipolar Spectrum Disorders Scale (BSDS). The BSDS is a unique screening scale consisting of a prototypic description of bipolar disorder. The respondent checks off which items in the prototypic paragraph describes them and also answers a single multiple-choice question at the end of the paragraph asking how well the paragraph describes them. The results of a receiver operating curve analysis found that the score summation and prototype matching approaches toward screening on the BSDS performed equally well. These findings provide preliminary evidence that an alternative approach toward psychiatric screening, the prototype matching approach, is as effective as the traditional score summation method. This raises the intriguing possibility of developing a combined screening scale/educational instrument that can be formatted as a brochure and thus placed in clinicians' waiting rooms, thereby facilitating use of the measure.

    12. J Psychiatr Res. 2010 Apr;44(6):405-8. Epub 2009 Nov 3. Borderline personality disorder and the misdiagnosis of bipolar disorder.Ruggero CJ, Zimmerman M, Chelminski I, Young D. Department of Psychology, University of North Texas, Denton, TX, USA. Camilo.Ruggero@unt.edu

    Abstract: Recent reports suggest bipolar disorder is not only under-diagnosed but may at times be over-diagnosed. Little is known about factors that increase the odds of such mistakes. The present work explores whether symptoms of borderline personality disorder increase the odds of a bipolar misdiagnosis. Psychiatric outpatients (n=610) presenting for treatment were administere