Evidence-based assessment/Preparation phase
The preparation phase is a great opportunity to work smarter, and not harder. We can think about what are the most common issues among the reasons people come to the clinic, and use that perspective as a way to filter and organize our assessments and actions.
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In the preparation phase, we:
- Identify and plan for the most common issues,
- Make sure that we have the best cost-effective assessments for them ready to use (and often built into our clinic's core battery), and
- Benchmark prevalence rates so that we have a sense of what is typical, and whether our local pattern differs in any interesting ways.
Identifying and planning for the most common issues allow us to avoid cognitive heuristics and errors that may cause us to miss out important diagnoses.
Benchmarking prevalence rates allows us to get a sense of how often we are seeing a particular disorder in this setting. Second, by comparing the local estimates to external benchmarks helps us to get a sense of whether we might want to invest in additional assessment methods, or reflect on reasons why our practice might be different from other settings.
Tables and Figures
editBase rates for transdiagnostic comparison
edit| Condition | Chapter | CDC | DAU | SDI | General Population | |
|---|---|---|---|---|---|---|
| ADHD | 4 | 11%[1] or 6.8%[2] | 23%[3] | 38%[3] | ||
| Conduct Problems | 5 | 3.5%[2] | 17% CD[3], 37% ODD[3] | 25% CD[3], 38% ODD[3] | 1.5-3.2% antisocial[4] | |
| Mood Disorders | 17% MDD[3], 10% dysthymia[3] | 26% MDD[3], 8% dysthymia[3] | ||||
| Pediatric Depression | 6 | 2.1%[2] | -- | |||
| Adult Depression | 7 | -- | ||||
| Late Life Depression | 8 | -- | -- | -- | ||
| Adult Bipolar | 9 | -- | -- | -- | 2.9%[5], 1% bipolar I[6], 2-4% spectrum[6] | |
| Pediatric Bipolar | mean= 1.8% (95% CI, 1.1%–3.0%)[7], bipolar I (mean =1.2%; 95% CI, 0.7%–1.9%)[7] | |||||
| Self-Injurious Thought and Behavior | 10 | |||||
| NSSI | ||||||
| Ideation | ||||||
| Attempt | ||||||
| Anxiety | 3.0%[2] | |||||
| Child and Adolescent | 11 | 8%(separation anxiety)[3] | 18%(separation anxiety)[3] | |||
| Specific & Social Phobia | 12 | -- | 6% (social)[3], 6% (specific)[3] | 20% (social)[3], 15% (specific)[3] | 9% social [5]& 19% specific[5] | |
| Panic & Agoraphobia | 13 | -- | 12% (panic)[3] | 11% (panic)[3] | 2.4% agora[5] & 2.3%panic[5] | |
| Generalized Anxiety Disorder | 14 | -- | 5%[3] | 10%[3] | 2.2%[5] | |
| Obsessive-Compulsive Disorder | 15 | -- | 9%[3] | 12%[3] | 1-2%(Ch. 15)[8] | |
| Post-Traumatic Stress Disorder | 16 | -- | 3%[3] | 9%[3] | 5%[5], 3.6%[9] | |
| Substance Use Disorders | 17 | 4.7%[2] | 14%[3] | 17%[3] | ||
| Alcohol Use Disorder | 18 | 4.2%[2] | 10%[3] | 13%[3] | ||
| Gambling Disorders | 19 | -- | -- | -- | ||
| Schizophrenia | 20 | -- | -- | -- | 0.014% child (Thomsen 1996)[8] | |
| Personality Disorders | 21 | -- | -- | -- | ||
| Cluster A | 3-6% life[4] | |||||
| Cluster B (antisocial separate) | 1-5%% life[4] | |||||
| Cluster C | 2-4% life[4] | |||||
| Couple Distress | 22 | -- | -- | -- | ~50% divorce rate(Ch. 22)[8] | |
| Sexual Dysfunction | 23 | -- | -- | -- | ||
| Eating Disorders | 24 | -- | -- | -- | ||
| Sleep/Wake Disorders | 25 | -- | -- | -- | ||
| Pain in Children and Adolescents | 26 | -- | -- | -- | ||
| Chronic Pain in Adults | 27 | -- | -- | -- | ||
Notes.
- Table from Hunsley GATW 2nd edition (Youngstrom & Van Meter 2016)
- (Perou et al., 2013) is epidemeological
- (Rettew et al., 2009) is derived from an outpatient clinic
- (Roth & Fonagy, 2005)
- Epidemiological rates refer to general population, not treatment seeking samples, and so often represent a lower bound of what might be expected at a clinic.
- DAU= diagnosis as usual
- SDI= standard diagnostic interview
Notes
editWhat is the right level of detail for for the list of topics? There is a recurring tension between "lumping" -- bunching things into fewer groups to keep things simple, at the expense of ignoring differences -- versus "splitting" and focusing more on the features that are distinctive.
At one extreme is the view that at heart, it's all one issue: General psychopathology or emotional distress. At the other extreme are classification systems like the DSM, which literally include several hundred different categories, or other systems that carve off subgroups based on etiology, treatment response, or some other factor.
There is not a clear "right answer" yet.
Our guiding principle is start simple, and add complexity when it clearly could inform clinical decision-making. The 3 Ps (Prediction, Prescription, Process) is a simple heuristic for quickly checking whether this is a distinction that is likely to matter clinically.
The big differences in treatment prescription are between externalizing and internalizing disorders[10], or perhaps between subtypes of conduct disorder versus other disruptive behavior disorders[11], or unipolar versus bipolar mood disorders[12][13]. The distinction between oppositional defiant disorder or disruptive behavior disorder not otherwise specified does not change the choice of treatment, so we do not lose predictive or prescriptive information by lumping them together[14][15]. If there is no electronic medical record, then some sort of random sampling of charts or cases can provide a good snapshot of services – perhaps drawing 5 or 10 percent of cases at a clinic from each month to get a picture of services throughout the year including the variation in referral patterns between the school year and summer.
Annotated bibliography
editClick here for annotated bibliography
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References
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