The article by Regier et al1 on the limitations of diagnostic criteria and assessment instruments for mental disorders raises important and critical questions. In particular, the use of diagnostic criteria that were developed primarily for clinical decision-making, in epidemiology and other research projects, predictably raises questions about the appropriate choice of thresholds and the resulting rates of false positives and false negatives.2 The article was nicely balanced by commentaries by Frances3 and Spitzer.4 In particular, Frances' discussion of the DSM-IV "clinical significance criteria" was largely undiscussed in the Regier article. It would be useful to understand more explicitly how the DSM-IV clinical significance criteria could have been operationalized in the Epidemiologic Catchment Area study and Diagnostic Interview Schedule, and how they might have affected the data they presented.
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