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Kessler et al1 err in stating that “ . . . theRegier-proposed restriction of cases in DSM-V isan attempt to declare that mild cases do not exist.”1 (p1118) Our earlier article had nothing to do with DSM-V; rather, we merely presented a method for updating DSM-III and DSM-III-R prevalence rates byapplying previously unused information embedded in the Epidemiologic CatchmentArea Study and National Comorbidity Survey data sets to recalculate ratesof more stringently defined DSM-IV disorders.2 We applied to the scoring algorithms for an entiresyndrome or diagnosis those rules contained in the original Diagnostic InterviewSchedule and Composite International Diagnostic Interview assessment instrumentsthat were used to assess the “clinical significance” of reportedsymptoms in the Epidemiologic Catchment Area Study and National ComorbiditySurvey. We did not, as these authors assert, require service use in the past12 months. If our approach to assessing the clinical significance of syndromesis flawed, it follows that the determination of the clinical significanceof all symptoms that have been used to determine prevalence rates in almostall mental disorder epidemiological studies since 1980 would be similarlyflawed.
Kessler et al showed that with DSM-III-R and DSM-IV definitions, there is a gradient in adverse consequencesassociated with symptoms that is nearly linear to their defined 5 categoriesof noncase, mild, moderate, serious, and severe. Across all of medicine, aneed exists to set thresholds for defining categorically distinct illnessesor disorders, where continuities exist between high-risk conditions and diseases.People with Borrelia burgdorferi or human immunodeficiencyvirus antibodies must demonstrates signs, symptoms, and functional impairmentbefore Lyme disease or AIDS can be diagnosed.3
High-risk conditions or risk factors by themselves do not constitutediseases. Evidence supporting overdiagnosis with DSM-III and DSM-III-R criteria prompted the DSM-IV authors to change the threshold for diagnosis. Afull discussion of the rationale for and controversies associated with thesechanges in DSM-IV is available.4
Although we did not address DSM-V directlyin our previous publication, those of us now at the American Psychiatric Association(Arlington, Va) are very interested in advancing epidemiological analysesand other research studies that can inform the next revision of the DSM. With current support from a National Institutes ofHealth (Bethesda, Md) grant and collaboration with the World Health Organization(Geneva, Switzerland), we will seek to identify new diagnostic concepts andcriteria that reflect the significant advances in neuroscience, genetics,functional imaging, pathophysiology, epidemiology, and cross-cultural researchon the expression of mental disorders.5 Ourobjective is to define increasingly homogenous diagnostic groups with greaterpredictive validity with respect to both prevention and treatment response.
Correspondence: Dr Regier, American PsychiatricInstitute for Research and Education, 1000 Wilson Blvd, Arlington, VA 22209(dregier@psych.org).
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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