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1. Historical Overview of the WHO CIDI
2. A Comparison of the WHO CIDI and CIDI 2.1
3. Survey Research Issues
4. What Diagnoses can be assessed using the WHO CIDI
The World Health Organization (WHO) first developed the CIDI in 1990 ( http://www3.who.int/cidi/). The CIDI (CIDI V2.1) was an expansion of the Diagnostic Interview Schedule developed by Lee Robins et. al with the support from the National Institute of Health (DIS; Robins, Helzer, Croughan and Ratcliff, 1981). The CIDI addressed the problem that the DIS diagnoses are exclusively based on the definitions and criteria of the Diagnostic and Statistical Manual (DSM) of Mental Disorders, while the international standard diagnostic system used is the WHO International Classification of Disease (ICD). Therefore, by including the ICD it was possible to do cross-national comparative research. WHO created the International Consortium in Psychiatric Epidemiology (ICPE) in 1997 ( http://www.hcp.med.harvard.edu/icpe/) to compare results from a dozen countries that translated and field-tested the CIDI when it first became available. They determined that this first generation of CIDI surveys was hampered by the fact that the comparability across countries was limited to the assessment of mental disorders. Measures of risk factors, consequences, patterns and correlates of treatment were not included in the WHO CIDI. As a result, the ICPE launched an initiative to coordinate these measures. The WHO World Mental Health (WMH) Survey Initiative was created in 1998 ( http://www.hcp.med.harvard.edu/wmh/). Scientists from participating countries from around the world came together to create measurements for risk factors, consequences, treatment, etc. and, in addition, the diagnostic sections of the CIDI were expanded to make it more operational. Thus, the WHO CIDI was born.
2. A Comparison of the WHO CIDI and CIDI 2.1
Changes in Diagnostic Assessment
Inclusion of New Sections
New sampling conventions for the Paper and Pencil Version (PAPI)
Methodological Issues of the WHO CIDI
Changes in Diagnostic Assessment
a. Distress and Impairment - Questions about distress and impairment have been added to each diagnostic section in an effort to improve the operationalization of the DSM-IV requirement that clinically significant distress or impairment must be present for a symptom cluster to qualify as a DSM disorder. The focus of these questions is on lifetime prevalence.
b. Clinical Severity - Respondents who meet WHO CIDI criteria for a lifetime diagnosis and who report recency within the past 12 months are administered a new series of questions regarding the 12-month severity of their disorder. These questions include the Sheehan Disability Scales (SDS), which are administered in each diagnostic section, and disorder specific clinical severity scales. Comparison of SDS scores across diagnoses will allow us to compare the severity distributions of different disorders.
c. Course - We expanded the standard CIDI assessment in each diagnostic section to add questions about the persistence of the course of the disorder. Included here are both questions about lifetime course (e.g., number of episodes, number of years with at least one episode) and questions about 12-month persistence (e.g., number of weeks out of 52 in the past 12 months with symptoms). The course questions differ somewhat across disorders in recognition of the fact that some disorders are episodic (e.g., depression, mania, nonaffective psychosis), while others consist of clusters of attacks (e.g., panic disorder, intermittent explosive disorder), and still others are more typically conceptualized as being defined in terms of fairly persistent dispositions (e.g., phobias).
d. Subthreshold Assessment - The skip logic in CIDI 2.1 has been revised to collect information on subthreshold diagnoses. For example, both minor depression and recurrent brief depression are assessed along with major depression. Our thinking here is that the information collected in WHO CIDI on impairments and adverse consequences of mental disorders can be used as external standards against which to evaluate the clinical significance of diagnostic threshold rules.
e. Noncore Disorders - The core diagnoses in WHO CIDI are the anxiety disorders, mood disorders, substance use disorders, and personality disorders. These disorders are agreed worldwide to be of considerable importance. However, we also have interest in a number of other disorders that may or may not prove to be important and that we have designated noncore disorders. The noncore disorders include PTSD, Neurasthenia, Tobacco, Eating Disorder, Premenstrual Dysphoric Disorder, Obsessive-Compulsive Disorder, Psychosis, Gambling, Attention Deficit Disorder and Hyperactivity, Oppositional Defiant Disorder, Conduct Disorder, and Separation Anxiety.
f. Disorders with a Special Focus - WHO CIDI includes in the core a number of disorder-specific in-depth assessments that are designed to expand our knowledge of the overall structure of psychopathology as well as of our knowledge regarding subtypes of particular disorders. Several diagnoses warrant mention in this regard here:
i. Depression - An expanded series of symptom questions is included in this section to create a subtype of people who become irritable during their depressive episodes as well as people with mixed episodes that include reverse vegetative symptoms in the manic spectrum.
ii. Panic: The WHO CIDI assessment of panic includes a newly developed series of questions designed to clarify the distinction between people whose panic attacks occur exclusively in phobic situations, those whose attacks sometimes occur "out of the blue," and a third type of respondent who has attacks of both types.
iii. Agoraphobia: In a similar way, the WHO CIDI assessment of agoraphobia includes a newly developed series of questions to distinguish a true subtype of agoraphobia without panic from people who in previous surveys were incorrectly diagnosed as agoraphobic when they actually had adult separation anxiety or specific phobia.
iv. Specific Phobia: The WHO CIDI assessment of specific phobia includes a new series of probe questions separately dating onset of fear and avoidance of a range of specific phobia subtypes. In addition, new clarifying questions are asked to distinguish subtypes triggered by mini-traumas (e.g., animal phobia among children who were attacked by an animal) versus those that occurred out of the blue. We also ask new questions to improve the accuracy of subtyping by assessing the foci of the specific fear. For example, we collect information from people with fear of flying regarding whether the fear is of heights, of closed spaces, of crashing, of being unable to escape in the event of a panic attack, some other focus, or some combination of multiple foci.
v. Intermittent Explosive Disorder: IED has not previously been included in CIDI surveys. Given the enormous public health importance of interpersonal violence, we decided that this diagnosis should be included in WHO CIDI. A new CIDI module for IED was consequently developed in collaboration with the core members of the DSM-V task force on IED. Given that WHO CIDI will be the first large-scale epidemiological survey to assess IED, a number of special subtyping questions have been included that will doubtlessly prove of great importance in refining the diagnostic criteria for this disorder.
vi. PTSD: The WHO CIDI section of PTSD has been greatly expanded in comparison to the standard CIDI in several ways. First, we now know that traumas are important predictors of a great many other disorders than PTSD. As a result, we have now collected comprehensive data on lifetime trauma exposure, including information on age of first exposure to each qualifying trauma. This information can be used in risk factor analysis to study the effects of traumas on a broad range of other disorders. Secondly, recent research has made it very clear that PTSD is a much more commonly occurring and seriously impairing disorder than previously believed to be the case. As a result, it is of importance to carry out a thorough evaluation of this disorder in WHO CIDI. We do this by expanding the question series to include information on duration and severity of symptoms in each of the main PTSD symptom clusters. In addition, we assess up to three episodes of PTSD for each respondent, including the worst lifetime episode, a randomly selected episode, and an episode in the past 12 months. Information on the worst lifetime episode is needed to generate lifetime diagnoses. However, this will not tell us about conditional risk of PTSD given trauma exposure or interactions between age and prior disorders in affecting risk of PTSD after trauma exposure. It is necessary to assess PTSD for a random sample of traumas to obtain information on these conditional risks. We do this by enumerating all traumas experienced by each respondent, assessing PTSD for the self-defined worst trauma, and then randomly selecting one trauma for additional assessment in the subsample of respondents who meet criteria for PTSD associated with the worst trauma and who report the lifetime occurrence of two or more traumas. In cases where the randomly selected trauma and the worst trauma are different in this subsample, we carry out a complete PTSD symptom assessment a second time focused on the random trauma. In addition, respondents who meet lifetime criteria for PTSD are administered a new series of questions about symptom frequency in the 12 months prior to the interview. Questions of this sort have never before been included in CIDI surveys, making it previously impossible to obtain an unbiased estimate of the current prevalence of PTSD.
g. The Screening Section - The very first section in the WHO CIDI interview is the Screening Section. This is section includes a series of introductory questions about the respondent's general health which is followed by the diagnostic stem questions for the primary disorders assessed in the survey. Methodological research has shown that separating the stem questions from the probe questions in this way dramatically increases the accuracy of diagnostic assessments by reducing the effects of respondent fatigue and unwillingness to disclose on stem question endorsement. Some of the other noncore disorders are screened at the beginning of the individual section. All respondents of the CIDI (either PAPI or CAPI) must complete the entire screening section, regardless of the diagnostic sections that you have decided to administer for your study. This allows comparison across samples and surveys that differ in the exact diagnoses assessed.
Inclusion of New Sections
a. Chronic Conditions - This section administers a standard physical chronic conditions checklist that obtains information on the prevalence, age of onset, and recency of a wide range of commonly occurring physical (e.g., cancer, heart disease) and potentially psychophysiological (e.g., irritable bowel syndrome, chronic fatigue syndrome) disorders. An important aspect of the chronic conditions section is that the Sheehan Disability Scales, the same scales used to assess the role impairments due to separate mental disorders, will be administered to one randomly selected physical disorder for each respondent. This will make it possible to carry out direct comparisons of the impairments caused by mental disorders and physical disorders.
b. The WHO Disability Assessment Schedule (WHO-DAS) - The WHO-DAS is a recently developed instrument designed to operationalize the criteria of the revised International Classification of Impairments, Disabilities, and Handicaps. Referred to in the instrument as "30-Day Functioning", WHO-DAS assesses these criteria for the past 30 days and without regard to specific causal conditions. Specifically, WHO-DAS asks respondents to report on the extent to which all their health problems together have had effects of various sorts on their functioning in the past 30 days. All WHO CIDI respondents will be asked the WHO-DAS questions whether or not they report health problems. The WHO-DAS assessments will be treated as a series of outcome variables in multivariate analyses aimed at evaluating the relative effects of different mental and physical disorders on role functioning and the nonadditive effects of commonly occurring comorbidities among disorders on role functioning.
c. Services - WHO CIDI has two different types of service assessments. The first is a disorder-specific assessment that asks a short series of questions about lifetime and recent treatment of each CIDI disorder in each diagnostic section of the interview. The second is a global assessment that asks a much more substantial series of questions that focus largely on service use in the 12 months prior to the interview. The standard CIDI does not include a services section of either type. This has dramatically reduced the policy significance of previous CIDI surveys. The inclusion of a detailed services section in WHO CIDI is designed to correct this situation.
d. Childhood - In keeping with the interest in the effects of traumatic life experiences on mental illness, WHO CIDI includes a fairly detailed retrospective assessment of childhood experiences. Data are collected on childhood adversities of a wide variety of sorts as well as on parental bonding and parental mental disorders. The purpose here is to expand the assessment of exposure to stress in order to provide all the information needed to carry out a detailed study of the effects of stress on the onset and course of mental disorders.
e. Expanded Demographic Sections - WHO CIDI includes a series of separate sections on marriage, work, children, and finances in addition to a separate section on demographics. This expanded series of assessments of sociodemographic variables is designed to provide life course information that can be used both to study risk factors for mental disorders and to study adverse social consequences of mental disorders. Family Burden is an example of a section added to measure adverse social consequences. However, for the paper and pencil version (PAPI) of the WHO CIDI this section is asked of only 30% of the subjects in the long form (see New Sampling Conventions for the Paper and Pencil Version (PAPI) below for more information regarding the PAPI long form).
CAPI Modularization - The CAPI Modularization program is the entrance point into the WHO CIDI CAPI instrument, allowing the selection of sections to administer in an interview. This is accomplished by offering a user-friendly interface for adding or removing sections as well as randomizing the proportion of respondents who receive a section, which in turn drives the instrument's routing behind-the-scenes in the WHO CIDI CAPI instrument. Therefore, the modularization program eliminates the need for a computer programmer to make such modifications. So for example, if a researcher is only interested in administering Depression and Mania, he/she will mark only these sections. In addition, the researcher may choose the % of subjects that will randomly enter these sections. To reduce interview length, a researcher may decide that in addition to Depression and Mania he/she will ask only 50% of the subjects the PTSD section. To do this, the Mania and Depression sections would be marked in the interface with 100% selection and the PTSD section would be marked with the percentage box set to 50%, meaning that 100% of the population that endorses the Mania or Depression screening question will go into those sections, but 50% of the total population will go into the PTSD section (there is no screener for PTSD).
PAPI Modularization - Modularization for the paper and pencil version of the CIDI is also possible. You may select the diagnostic sections that are entered for the short form (or Part I of the interview) other than the screening section which all respondents must complete and you may select the diagnostic sections that are entered for the long form (or part II of the interview). Or, if you prefer not to do a long/short interview, you may select which diagnoses out of the entire set you are interested in studying and set the percentages that receive each section in the front-end PAPI Modularization interface. If you choose this option, you must handle the randomization at the end of each section to go into the next section, and you must enter these data in a separate data entry program (you will not be able to enter this into the DDE we provide). Further details and examples will be given in the WHO CIDI training. See a further explanation of the long/short form below in New Sampling Conventions for the Paper and Pencil Version (PAPI).
New Sampling Conventions for the Paper and Pencil Version (PAPI)
The Long Form and Short Form - The rationale for making a long versus short distinction revolves around the optimal allocation of resources. It is more expensive to carry out a long interview than a short interview, which means that the number of interviews that can be completed for a fixed budget will be greater if the interview is shorter. It is necessary for the interview to be long for respondents who meet criteria for mental disorders, as we need to ask these people a great many symptom questions, as well as questions about service use, risk factors, and impairments. It is also important to collect data on services, risk factors, and impairments from some people who do not have mental disorders as a baseline for comparison on these variables. However, given that only a fairly small minority of people in the general population meet criteria for any one mental disorder, it is not necessary to collect comparison data on all controls in the general population. Controls can be subsampled. This leads to a substantial reduction in the average length of the interview and, thereby, reduces study costs. The paper and pencil instrument is designed to have an average interview length of two hours in the subsample of respondents who receive the long form and 45 minutes in the subsample who receive the short form. The long form is administered to 100% of respondents who score in the positive range for any of a subset of the core diagnoses plus a random subsampleof other respondents. The proportion of others to select depends on considerations of statistical power based on prior assumptions about likely prevalence using the logic of a retrospective case-control design. We have chosen a 25% subsample. However, you may change this percentage. The standard selection strategy makes use of pre-assigned interview ID numbers. Note that the last two digits of these numbers have to be assigned randomly for this approach to work.
Deleting the Long/Short Form Interviewer Checkpoint (L/S2) - Another option is to remove the Long/short distinction altogether,in which case you would select the diagnoses you are interested in and you may choose the percentage of respondents that enter them. For example, you may choose to have 100% of your respondents be screened for Depression and Mania, but only a random 50% of respondents will be screened for PTSD. If you choose to set up your study in this manner, you must handle the randomization yourself and you will have to data-enter this information independent from the DDE that we provide. See PAPI Modularization above for more information.
The Sampling Grid - We select one random trauma in the PTSD section and one random chronic condition in the chronic conditions section for detailed assessment. A somewhat more complex randomization scheme is needed here due to the fact that the number of traumas and the number of chronic conditions reported to have occurred wil vary from one respondent to another. This is done automatically in the computer assisted version of the WHO CIDI (CAPI). It has to be done manually, in comparison, in the PAPI version. This is accomplished using a sampling grid. The details of how to use the sampling grid are described in the interviewer training materials for paper and pencil administration. The implementation of the selection procedure is again based on a random number scheme.
The Reference Card - The complexity of the WHO CIDI PAPI version requires that the interviewer frequently make reference to answers given earlier in the interview in order to determine the appropriate logical skips for the individual respondent. We have found on the basis of past experience that the job of the interviewer is made considerably easier if we avoid turning back many pages by recording critical information on a special reference card at the time the information is collected. When necessary, the interviewer can then refer to that card in making skip decisions. As with the sample grid, the reference card is explained in detail in the training materials and thoroughly covered in interviewer training.
Methodological Issues of the WHO CIDI
For an in-depth analysis of the methodological issues involved in designing the WHO CIDI please see Full Text of Kessler R.C., Ustun, T.B. (2004). The World Mental Health (WMH) Survey Initiative version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). The International Journal of Methods in Psychiatric Research, 13(2), 93-121.
3. Survey Research Issues
We do not have the staff and/or resources to offer consultation for survey research methods. We expect that principal investigators who wish to use the WHO CIDI will have an understanding of how to do survey research including: sampling and standardized interviewing techniques, as well as an understanding of data collection, editing, coding and data cleaning. The Survey Research Center (SRC) of the Institute for Social Research (ISR) at the University of Michigan offers many courses on survey research ( http://www.isr.umich.edu/src/si/) as does the Inter-University Consortium for Political and Social Research (ICPSR) Summer Program in Quantitative Methods of Social Research ( http://www.icpsr.umich.edu/training/summer/index.html). The training offered for the WHO CIDI will cover general interviewing techniques, study specific interviewing techniques and field quality control issues, but will NOT cover general survey methodology.
4. What Diagnoses can be assessed using the WHO CIDI?
The following table lists the diagnoses available and those instruments or sections of the WHO CIDI that must be administered to make the diagnoses. Please note that all respondents must complete the Screening section of the WHO CIDI.
Frequently Asked Questions for potential CIDI users
Q.Is training required to use the CIDI?
A. Training at an official CIDI Training and Reference Centre (TRC) is required to use the CIDI. This is true whether you want to use only a single section or the entire instrument. Training is offered on a regular schedule and you can sign up as an individual trainee, in which case you will have to travel to a TRC for the training. Or, if you have a group of people who need to be trained, you can arrange for CIDI trainers to come to your site for a special training session. For information on training dates and options for trainers to come to your site, go to the Training tab at the WHO-CIDI website, www.hcp.med.harvard.edu/wmhcidi.
The website covers a lot of information including what modes are available for the CIDI (paper versus computerized), the differences between these modes, questions regarding access to data entry program and diagnostic algorithms. The training cost varies depending upon the centre you attend; there are some WHO funded spots for each training, if funding is an issue please enquire at the individual TRC you are planning to attend.
Q. Can I use only part of the CIDI? Or must I use the whole thing? It's quite long and I'm not interested in some sections.
A. The CIDI is modularized so that you can pick and choose sections. However, we recommend that you always administer the screening section even if you are only interested in a single disorder in your work. This will give you screening information about diagnoses that are not the focus of your investigation. The details of administering and scoring the instrument when you only use selected sections are reviewed in CIDI training.
Q. How long does training last?
A. The standard CIDI training program includes 30 hours of at-home self-study with a series of manuals and CD-ROMs followed by 3- 5 days of in-person training by CIDI Trainers (depending on the TRC you train with). There is a certification assessment at the end of the in-person training and only trainees who pass this assessment are approved as certified CIDI users. Trainees who fail the training test are allowed to attend a second training session for free in order to retake the test after they have gone home and studied the at-home materials again.
Q. This sounds like a lot of effort. How can I decide whether the CIDI is for me? Maybe I should use another instrument instead.
A. You can review a copy of the CIDI by going to www.hcp.med.harvard.edu/wmhcidi and clicking on the Instruments tab. You will note that the instrument begins with a screening section and then has separate diagnostic sections that are administered or not based on screening responses. Some diagnostic sections are administered to all respondents without prior screening. The latter often have internal skips within sections, although others do not if there are no diagnostic skips in the DSM or ICD criteria.
In addition to the diagnostic sections, the CIDI includes a number of sections on correlates of disorder -- impairment, treatment, socio-demographics, and the like. These sections are not needed to generate diagnoses, but we have found that inclusion of such sections is often desired by users for research purposes. Certified users can choose to delete these sections or to pick and choose among items and add other items on the same themes of their own choosing as part of their larger data collection project (which might include yet other questions on topics that go beyond those covered in the CIDI). Details about skipping patterns and modularization will be reviewed in CIDI training, including details regarding use of sections with others to insure certain types of diagnoses. Our experience is that most users find it useful to include many or all of these non-diagnostic CIDI sections in order to obtain data that can be compared to the information based on the same questions obtained in previous surveys. For example, all of these sections were administered in the US National Comorbidity Survey Replication (NCS-R), which can be used to benchmark data from other surveys. For information on access to the public use NCS-R dataset, go to: www.hcp.med.harvard.edu/ncs.
Q. I reviewed the CIDI at the web site given above. I like it. It looks pretty easy to administer. Why can't I simply use it? Why do I need training?
A. Accurate use of the CIDI requires compliance with a number of field quality assurance principles that require training to implement. Examples include rules for dealing with respondents who say they don't understand a particular question, probes and coding rules for respondents who say they don't know the exact answer to a question but can approximate an answer, scoring rules in the presence of item missing data, organic exclusion codes for open-ended responses, and diagnostic algorithms for generating ICD and DSM diagnoses. Study of the detailed CIDI training materials -- including manuals and CD-ROMs -- in addition to the in-person CIDI training sessions -- is needed to correctly implement CIDI procedures. As a result, you are prohibited from using any part of the CIDI without official training and certification by a WHO CIDI TRC.
Q. I am contacting you because I am interested in administering the CIDI to my sample in a foreign language that is not currently listed on your website and want to know if there is a foreign language version of the CIDI I could use?
A. The CIDI has been translated into several different foreign language versions (you can find the list of languages here). However, many of these versions were done for specific studies and are out of date. In order to use the CIDI in a foreign language you need update the language version to the current version of the CIDI using the World Health Organization approved protocol for translations (click here for translation protocol). Please note also that some translations are for paper and pencil administration and some are for computer assisted administration (for information about the two different formats www.hcp.med.harvard.edu/wmhcidi/instruments_choose.php ).
After you have updated the CIDI into the current version in another language you then also have to make this version available for other CIDI certified users interested in administration of the CIDI in that language. This is because the CIDI is a WHO copyrighted instrument and is to be made available to all researchers who participate in the training program.
Additionally, you must attend CIDI training at one of the WHO CIDI TRC locations (see questions above regarding training information). You also would need to acquire the appropriate license from Blaise in order to program the translation into the CAPI format. For information about Blaise licensing see next question.
For a list of translations currently being trained on visit the training page:
Q. Can you tell me more about Blaise licensing?
A. In order to administer the CIDI you need to purchase a license (or licenses) for the Blaise software which the CIDI is programmed in. The best way to get cost information for the Blaise license is to contact the appropriate distributor for your country. Please remember when contacting them that in order to update the translation you need to purchase a developer’s license on top of the users’ license(s).
Statistics Netherlands is the distributor of the Blaise system for Europe, Asia, Africa and
Westat USA is the distributor of the Blaise system for North, Central and South America.
Q. I am interested in assessing 6 month disorders in my research study. Do you recommend the CIDI?
A. The CIDI evaluates lifetime and 12 month disorders and would not be a good tool for 6 month follow up.
Q. I want to administer CIDI version 2.1, can you tell me where I can train on this version?
A. We do not support the CIDI 2.1 anymore but only the CIDI version 3.0. The instruments are
different in many ways. There is a description on the website:
Q. I would like to administer the CIDI Short Form (SF). Is this version available?
A. We no longer support the use of the CIDI short form. Please read the memo by Dr. Kessler on the subject: www.hcp.med.harvard.edu/ncs/ftpdir/cidisf_readme.pdf
"No longer support" means that we cannot answer questions and such about use of the CIDI SF. Further, we decided that the CIDI-SF was not a very useful instrument and we consequently do not recommend its use. For those who have used it, we recommend that they carry out a clinical reappraisal study whenever possible to generate empirical calibration rules of their own.
Q. What is the target age for the CIDI?
A. The CIDI is meant for adults ages 18+ but could be given to 16-17 year olds as well.
Q. I would like to use the CIDI-SAM (Substance Abuse Module).
A. The CIDI-SAM was created by Linda Cottler and is maintained and distributed by her group at University of Florida, Department of Epidemiology. It is distributed as a stand-alone assessment with the algorithms and data entry included. There are several versions available as well: the full SAM, the rx SAM , the inhalant SAM and the Club Drugs SAM. Please contact Dr. Cottler for more information at firstname.lastname@example.org
Q. Can you tell me how long each section of the CIDI takes to administer on average?
A. Please refer to the document NCS section lengths (click here to download the NCS section lengths document) which shows the average administration times of each CIDI section when we used the CAPI questionnaire to administer the CIDI in our general population sample of 10,000 respondents in the US. This should give you a good idea of the average length of time needed.
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