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Diagnostic co-morbidity in 2300 psychiatric out-patients presenting for treatment evaluated with a semi-structured diagnostic interview

  • M. Zimmerman (a1), J. B. McGlinchey (a1), I. Chelminski (a1) and D. Young (a1)

The largest clinical epidemiological surveys of psychiatric disorders have been based on unstructured clinical evaluations. However, several recent studies have questioned the accuracy and thoroughness of clinical diagnostic interviews; consequently, clinical epidemiological studies, like community-based studies, should be based on standardized evaluations. The Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project is the largest clinical epidemiological study using semi-structured interviews assessing a wide range of psychiatric disorders conducted in a general clinical out-patient practice. In the present report we examined the frequency of DSM-IV Axis I diagnostic co-morbidity in psychiatric out-patients.


A total of 2300 out-patients were interviewed with the Structured Clinical Interview for DSM-IV (SCID) upon presentation for treatment.


The mean number of current and lifetime DSM-IV Axis I disorders in the 2300 patients was 1.9 (s.d.=1.5) and 3.0 (s.d.=1.8) respectively. The majority of patients were diagnosed with two or more current disorders, and more than one-third were diagnosed with three or more current disorders. Examination of the most frequent current disorders in the patients with the 12 most common principal diagnoses indicated that the pattern of co-morbidity differed among the disorders. The highest mean number of current co-morbid disorders was found for patients with a principal diagnosis of post-traumatic stress disorder and bipolar disorder.


Clinicians should assume that psychiatric patients presenting for treatment have more than one current diagnosis. The pattern of co-morbidity varies according to the principal diagnosis.

Corresponding author
*Address for correspondence: M. Zimmerman, M.D., Bayside Medical Center, 235 Plain Street, Providence, RI 02905, USA. (Email:
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Alegria M, Bijl R, Lin E, Walters E, Kessler R (2000). Income differences in persons seeking outpatient treatment for mental disorders: a comparison of the United States with Ontario and the Netherlands. Archives of General Psychiatry 57, 383391.
Alonso J, Lepine JP (2007). Overview of key data from the European Study of the Epidemiology of Mental Disorders (ESEMeD). Journal of Clinical Psychiatry 68 (Suppl. 2), 39.
Andrews G, Henderson S, Hall W (2001). Prevalence, comorbidity, disability and service utilisation. Overview of the Australian National Mental Health Survey. British Journal of Psychiatry 178, 145153.
Andrews G, Slade T, Issakidis C (2002). Deconstructing current comorbidity: data from the Australian National Survey of Mental Health and Well-Being. British. Journal of Psychiatry 181, 306314.
Barlow DH, DiNardo PA, Vermilyea BB, Vermilyea J, Blanchard EB (1986). Co-morbidity and depression among the anxiety disorders: issues in diagnosis and classification. Journal of Nervous and Mental Disease 174, 6372.
Basco MR, Bostic JQ, Davies D, Rush AJ, Witte B, Hendrickse W, Barnett V (2000). Methods to improve diagnostic accuracy in a community mental health setting. American Journal of Psychiatry 157, 15991605.
Berkson J (1946). Limitations of the application of fourfold table analysis to hospital data. Biometric Bulletin 2, 4753.
Brown C, Schulberg HC, Madonia MJ, Shear MK, Houck PR (1996). Treatment outcomes for primary care patients with major depression and lifetime anxiety disorders. American Journal of Psychiatry 153, 12931300.
Brown TA, Barlow DH (1992). Comorbidity among anxiety disorders: implications for treatment and DSM-IV. Journal of Consulting and Clinical Psychology 6, 835844.
Brown TA, Campbell LA, Lehman CL, Grisham JR, Mancill RB (2001). Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a large clinical sample. Journal of Abnormal Psychology 110, 585599.
Cassano GB, Perugi G, Musetti L (1990). Comorbidity in panic disorder. Psychiatric Annals 20, 517521.
Coryell W, Endicott J, Andreasen NC, Keller MB, Clayton PJ, Hirschfield RMA, Scheftner WA, Winokur G (1988). Depression and panic attacks: the significance of overlap as reflected in follow-up and family study data. American Journal of Psychiatry 145, 293300.
Coryell W, Noyes R (1988). Placebo response in panic disorder. American Journal of Psychiatry 145, 11381140.
Davidson J, Smith R (1993). Traumatic experiences in psychiatric outpatients. Journal of Traumatic Stress 3, 459475.
DeRuiter C, Rijken H, Garssen B, VanSchaik A, Kraaimaat F (1989). Comorbidity among the anxiety disorders. Journal of Anxiety Disorders 3, 5768.
Diniz J, Rosario-Campos M, Shavitt R, Curi M, Hounie A, Brotto S, Miguel E (2004). Impact of age at onset and duration of illness on the expression of comorbidities in obsessive-compulsive disorder. Journal of Clinical Psychiatry 65, 2227.
Fava M, Rankin MA, Wright E, Alpert JE, Nierenberg AA, Pava J, Rosenbaum JF (2000). Anxiety disorders in major depression. Comprehensive Psychiatry 41, 97102.
Fava M, Uebelacker LA, Alpert JE, Nierenberg AA, Pava JA, Rosenbaum JF (1997). Major depressive subtypes and treatment response. Biological Psychiatry 42, 568576.
First MB, Spitzer RL, Gibbon M, Williams JBW (1995). Structured Clinical Interview for DSM-IV Axis I Disorders – Patient Edition (SCID-I/P, Version 2.0). Biometrics Research Department, New York State Psychiatric Institute: New York.
Franklin C, Sheeran T, Zimmerman M (2002). Screening for trauma history, posttraumatic stress disorder, and subthreshold PTSD in psychiatric outpatients. Psychological Assessment 14, 467471.
Gaynes BN, Magruder KM, Burns BJ, Wagner HR, Yarnall KSH, Broadhead WE (1999). Does a coexisting anxiety disorder predict persistence of depressive illness in primary care patients with major depression? General Hospital Psychiatry 21, 158167.
Goisman RM, Goldenberg I, Vasile RG, Keller MB (1995). Comorbidity of anxiety disorders in a multicenter anxiety study. Comprehensive Psychiatry 36, 303311.
Goodwin R, Hoven C, Lyons J, Stein M (2002). Mental health service utilization in the United States. The role of personality factors. Social Psychiatry and Psychiatric Epidemiology 37, 561566.
Grant B, Stinson F, Dawson D, Chou P, Dufour M, Compton W, Pickering R, Kaplan K (2004). Prevalence and co-occurrence of substance use disorders and independent mood and anxiety disorders. Archives of General Psychiatry 61, 807816.
Green BL, Lindy JD, Grace MC, Gleser GD (1989). Multiple diagnoses in posttraumatic stress disorder: the role of war stressors. Journal of Nervous and Mental Disease 177, 329335.
Grunhaus L (1988). Clinical and psychobiological characteristics of simultaneous panic disorder and major depression. American Journal of Psychiatry 145, 12141221.
Keller MB, Klerman GL, Lavori PW, Coryell W, Endicott J, Taylor J (1984). Long-term outcomes of episodes of major depression. Journal of the American Medical Association 252, 788792.
Kessler R, Chiu W, Demler O, Walters E (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry 62, 617627.
Kessler RC, McGonagle KA, Zhao S, Nelson CB, Hughes M, Eshelman S, Wittchen HU, Kendler KS (1994). Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States. Archives of General Psychiatry 51, 819.
Kessler RC, Zhao S, Katz SJ, Kouzis AC, Frank RG, Edlund M, Leaf P (1999). Past-year use of outpatient services for psychiatric problems in the National Comorbidity Survey. American Journal of Psychiatry 156, 115123.
Koenigsberg HW, Kaplan RD, Gilmore MM, Cooper AM (1985). The relationship between syndrome and personality disorder in DSM-III: experience with 2,462 patients. American Journal of Psychiatry 142, 207212.
Loranger AW (1990). The impact of DSM-III on diagnostic practice in a university hospital. Archives of General Psychiatry 47, 672675.
Markowitz JC, Moran ME, Kocsis JH, Frances AJ (1991). Prevalence and comordibity of dysthymic disorder among psychiatric outpatients. Journal of Affective Disorders 24, 6371.
McElroy S, Altshuler L, Suppes T, Keck P, Frye M, Denicoff K, Nolen W, Kupka R, Leverich G, Rochussen J, Rush A, Post R (2001). Axis I psychiatric comorbodity and its relationship to historical illness variables in 288 patients with bipolar disorder. American Journal of Psychiatry 158, 420426.
Melartin TK, Rytsala HJ, Leskela US, Lestela-Mielonen PS, Sokero TP, Isometsa ET (2002). Current comorbidity of psychiatric disorders among DSM-IV major depressive disorder patients in psychiatric care in the Vantaa Depression Study. Journal of Clinical Psychiatry 63, 126134.
Mezzich J, Fabrega H, Coffman G, Haley R (1989). DSM-III disorders in a large sample of psychiatric patients: frequency and specificity of diagnoses. American Journal of Psychiatry 146, 212219.
Mezzich JE, Fabrega H, Coffman GA (1987). Multiaxial characterization of depressive patients. Journal of Nervous and Mental Disease 175, 339346.
Miller PR, Dasher R, Collins R, Griffiths P, Brown F (2001). Inpatient diagnostic assessments: 1. Accuracy of structured vs. unstructured interviews. Psychiatry Research 105, 255264.
Narrow WE, Regier DA, Rae DS, Manderscheid RW, Locke BZ (1993). Use of services by persons with mental and addictive disorders: findings from the National Institute of Mental Health Epidemiologic Catchment Area Program. Archives of General Psychiatry 50, 95107.
Noyes R, Reich J, Christiansen J, Suelzer M, Pfohl B, Coryell WA (1990). Outcome of panic disorder. Archives of General Psychiatry 47, 809818.
Oldham JM, Skodol AE (1991). Personality disorders in the public sector. Hospital and Community Psychiatry 42, 481487.
Olfson M, Marcus SC, Druss B, Elinson L, Tanielian T, Pincus HA (2002). National trends in the outpatient treatment of depression. Journal of the American Medical Association 287, 203209.
Perugi G, Toni C, Frare F, Travierso M, Hantouche E, Akiskal H (2002). Obsessive-compulsive-bipolar comorbidity: a systematic exploration of clinical features and treatment outcome. Journal of Clinical Psychiatry 63, 11291134.
Pfohl B, Blum N, Zimmerman M (1997). Structured Interview for DSM-IV Personality. American Psychiatric Press, Inc.: Washington, DC.
Robins LN, Locke BZ, Regier DA (1991). An overview of psychiatric disorders in America. In Psychiatric Disorders in America: The Epidemiologic Catchment Study (ed. Robins L. N. and Regier D. A.), pp. 328386. The Free Press: New York.
Rush A, Zimmerman M, Wisniewski S, Fava M, Hollon S, Warden D, Biggs M, Shores-Wilson K, Shelton R, Luther J, Thomas B, Trivedi M (2005). Comorbid psychiatric disorders in depressed outpatients: demographics and clinical features. Journal of Affective Disorders 87, 4345.
Sanderson WC, Beck AT, Beck J (1990 a). Syndrome comorbidity in patients with major depression or dysthymia: prevalence and temporal relationships. American Journal of Psychiatry 147, 10251028.
Sanderson WC, DiNardo PA, Rapee RM, Barlow DH (1990 b). Syndrome comorbidity in patients diagnosed with a DSM-III-R anxiety disorder. Journal of Abnormal Psychology 3, 308312.
Schwalberg MD, Barlow DH, Alger SA, Howard LJ (1992). Comparison of bulimics, obese binge eaters, social phobics, and individuals with panic disorder on comorbidity across DSM-III-R anxiety disorders. Journal of Abnormal Psychology 101, 675681.
Shear MK, Greeno C, Kang J, Ludewig D, Frank E, Swartz HA, Hanekamp M (2000). Diagnosis of nonpsychotic patients in community clinics. American Journal of Psychiatry 157, 581587.
Sherbourne CD, Wells KB (1997). Course of depression in patients with comorbid anxiety disorders. Journal of Affective Disorders 43, 245250.
Sierles FS, Chen JJ, McFarland RE, Taylor MA (1983). Posttraumatic stress disorder and concurrent psychiatric illness: a preliminary report. American Journal of Psychiatry 140, 11771179.
Stangler RS, Printz AM (1979). DSM-III: psychiatric diagnosis in a university population. American Journal of Psychiatry 137, 937940.
The ESEMeD/MHEDEA 2000 investigators (2004). 12-Month comorbidity patterns and associated factors in Europe: results from the European Study of the Epidemiology of Mental Disorders (ESEMeD) project. Acta Psychiatrica Scandinavica 109 (Suppl. 420), 2837.
Trivedi M, Rush A, Wisniewski S, Nierenberg A, Warden D, Ritz L, Norquist G, Howland R, Lebowitz B, McGrath P, Shores-Wilson K, Biggs M, Balasubramani G, Fava M, STAR*D Study Team (2006). Evaluation of outcomes with citalopram for depression using measurement-based care in STAR*D implications for clinical practice. American Journal of Psychiatry 163, 2840.
Turner SM, Beidel DC, Borden JW, Stanley MA, Jacob RG (1991). Social phobia: Axis I and II correlates. Journal of Abnormal Psychology 100, 102106.
Van Valkenburg C, Winokur G, Behar D, Lowry M (1984). Depressed women with panic attacks. Journal of Clinical Psychiatry 45, 367369.
Wilfley D, Friedman M, Dounchis J, Stein R, Welch R, Ball S (2000). Comorbid psychopathology in binge eating disorder: relation to eating disorder severity at baseline and following treatment. Journal of Consultng and Clinical Psychology 68, 641649.
Zimmerman M (2003). Integrating the assessment methods of researchers in routine clinical practice: the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project. In Standardized Evaluation in Clinical Practice (ed. First M.), pp. 2974. American Psychiatric Publishing, Inc: Washington, DC.
Zimmerman M, Chelminski I (2006). A scale to screen for Axis I disorders in psychiatric outpatients: performance of the Psychiatric Diagnostic Screening Questionnaire. Psychological Medicine 36, 16011611.
Zimmerman M, Chelminski I, McDermut W (2002). Major depressive disorder and Axis I diagnostic comorbidity. Journal of Clinical Psychiatry 63, 187193.
Zimmerman M, Mattia JI (1999 a). Psychiatric diagnosis in clinical practice: is comorbidity being missed? Comprehensive Psychiatry 40, 182191.
Zimmerman M, Mattia JI (1999 b). Differences between clinical and research practice in diagnosing borderline personality disorder. American Journal of Psychiatry 156, 15701574.
Zimmerman M, Mattia JI (1999 c). Is posttraumatic stress disorder underdiagnosed in routine clinical settings? Journal of Nervous and Mental Disease 187, 420428.
Zimmerman M, Mattia JI (1999 d). The reliability and validity of a screening questionnaire for 14 DSM-IV Axis I disorder (The Psychiatric Diagnostic Screening Questionnaire). Journal of Clinical Psychiatry 60, 677683.
Zimmerman M, Mattia JI (2000). Principal and additional DSM-IV disorders for which outpatients seek treatment. Psychiatric Services 51, 12991304.
Zimmerman M, Mattia JI (2001 a). The Psychiatric Diagnostic Screening Questionnaire: development, reliability and validity. Comprehensive Psychiatry 42, 175189.
Zimmerman M, Mattia JI (2001 b). A self-report scale to help make psychiatric diagnoses: the Psychiatric Diagnostic Screening Questionnaire (PDSQ). Archives of General Psychiatry 58, 787794.
Zimmerman M, Posternak M, Attiullah N, Friedman M, Boland R, Baymiller S, Berlowitz S, Uy K, Singer S, Chelminski I (2005). Why isn't Bupropion the most frequently prescribed antidepressant? Journal of Clinical Psychiatry 66, 603610.
Zimmerman M, Posternak M, Friedman M, Attiullah N, Baymiller S, Boland R, Berlowitz S, Rahman S, Uy K, Singer S (2004). Which factors influence psychiatrists' selection of an antidepressant? American Journal of Psychiatry 161, 12851289.
Zimmerman M, Sheeran T (2003). Screening for principal versus comorbid conditions in psychiatric outpatients with the Psychiatric Screening Questionnaire. Psychological Assessment 15, 110114.
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