Differences in diagnostic patterns in Britain and America

Since 1935, it has been repeatedly noted that English psychiatrists diagnose affective disorders, particularly manic depressive psychosis, more often on first admission than American psychiatrists.^1,2 They diagnose schizophrenia less frequently.The first systematic review of these differences was done by Kramer in 1961.^3,4 He observed that overall first admission rates in the United States and United Kingdom were reasonably close, but in the United Kingdom schizophrenia was diagnosed 50% less often and manic depressive psychosis nearly 900% more often than in the United States.In a study at the New York Psychiatric Institute, it was noted that the diagnosis of schizophrenia increased rapidly in the 1940s and peaked about 1952.⁵ When charts were reviewed and rediagnosed by a British-trained psychiatrist, the number of cases diagnosed as schizophrenia decreased. These and other observations led naturally to speculation.Are hospitalized patients different in Britain or is the difference only one of diagnostic criteria? If the patients are different, is the difference in first admission diagnosts the result of toleration of different forms of mental aberration or are different diagnoses kept at home in the two countries? Is the major difference in psychiatric training? These questions seemed to present an excellent, naturally occurring opportunity to study patient pathology, psychiatric criteria for diagnosis, and the cultural attitudes and tolerance toward varying forms of mental aberration.     

Reasons for the diagnostic discordance between clinicians and researchers in schizophrenia in the Northern Finland 1966 Birth Cohort

Background: The diagnosis of schizophrenia by clinicians is not always accurate in terms of operational diagnostic criteria despite the fact that these diagnoses form the basis of case registers and routine statistics. This poses a challenge to psychiatric research. We studied the reasons for diagnostic discordance between clinicians and researchers. Methods: The Northern Finland 1966 Birth Cohort (n = 11,017) was followed from mid-gestation to the end of the 31st year. Psychiatric outcome was ascertained through linkage to the national hospital discharge register containing clinical diagnoses made by the attending physician. The hospital notes of all subjects admitted to hospital during the period 1982–1997 due to psychiatric disorder were reviewed and 475 research, operational DSM-III-R diagnoses were formulated. Results: Ninety-six cases met operational criteria for schizophrenia. Fifty-five (57 %) had concordant diagnoses: both the clinical and research diagnoses were schizophrenia. Forty-one (43 %) had discordant diagnoses: the clinical diagnosis was other than schizophrenia (mainly schizophreniform or other psychosis). Discordant cases were more likely to be older at onset, experience a shorter treatment duration, fewer treatment episodes, and to have a comorbid diagnosis mental retardation. Conclusions: Clinicians do not make the diagnosis of schizophrenia as often as the application of operational criteria would suggest they should. The discordance between clinical diagnosis and the research, operational diagnosis is especially likely in cases having late onset and few contacts to psychiatric hospital. Accepted: 12 December 2002 Correspondence to Kristiina Moilanen, MD     

The diagnosis of hysterical personality disorder: A study of attitudes

The concept of personality disorder must, as other psychiatric diagnoses, be evaluated in terms of reliability, utility, and validity. In recent years, there has been growing interest in such issues for personality diagnoses in general^1,2 and for obsessive-compulsive,^3–6 antisocial,⁷ and hysterical personality disorders in particular. Since these diagnoses rest on the judgment that an individual is deviant in respect of traits shared to a greater or lesser degree by everyone, the diagnostic process itself, the exercise whereby that judgment is made, should receive particular study. In this way, we might learn which clinical features can be reliably recognized and, thus, used to form the basis for operational definitions of personality disorders. As an initial step in such research, a group of psychiatrists was asked to comment on several factors important in the diagnosis of hysterical personality disorder.     

Biochemical correlates of schizophrenia

Schizophrenia is an ailment of the complex and diverse manifestations springing from evolution's most complicated product—the human mind. Despite the splendid formulation of schizophrenia by Bleuler in 1911, this disease has remained poorly defined.Szasz¹ is of the opinion that the term “schizophrenia” is a “panchreston.” In other words, schizophrenia is supposed to explain abnormal behavior in much the same way as “protoplasm” explains the nature of life. The term schizophrenia, he points out, interferes with better understanding of psychiatric entities, and without modifying psychiatric nosology, all these entities are no more than panchrestons.Along this line, Laing² views schizophrenia as a label which imposes consequences on the individual labeled schizophrenic. He points out that some individuals undergo unusual experiences and manifest unusual behavior which appears to be a natural sequence of their experiences. From laing's point of view, what we observe in some individuals whom we label schizophrenic is the behavioral expression of an experiential drama, and schizophrenia is an “abnormal way of dealing with an abnormal situation.”The American Psychiatric Association³ describes schizophrenia as “a group of disorders manifested by characteristic disturbances of thinking, mood and behavior. Disturbances in thinking are marked by alterations of concept formation which may lead to misinterpretation of reality and sometimes to delusions and hallucinations which frequently appear psychologically self-protective. Corollary mood changes include ambivalent, constricted and inappropriate emotional responsiveness and loss of empathy with others. Behavior may be withdrawn, regressive, and bizarre.”As an outcome of the National Conference on Schizophrenia held at the Menninger Foundation in 1969, it was suggested that one refer to a “schizophrenic syndrome” rather than “schizophrenia” with connotations of a disease state.     

Les troubles paraphiliques dans le DSM-5 : analyse critique et considérations médicolégales

IntroductionThe 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) aimed to improve the reliability of psychiatric diagnoses, to address problems identified in DSM-IV, and to improve its clinical and forensic utility. Some of the changes in the diagnostic criteria for the paraphilic disorders in the DSM-5 were guided by forensic concerns, since these are the ones of most interest to forensic psychiatrists. The aim of this paper is to describe and comment the changes made from DSM-IV to DSM-5 concerning paraphilic disorders, and to discuss their legal implications.MethodsPubMed and Medline search, Scopus, journal and textbook articles have been accessed for a detailed literature review on DSM-5 changes related to paraphilic disorders. We conducted the search using the following keywords: Paraphilia; DSM-5; Diagnosis; Diagnostic criteria.ResultsSeveral minor but important changes have been made to the paraphilic disorders diagnostic criteria in DSM-5. DSM-5 redefines the term “paraphilia” which now refers to non pathological, atypical sexual interests (Criterion A); and introduced the term “paraphilic disorder” which is reserved for individuals who meet both Criterion A and Criterion B (individuals who have clinically significant distress or impairment). The DSM-IV category of “paraphilia not otherwise specified” has been replaced with two disorders in DSM-5, “other specified paraphilic disorder” and “unspecified paraphilic disorder”. Both of these categories are considered to be residual. The decision to use one or other of the two disorders depends on whether the clinician wants to specify explicitly the type of atypical paraphilic focus. These residual categories don’t have the same degree of utility as the specific named categories, and can be misused in forensic contexts. In addition, for all of the paraphilic disorders except pedophilic disorder, there are two new course specifiers, “in full remission” and “in a controlled environment”. The decision to provide a specific duration threshold at which the individual must not have acted on his paraphilic urges nor have experienced any distress or impairment, was mainly motivated by forensic issues. Otherwise, three conditions were considered for inclusion in DSM-5: “hypersexual disorder”, “paraphilic coercive disorder”, and “pedophebophilic disorder”. Hypersexual disorder was defined as intense interest in normal sex that was causing problems. Paraphilic coercive disorder was defined as sexual arousal by coercive sex in men who do not meet the diagnostic criteria for sexual sadism. In pedophebophilic disorder, the range of pathologic sexual interest was extended to include adolescents. These proposed diagnosis have received considerable Criticism, and have been abandoned, largely due to a lack of empirical evidence.ConclusionChanges proposed in the DSM treatment of paraphilic disorders are relatively modest and the core of the DSM-IV diagnostic criteria is retained. Many of the changes that occur in paraphilic disorders diagnostic criteria increase the risk of false-positive diagnoses by making it easier to assign a specific paraphilia to an individual, and must be considered with caution. The classification of certain sexual behaviors as pathological, even in the absence of distress, reveals an underlying moral design. As a result, some authors question the validity and reliability of paraphilic disorders, and suggest revolutionary changes, depathologizing paraphilias and removing them from systems of mental disorder classification.     

Familial concordance in schizophrenia: a comparative study of pairs of sibs.

Intrafamilial resemblance in psychiatric clinical features may provide a powerful tool to the search for an explanation of the distheis-stress duality. Family studies of schizophrenia have emphasized the role of familial concordance for subtype diagnosis,^1,2 symptomatology,^2,3,5 mode,² and age of onset,^2,5,7 outcome,⁸ and sex^9–14 in psychiatric research. Most of these studies have failed, however, to apply uniform criteria for the selection of patients and were based on retrospective and non-blind evaluation of family members.An attempt has been made in this study to apply updated research criteria for the diagnosis of schizophrenia and to evaluate probands in a blind fashion as regards their relatives. Combined variables have been analyzed in order to further elucidate the issue of familial homogeneity in schizophrenia. Efforts to correlate between the results of this study and certain biologic derangements are currently being made (Baron, et al.: Tissue-Serum Affinity in Schizophrenia: Clinical and Familial Determinants, in preparation), aimed at achieving a better understanding of the “nature-nurture” duality.     

Diagnostic confusion in treatment-refractory psychotic patients.

BACKGROUND: Two surveys of diagnostic practices in the United States suggest that many clinicians base their diagnoses on presenting symptoms and pay little attention to course and exclusionary criteria. Failure to correctly diagnose patients may result in inappropriate therapy and poor treatment response. The purpose of the present study was to investigate diagnostic practices. METHODS: We made detailed assessments of 50 consecutively admitted treatment-refractory psychotic patients and carefully applied DSM-III-R criteria. RESULTS: Referral diagnoses were changed in 23 of the 50 patients. Diagnoses of schizophrenia and schizoaffective disorder were made far less frequently and mood disorders (bipolar disorder and major depression) were diagnosed far more frequently by our group than by referring psychiatrists. Patients whose diagnosis was changed were more likely to be given mood-stabilizing medication and tended to show more improvement than patients whose diagnosis was not changed. CONCLUSIONS: These findings raise the possibility that patients may not respond to treatment because incorrect diagnoses result in inappropriate treatment.     

Autism Plus Versus Autism Pure

The reported prevalence of autism is going up and up. We propose that some—even much—of the increase in the rate of autism spectrum disorder (ASD) is driven by “Autism Plus”. Autism Plus refers to autism with comorbidities (including intellectual developmental disorder, language disorder, and attention-deficit/hyperactivity disorder), and this is what is now being diagnosed by clinicians as ASD. In clinical practice, a diagnosis of ASD much more often entails that the child will receive support at school and in the community, which is not the case for other diagnoses. In the past the comorbidities were given diagnostic priority and the “autistic features” might, or might not be mentioned as the “plus bit” in the diagnostic summary. It is high time that the comorbidities, sometimes even more important than the autism, came back on the diagnostic agenda. Autism is but one of the Early Symptomatic Syndromes Eliciting Neurodevelopmental Clinical Examination (ESSENCE), not the one and only.     

Non-psychotic disorders in the families of process schizophrenics.

The present study was designed to test the hypothesis of “schizophrenic spectrum” disorders. The families of 60 process schizophrenics were systematically interviewed with structured interview forms, and evaluated for psychiatric illness according to strict diagnostic criteria The interviewed persons were then separated into two groups for comparative analysis according to a positive (FH+) or negative (FH-) family history for schizophrenia. The frequencies of affective disorder and all non-psychotic conditions did not differ to a convincingly significant degree between the two groups. Our data thus fail to support the “schizophrenic spectrum” hypothesis in which neurosis and sociopathy occur as a consequence of a genetic loading for schizophrenia.     

Histrionic Personality and Antisocial Personality: Caricatures of stereotypes?

The proposal that the diagnoses Histrionic personality and Antisocial Personality represent sex-role caricatures of the concepts “woman” and “man”, respectively, was examined utilizing the semantic differential technique for the assessment of connotative meanings. Twenty-eight psychiatric residents and 21 academic psychiatrists rated the concepts “woman”, “man”, “histrionic personality”, and “antisocial personality” on each of 15 bipolar adjectival scales. No important differences were found between the ratings made by male or female psychiatrists or by resident and faculty psychiatrists. The subjects clearly distinguished between the connotative meanings of “woman” and “histrionic personality” and between “man” and “antisocial personality”, though there was a greater resemblance between the first pair of concepts than between the second. The linkages in meaning between women and the diagnosis Histrinic Personality are discussed, and it is proposed that the concept of sex-role caricatures be abandoned since the political overtones of the term “caricature” tend to undermine the empirical work needed to validate or reject clinical diagnoses.     

Relationship between reactive psychosis and the depressive disorders

The diagnostic validity of acute schizophrenia has come under close scrutiny since 1970, when Robins and Guze¹ disclosed that clinical symptomatology, family history, and treatment outcome consistently differentiate between schizophrenics who recover and schizophrenics who follow a chronic, deteriorating course. Not only have recent clinical and empirical investigations into prognosis in schizophrenia confirmed Robins and Guze's hypothesis that good prognosis schizophrenia,^2–5 acute schizophrenia,^6,7 and schizoaffective psychoses^8,9 bear little relation to poor prognosis schizophrenia, studies have also demonstrated that the phenomenology of these good prognosis disorders generally coincide with patterns typically associated with the depressive disorders.^2–7,9 In fact, one-half to two-thirds of the patients receiving admission diagnoses of acute schizophrenia have met strict research criteria for bipolar mania, while less than 5% have fulfilled strict requirements for a diagnosis of schizophrenia.^2–7,9McCabe has recently proposed that many of the remaining third of recovered schizophrenics suffer from a reactive, psychogenic psychosis that is different from both schizophrenia and depressive disorder.^10–14 In a series of studies, he has suggested that certain genetically and/or developmentally vulnerable individuals manifest an abrupt, acute psychosis when subjected to overwhelming psychologic trauma. However, the results of his symptomologic and genetic study do not equivocally support the thesis of a third functional disorder masquerading as acute schizophrenia.^10,11 Rather, much of the data on reactive psychoses overlap with typical phenomenology of the depressive disorders.The congruence of these disorders, one predominantly biologic, the other psychologic in etiology, lends additional support to the integrated models of depressive disorder recently proposed by Akiskal and McKinney^15,16 and Depue and Evans,¹⁷ which suggest that depressive behaviors must be understood as occurring on several levels simultaneously, and that a multiplicity of genetic, developmental, pharmacologic, and interpersonal factors converge in the midbrain and lead to a reversible functional derangement of the mechanisms of reinforcement.¹⁵     

Presenting problems and diagnosis.

As an object of widespread criticism, psychiatric diagnosis has amassed a voluminous body of literature, most of it being focused on questions of validity, reliability, and consistency. Even though germane to the issue, less attention has been directed to the process of diagnostic decision making, i.e., how such assessments are made, what identifiable factors they are based on, and so forth. The work of Gauron and Dickinson,⁶ Petzel and Gynther,⁴ Sandifer et al.,⁵ and Kendall⁷ are among the few studies addressed to these questions.This paper continues this line of inquiry by exploring psychiatric diagnosis in relation to presenting problems. At times a presenting problem is simply a short-hand verbal account of a person's “story”. Generally, however, it is a composite presentation that also includes accounts about his condition made by “significant others” acting as complainant and/or concerned party, as well as the clinician's gross observations.Except for the work of a few investigators,^8–10 presenting problems remain a relatively unexplored area. Taken at face value, without interpretation or inference, presenting problems provide a unique body of information. As such, they constitute one of the few variables that stand at the interfaces of demographic, psychosocial, and clinical data and can thus provide a fruitful, empirically-grounded research tool.Accordingly, data and findings are presented from a recent community-wide survey of psychiatric utilization,¹¹ i.e., specifically, the presenting problems of a 1-year adult population of applicants (unduplicated count) who sought psychiatric care from either a large urban mental health center or from the private sector (i.e., the office and hospital clientele of psychiatrists in private practice; 86% of the private psychiatrists cooperated and participated in the study).     

Differential diagnosis on the autism spectrum: Theorizing an “Ordinary Autism”

ObjectivesData on the prevalence of Autism Spectrum Disorder (ASD) reveal several clinical evolutions inducing new psychiatric definitions and diagnostic practices. Thus, autism has shifted from being a rare syndrome with severe clinical forms to a new paradigm: the paradigm of “ordinary” or “invisible” autism, in terms of the frequency and the intensity of the disorders. These changes incorporate new populations into our conception of autism, with new phenotypes that pose theoretical and clinical challenges to clinicians. In response, we propose the hypothesis — based on psychoanalytic theories of psychic structures — of an “ordinary autism” as a definition of a non-prototypical autistic psychic functioning that falls outside the DSM diagnostic framework. This idea seems to provide us new theoretical references that nourish our practices as well as fundamental research.MethodFirst, we will review the nosographic mutations of the DSM-5 and their implications for non-prototypical psychic modes of functioning of autistic people that may not be contained within the autism spectrum's blurry boundaries — especially for the adult population without intellectual delay and in the case of complicated differential diagnosis for clinical and societal reasons. Next, we will discuss the definition of “ordinary” or “invisible” autism in a psychoanalytic structural model, as a possible epistemological orientation for identifying and designing practice with the clinical heterogeneity of autism outside the boundaries of psychiatric ASD.ResultsThe autistic population targeted by the DSM-5 criteria is different from that previously defined by DSM-IV. This leads to two consequences: on the one hand, autistic modes of functioning are not limited to individuals who have been diagnosed with Autism Spectrum Disorders as defined by the DSM-5; thus individuals with autism do not have access to the diagnosis of ASD or are given other diagnoses. The alternative diagnoses proposed by the DSM-5 that attempt to correct this diagnostic exclusion — such as Social (Pragmatic) Communication Disorder — are unsatisfactory. Therefore, there is an entire segment of the autistic population that has subclinical, non-prototypic autistic manifestations or more subtle phenomena discernible in the broader autistic phenotype or sub-threshold autism spectrum that does not have access to the ASD diagnosis and raises differential diagnostic issues. On the other hand, it appears that the autism spectrum brings together extremely different entities and false positives such as schizophrenia and schizophrenic spectrum personality disorders under one diagnostic rubric. Then, the differential problem appears central: both at the theoretical level and in diagnostic practices. The recognition of these limits should encourage us to promote research and clinical applications on this subject. One solution that we envisage is to be found in an extension of Maleval's structural psychoanalytical model: we propose the notion of “ordinary autism” — an echo of ordinary psychosis — to define attenuated or compensated non-prototypical autistic phenotypes, increasingly frequent and with fewer “extraordinary” phenomenological expressions than the classic cases of autism which now call into question the relationship between the normal and the pathological.Discussion“Ordinary autism” seems to offer clinicians the opportunity to formalize the new contemporary and extensive clinical reality of autism. This term situates itself within a theoretical model whose current and future developments might help us respond to clinical and diagnostic issues, but also to therapeutic and societal ones. We propose to continue on the path of the operationalization of these theoretical models in order to identify autistic structural constants that could be found throughout the “ordinary” clinic of autism and could serve as differentiating tools for diagnosis as well as a support in developing and refining therapeutic practices.ConclusionWe conclude that there is an urgent need to conceive of “ordinary autism” to provide us with reference points to respond to new clinical issues, but also to reintroduce respect for the autistic person in his or her subjectivity to the center of our therapeutic practices.     

Clinique différentielle du spectre de l’autisme : l’intérêt de penser un « autisme ordinaire »

ObjectivesData on the prevalence of Autism Spectrum Disorder (ASD) reveal several clinical evolutions inducing new psychiatric definitions and diagnostic practices. Thus, autism has shifted from being a rare syndrome with severe clinical forms to a new paradigm: the paradigm of “ordinary” or “invisible” autism, in terms of the frequency and the intensity of the disorders. These changes incorporate new populations into our conception of autism, with new phenotypes that pose theoretical and clinical challenges to clinicians. In response, we propose the hypothesis—based on psychoanalytic theories of psychic structures—of an “ordinary autism” as a definition of a non-prototypical autistic psychic functioning that falls outside the DSM diagnostic framework. This idea seems to provide us new theoretical references that nourish our practices as well as fundamental research.MethodFirst, we will review the nosographic mutations of the DSM-5 and their implications for non-prototypical psychic modes of functioning of autistic people that may not be contained within the autism spectrum's blurry boundaries—especially for the adult population without intellectual delay and in the case of complicated differential diagnosis for clinical and societal reasons. Next, we will discuss the definition of “ordinary” or “invisible” autism in a psychoanalytic structural model, as a possible epistemological orientation for identifying and designing practice with the clinical heterogeneity of autism outside the boundaries of psychiatric ASD.ResultsThe autistic population targeted by the DSM-5 criteria is different from that previously defined by DSM-IV. This leads to two consequences: on the one hand, autistic modes of functioning are not limited to individuals who have been diagnosed with Autism Spectrum Disorders as defined by the DSM-5; thus individuals with autism do not have access to the diagnosis of ASD or are given other diagnoses. The alternative diagnoses proposed by the DSM-5 that attempt to correct this diagnostic exclusion—such as Social (Pragmatic) Communication Disorder— are unsatisfactory. Therefore, there is an entire segment of the autistic population that has subclinical, non-prototypic autistic manifestations or more subtle phenomena discernible in the broader autistic phenotype or subthreshold autism spectrum that does not have access to the ASD diagnosis and raises differential diagnostic issues. On the other hand, it appears that the autism spectrum brings together extremely different entities and false positives such as schizophrenia and schizophrenic spectrum personality disorders under one diagnostic rubric. Then, the differential problem appears central: both at the theoretical level and in diagnostic practices. The recognition of these limits should encourage us to promote research and clinical applications on this subject. One solution that we envisage is to be found in an extension of Maleval's structural psychoanalytical model: we propose the notion of “ordinary autism”—an echo of ordinary psychosis—to define attenuated or compensated non-prototypical autistic phenotypes, increasingly frequent and with fewer “extraordinary” phenomenological expressions than the classic cases of autism which now call into question the relationship between the normal and the pathological.Discussion“Ordinary autism” seems to offer clinicians the opportunity to formalize the new contemporary and extensive clinical reality of autism. This term situates itself within a theoretical model whose current and future developments might help us respond to clinical and diagnostic issues, but also to therapeutic and societal ones. We propose to continue on the path of the operationalization of these theoretical models in order to identify autistic structural constants that could be found throughout the “ordinary” clinic of autism and could serve as differentiating tools for diagnosis as well as a support in developing and refining therapeutic practices.ConclusionWe conclude that there is an urgent need to conceive of “ordinary autism” to provide us with reference points to respond to new clinical issues, but also to reintroduce respect for the autistic person in his or her subjectivity to the center of our therapeutic practices.     

Accuracy of diagnoses of schizophrenia in Medicaid claims.

Medical insurance claims are increasingly important as a source of data in monitoring health care utilization and patient outcomes and in identifying patient cohorts for research. In a study that attempted to verify that those with Medicaid claims for treatment of schizophrenia did indeed have the disorder, two psychiatrists evaluated clinical information obtained from primary mental health care providers in relation to DSM-III-R criteria. The psychiatrists classified 86.8 percent of 319 patients with claims for treatment of schizophrenia and 27.5 percent of 156 patients with claims for treatment of other psychiatric diagnoses as definitely or probably having schizophrenia. The authors conclude that most diagnoses of schizophrenia listed on Medicaid claims are accurate, but that a substantial number of individuals with schizophrenia may not be identified by claims data.     

A comparative study of diagnostic practice in psychiatry in Northern Norway and Northwest Russia

BACKGROUND: The co-operation between psychiatrists in Norway and Russia is increasing. The object of this study was to find out whether there were differences in diagnostic practice of psychiatrists in both countries, to look at the nature of the differences and to examine whether these differences affected diagnostic quality. METHOD: Thirty medical doctors working at psychiatric hospitals in both countries diagnosed 12 clinical case vignettes selected from a wide spectre of psychiatric disorders. RESULTS: The Russian clinicians used a larger range of diagnoses than the Norwegians. The Russians tended to diagnose schizophrenia and schizophrenia-like disorders in cases that presented psychotic syndromes, and somatoform disorders in cases that presented agoraphobia. The Norwegians tended to evaluate affective aspects in preference to psychotic symptoms in the case of schizoaffective disorder and overestimate the degree of depression. In general, the Russians had lower total score of correct answers than the Norwegians. CONCLUSION: In spite of the limitations due to minor differences in the data collection phase in the two countries, the study clearly demonstrates differences in diagnostic practice between the countries.     

Japanese midwives as psychiatric diagnosticians: application of criteria of DSM-IV mood and anxiety disorders to case vignettes

It is believed in Japan that only psychiatrists are capable of providing reliable psychiatric diagnosis. However, more awareness of mental health issues related to perinatal care means that midwives are now required to have psychiatric diagnostic skills. The purpose of the present paper was to examine how well Japanese midwives agreed with a psychiatrist on diagnoses of different psychiatric disorders. Vignettes of 29 cases including DSM-IV mood disorders (major depressive disorder and bipolar disorder) and anxiety disorders (generalized anxiety disorder, panic disorder, phobic disorders, and obsessive-compulsive disorder) were distributed to 12 Japanese midwives. They decided the DSM-IV diagnoses independently and compared them with those made by an expert. The kappa coefficients of the diagnoses with a base rate of 0.1 or more were moderate to almost perfect (0.64-0.83). The accuracy of symptom assessment was also satisfactory. Appropriately trained Japanese midwives can use the diagnostic criteria for psychiatric disorders reliably. It is therefore feasible to dispatch midwives who are trained in psychiatric diagnosis to antenatal clinics.