Challenges in Operationalizing the DSM-IV ClinicalSignificance Criterion

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Abstract
Recent advances in the Diagnostic and StatisticalManual of Mental Disorders (DSM)1 havefocused on developing definitions of mental disorder that faithfully representclinicians’ experiences and can be consistently replicated among practitioners.2 Although primarily a clinical tool, the DSM’s formal operationalizations of disorder also allow researchersto design and field structured and semistructured interview protocols, makingpossible estimation of the prevalence and incidence of the more common mentaldisorders within populations. Recently, critiques of such estimates have shiftedtheir focus from reliability to validity.3-6Inparticular, many question whether structured lay interviews overestimate therates of disorder.3 This “false positive”problem is probably best understood in the context of the largest psychiatricepidemiological studies in the United States to date. The Epidemiologic CatchmentArea (ECA) studies7and the National ComorbiditySurveys(NCS)8,9 suggest that,in any given year, almost 20% to 30% of the population experiences a mentalor addictive disorder, while lifetime rates range between 32% and 49%.4,7 Clearly, the implications of such estimatesfor mental health policy in the United States are enormous and have calledinto question whether these rates accurately reflect the need for treatment.3,10-13