1. and its ability to gauge a therapeutic response
The accuracy of the M3 in validating the psychiatric diagnosis in a clinical sample
and its ability to gauge a therapeutic response
Kamal Gandotra, M.D.1, Sharlene Leong.2, Maria M. Hipolito, MD1, William B. Lawson, MD, PhD1
1Department of Psychiatry, Howard University College of Medicine, 2Department of Psychology, Howard University
Background
The M3 Screen is a 27-item questionnaire that screens not only for depression but also anxiety, bipolar disorder and post-traumatic stress disorder. It is mostly a primary care tool. While most studies have shown an association between M3 scores and Depression, there have been no studies demonstrating the efficacy of the M3 in providing ancillary support in the clinical diagnosis of anxiety, PTSD and bipolar disorder in a mental health setting. Investigation of the dimensional subscores of the M3 can provide important information regarding the understanding and management of psychiatric pathologies.
Methods
Patients diagnosed with various mental health disorders seen in an urban outpatient mental health setting received M3 screen. The sensitivity and specificity of the M3 scores were compared to the patients’ clinical diagnosis and psychotropic medications.
Results
Frequency of clinical endorsement on the M3 included 64 (82%) in MDD, 69 (89%) in GAD, 63 (81%) in PTSD, and 58 (74%) in BPAD. While chi-square analysis confirmed that the M3 did capture the associated diagnosis in the chart for these individuals, there was also a considerable amount of false positives
Conclusions
The strong relationship between M3 scores and Mood Disorders and General Anxiety Disorders suggests the possibility that M3 screen can provide ancillary support not only in the clinical diagnosis of these disorders, but also in medication management. For patients in treatment, antidepressants in particular, it is important to watch for burgeoning anxiety or bipolar symptoms. When bipolar, anxiety, and PTSD M3 subscores rise with treatment, an adjustment in medication may be required.
*Although the M3 appears to validate psychiatric diagnoses it is associated with a large number of false positives in certain subdivisions. From the analyses of the data it has a high sensitivity for the detection of unipolar depression but a low sensitivity in reference to detecting PTSD, BPAD, and anxiety.
*The M3 appears to be a useful screening tool for the detection of depression in the primary care setting. It also is a useful tool for symptom assessment in a psychiatric outpatient setting. A substantial portion of our study sample had an overall elevated score above the reference range a score above 33.
* Thus far the most widely used screen is the PHQ-9, similar to others available the PHQ-9 is targeted to a single diagnosis. Failure to recognize BPAD in depressed patients may lead to administration of incorrect psychotropic medications which has been shown to worsen the underlying disorder. These costs include increased morbidity, hospitalization, and a significantly higher risk of suicide. The M3 Checklist, a 27-item, self-administered screen for depression, anxiety disorders, PTSD, and bipolar disorder, provides a single overall score which assists both mental health professionals and clinicians. The M3 score has also been shown to correlate with the SF-12 health survey, further evidence of the M3’s ability to find clinically significant cases with an emphasis on impairment in function. Also a validation study performed in the primary care setting at the University of North Carolina (Ann Fam Pract 8, 2010) illustrated that the M3 matched the diagnostic sensitivities and specificities of four mono-diagnostic screens (PHQ-9 for depression, GAD-7 for anxiety, CAPS for PTSD and MDQ for bipolar disorder). To date no study utilizing nor confirming the validity of the M3 in a mental health outpatient setting has been conducted in an underserved population.
*In the present report from Howard University’s Faculty Practice Plan to enhance Diagnostic Assessment and Treatment, we examined the reliability and validity of the “My mood monitor” application (M3). The M3 was constructed to be brief (completed in less than 5 minutes), subsequently the application generating an automatic score with subdivisions in literally a few seconds, clinically useful (completely covering the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition symptoms of bipolar disorder, PTSD, anxiety disorders, and substance abuse), valid, reliable and sensitive to change. We studied the M3 in more than 70 psychiatric outpatients and found that the scale had high internal consistency and test-retest reliability when evaluating depressive symptoms. The M3 can potentially diminish the number of missed psychiatric diagnoses and facilitate appropriate treatment of identified cases. The M3 correlated highly with interviewer ratings of severity of all its subdivisions, and M3 scores were significantly different in patients with mild, moderate, and severe levels of psychiatric pathologies. It was a valid measure of symptom change in reference to unipolar depression. Finally, the M3 was significantly associated with a diagnosis of unipolar depression and did not appear to be associated with a diagnosis of Bipolar Disorder, PTSD, and anxiety Disorders. Thus, the results of this large validation study of the M3 illustrates that it is a reliable and valid measure of unipolar depression that is feasible to implement into routine outpatient settings.
*It is unclear from this current sample whether or not the M3 is a good monitor of patient response to psychotropic medication. There was a decrease in M3 scores for patients on psychotropic medication. This may be due to variation in patient visits, as some patients had completed the M3 many more times than others indicating further progress in treatment. Further research should compare M3 scores at several set times throughout the patient’s visits with their physician.
ABSTRACT
Based on the clinical cut off scores of the M3, 51 (65%) subjects’ scores were of clinical concern. T-tests indicated significant differences between scores in each of the subscales the M3 between those who were considered a clinical concern and those who were not, including indications of substance and alcohol use.
DISCUSSION
TABLE 1
T-test results comparing subscales of clinical and non-clinical
concerning scores on the M3
Non-clinical
Clinical M SD
t-value
20.52
8.54
53.37
14.41
-12.63*
3.56
2.17
8.90
2.50
-9.35*
2.78
2.06
12.10
5.61
-10.59*
0.90
1.05
3.72
2.20
-7.70*
0.81
0.96
2.56
1.93
-5.69*
*p<.01, Table 1 compares the subscales of the M3 between those endorsing at a level of clinical concern and those who are not.
FIGURE 1: DBP reactivity to psychological challenge as a function of triglyceride levels.
Frequency of clinical endorsement on the M3 out of all individuals above the clinical cut off scores is reported here as more than one subscale can be clinically elevated. This included 64 (82%) clinical endorsements in MDD, 69 (89%) in GAD, 63 (81%) in PTSD, and 58 (74%) in BPAD.
While chi-square analysis confirmed that the M3 did capture the associated diagnosis in the chart for these individuals, there was also a considerable amount of false positives
TABLE 2
* The M3 Checklist, a 27-item, self-administered screening tool for depression, anxiety disorders, PTSD, and bipolar disorder, that provides a single overall score which assists both mental health professionals and clinicians.
* Use of M3 in a primary care clinic matched the diagnostic sensitivities and specificities of four mono-diagnostic screens (PHQ-9 for depression, GAD-7 for anxiety, CAPS for PTSD and MDQ for bipolar disorder). (1)
* To date no study utilizing the M3 in validating a psychiatric diagnosis and monitoring treatment response in a targeted mental health outpatient setting has been conducted.
* The aim of the study is to obtain data from M3 that may corroborate a patients’ psychiatric diagnosis and possibly identify its ability to serve as a gauge for psychotropic response.
INTRODUCTION
Comparison of M3 symptom endorsement and
presence of diagnosis in chart
Diagnosis present in chart data
M3 endorsement
Yes No p
χ2 value
n (%)
MDD
0.51
0.32
Clinical 25
37%
Not Clinical 1 1% 0%
GAD
N/A 6 9% 45
67%
PTSD
0.74
0.57 7
10% 42
63% 2 3%
BPAD
0.54
0.47 11
16% 33
49%
METHODS
* The study evaluated the accuracy of the M3 by determining inter rater reliability. The clinical diagnosis was achieved by utilizing face to face interviews and chart diagnosis by two clinicians.
* The interviews were administered by board certified psychiatrists and psychiatry residents with three years of experience working in the field of psychiatry for at least three years.
* A repeat measures T-test was used to compare the progress of M3 patient scores on psychotropic medications indicating medication response.
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REFERENCES
∙The strong relationship between M3 scores and Mood Disorders and General Anxiety Disorders suggests the possibility that M3 screen can provide ancillary support not only in the clinical diagnosis of these disorders, but also in medication management.
∙For patients in treatment, antidepressants in particular, it is important to watch for vicissitude of anxiety or bipolar symptoms. When bipolar and unipolar depression M3 subscores rise with treatment, an adjustment in medication may be required.4,5
∙Frequencies of clinical diagnosis were based on the primary diagnosis period. Of the total individuals, this included 36 (46%) with MDD, 10 (13%) with GAD, 7 (9%) with PTSD, and 18 (23%) with BPAD. When looking at substance use, 27 (35%) indicated use of substances and 3 (4%) indicated use of alcohol.
∙Frequency of clinical endorsement on the M3 out of all individuals above the clinical cut off scores is reported here as more than one subscale can be clinically elevated. This included 64 (82%) clinical endorsements in MDD, 69 (89%) in GAD, 63 (81%) in PTSD, and 58 (74%) in BPAD.
∙Chi-square analysis confirmed that the M3 did capture the associated diagnosis in the chart for these individuals, there was also a considerable amount of false positives.
∙Using a repeat measures T-test to compare progress of M3 patient scores, a significant decrease in M3 scores was found between the first (M=37.6, SD=19.5) and the most recent (M=31.9, SD=17.9) visits of all the patients, t(44) = 2.30, p <.05.
RESULTS
GRAPH 1
ACKNOWLEDGEMENTS
This project was supported by the Department of Psychiatry and Behavorial Sciences, Office of Research and Compliance, Special thanks to Society of Biological Psychiatry.