In the last three decades, the field of psychiatric epidemiology has rapidly expanded. One of the contributing factors to this development has been the progressive design, development and application of various highly structured and standardized diagnostic interviews which can be used by lay interviewers with no formal clinical training.1,2 In the early 1980s, the Diagnostic Interview Schedule (DIS) was the first structured clinical diagnostic interview specifically designed for use by lay trained interviewers who were not clinicians and its purpose was to generate accurate clinical psychiatric diagnoses using computerized algorithms based on the American Psychiatric Association (APA) Diagnostic and Statistical Manual of Mental Disorders 3rd edition (DSM-III) criteria. This instrument was used in the Epidemiologic Catchment Area (ECA) study, the first United States (U.S.) national survey conducted from 1981 to 1984 that ascertained prevalence rates and risk factors of mental disorders in the U.S.3 This landmark project led to replications in other countries as well as to the development of other structured diagnostic interviews, most notably the World Health Organization Composite International Diagnostic Interview (WHO-CIDI, hereafter referred to as CIDI), currently the most widely used mental health diagnostic interview worldwide.4 The CIDI was designed by the World Health Organization (WHO) for the purpose of ascertaining diagnoses based on definitions and criteria based on the WHO International Classification of Disease (ICD) and not exclusively on DSM definitions and criteria. This was particularly important for cross-national comparative research of epidemiological studies of mental illnesses since the ICD is the most widely used international classification system.

The International Consortium of Psychiatric Epidemiology, ICPE (http://www.hcp.med.harvard.edu/icpe/),5 funded by the U.S. National Institute of Mental Health (NIMH) used the CIDI as the diagnostic tool to facilitate cross-national comparisons of epidemiological surveys of mental illness in the general population. The ICPE was the precursor to the WHO sponsored World Mental Health (WMH) Surveys, which initiated in 1999. The primary aim of the WMH Surveys Consortium is to obtain objective estimates of the prevalence of mental disorders, their associated disability, and patterns of treatment by: (1) assessing the global burden of mental disorders; (2) determining the psychosocial risk factors and correlates of mental disorders; (3) establishing mental health utilization patterns; and (4) identifying modifiable barriers to help-seeking by carring out surveys in a representative number of countries in all major regions of the world.6 This consortium has coordinated the performance of CIDI surveys in the general population in more than 28 countries in all continents (http://www.hcp.med.harvard.edu/wmh), including many in Latin America such as México,7,8 Colombia9 and Perú.10 In this context, the European Study of the Epidemiology of Mental Disorders (ESEMeD) surveys11,12 coordinated the participation of six European countries (Belgium, France, Germany, Italy, Holland and Spain), which was a result of the ICPE experience.

The cultural and linguistic adaptation process of the CIDI follows a protocol-based pathway and has to be accepted and supervised by the editorial committee of WHO-CIDI.14 In brief, it comprises the following stages (Fig. 1): (1) formal training and accreditation for its use; (2) evaluation of the diagnostic interview by an expert panel; (3) formal acceptance of the proposed changes; (4) adaptation of the software for the CAPI format; and (5) pilot testing the instrument.

Fig. 1.

Flow chart of the cultural and linguistic adaptation of the Latin American WHO-CIDIa version for use in Spain.

(0.47MB).

As part of the cultural and linguistic adaptation process of the Latin American version of the CIDI for its use in Spain, adaptations and changes were made to a total of 372 questions (approximately 7.4% of the total) with a mean of nine per section (standard deviation of 11.57), range from zero (Psychosis and Respondent Contacts sections) to 68 (34%) (Chronic Conditions section) (Table 2).

The majority of changes made were minor linguistic adaptations related to grammatical terms or vocabulary unique to Spain (semantic of idiomatic equivalences) (Table 3). Others needed a modification to capture experiential or conceptual equivalences more appropriate in Spain. For example, the expert panel considered that the psychological consequences of being beaten up by a spouse or romantic partner is not a matter of the intensity of the beat (badly beaten in PT14, Table 3), but they are related to the experience itself. Consistently, the adjective “muy fuerte” was eliminated looking for an experiential equivalence in Spain.

Other changes, including healthcare personnel designation, units of measurement and currency, names of Spanish institutions, organizations and psychotropic medication, as well as some other healthcare resources, also needed to be adapted for use in Spain (Table 4).

Most of the 32 participants of the pilot study were males (66%), married or cohabiting (64.5%), with a mean age of 39 years (SD: 13.6), and a mean duration of formal education of 14 years (SD: 3.3). The median time to complete the entire interview was 2h and 10min with an interquartile range of between 1h 25min and almost 3h.

The correct functioning of the electronic adapted version (CAPI) was verified, specifically focusing on the complex skip out patterns of questions arising from the combination of answers previously given. Finally, after performing all the documentation necessary to reflect the changes made (Fig. 1), the adaptation of the LA versión of CIDI for Spain received official approval by the Editorial Committee of WMH-CIDI.

The CAPI format of the most current Latin American (v 20.0) Spanish version of the WHO-CIDI has been adapted following a rigorous and meticulous cross-cultural adaptation process and has been successfully pilot tested. It is over ten years since the last WHO-CIDI CAPI version was used in Spain and there have been many changes made during this time to improve the diagnostic interview and, therefore, to make it more relevant to present-day mental health availability and organization of services. However, this continuing process of up-dating the instrument has only been applied to the LA version which, because of cultural and linguistic factors, makes it unsuitable for use in Spain in its present form.

Although the questionnaire had already been translated into many languages, the last version specifically adapted for Spain was in the context of the ESEMeD project. During this time, the WHO-CIDI had gone through various iterations of improvement but the only currently available updated version was the LA CIDI (v. 20.0). We, therefore, used the most updated Spanish version of the CIDI available but only following the cultural and linguistic adaptation process described above.

The comprehensiveness and complexity of the instrument made the adaptation process particularly challenging, especially because of the interactive design of the diagnostic interview in the form of elaborate skip out patterns, complex randomization routines, question fills and edit checking during the course of the interview. This process results in the generation of questions which are directly linked to the answers previously provided by the interviewee. This, therefore, requires a very careful review of the CAPI version of the CIDI and a rigorous process of evaluation in the form of a pilot study.

The number of participants in the pilot study, included in the range previously suggested,17 was sufficient to activate and test all the survey sections to confirm their correct functioning and to allow an estimate of the administration time of the survey to be made. This administration time of the interview in our experience (2h and 10min approximately) was similar to that previously described in international studies.4 This time represents the median time for an interview when all the sections are answered. The administration time, however, can vary greatly depending on the number of diagnostic sections activated according to the pattern of positive responses answered by the interviewee in the initial screening section. In our case, the time ranged from a minimum of 54min to a maximum of 5h. The interactive design of the diagnostic interview allows the administration time of the interview to be shortened considerably for those interviewees who did not endorse symptoms of mental disorders in their lives and therefore respond negatively to many questions, but it can be very lengthy for those who respond affirmatively to a large number of questions in the screening interview. Moreover, the design also gives great flexibility to researchers to select the sections or modules to be activated depending on the study research questions. For example, certain research projects may wish to focus only on specific sections of the interview, depending on the topic under investigation, such as major depressive disorders. The CAPI format ensures maximum efficiency in terms of reducing the length of the interview as well as optimizing data management following completion of the interview.

The conventional cross-cultural adaptation process should be considered within a continuum, from one situation where no adaptation is needed as it is intended to be used in the same language and culture in which it was developed to the opposite pole in which the application of the questionnaire is to be used in a different culture, language and country.17,18 The situation outlined here falls somewhat in the middle (another country with the same language) so that no translation but only a cultural adaptation is needed. It is beyond the scope of this paper to completely assess all the psychometric characteristics of the CIDI (v. 3.0) for its use in Spain. As mentioned earlier, the process described here should be considered as part of the ongoing improvement process of continuous updating, refinement, validation and clinical calibration of the questionnaire led by the Editorial Committee of the WHO-CIDI.13–16,20

In summary, the CAPI format of the most current Latin American Spanish version of the CIDI has been adapted for use in Spain and its correct functioning has been successfully pilot tested. This version has been successfully tested and received official approval, so that it can now be widely employed for further mental health epidemiological studies in Spain.

M.J. Tormo, J. Alonso, S. Aguilar-Gaxiola, C. Navarro and F. Navarro-Mateu conceived the design and supervised the whole process of the study. I. Morán-Sánchez, F. Navarro-Mateu, M.L. Pujalte and A. Garriga were, simultaneously, accredited as trainers for future interviewers. I. Morán-Sánchez, M.L. Pujalte, A. Garriga, J. Alonso, M.J. Tormo, S. Aguilar-Gaxiola and F. Navarro-Mateu participated in the adaptation process. All authors read, edited and approved the final manuscript.

This work has been financed by the Murcian Health Service, the Cajamurcia Foundation and the Foundation for Healthcare Training and Research (FFIS) of the Murcia Region.

None.