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Validation of the Mood and Anxiety Semi-structured (MASS) Interview for

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 Journal of Intellectual Disability Research doi: 10.1111/j.1365-2788.2007.00972.x
821
volume 51 part 10 pp 821–834 october 2007

Validation of the Mood and Anxiety Semi-structured

(MASS) Interview for patients with intellectual
disabilities
L. Charlot,1 C. Deutsch,2 A. Hunt,2 K. Fletcher1 & W. Mcllvane1
1 Department of Psychiatry, University of Massachusetts Medical School (UMMS),Worcester, MA, USA
2 Eunice Kennedy Shriver Center UMMS, Waltham, MA, USA

Abstract Results Agreement with the MASS Interview was

Background When assessing people with intellec-
tual disabilities (ID), using the DSM-IV-TR can be
challenging. Frequently, significant clinical data
must be obtained from interviews with key infor-
mants. A new semi-structured interview tool was
developed including behavioural descriptions of
each DSM-IV-TR symptom criterion for a number
of mood and anxiety disorders. A goal was to
provide mental health clinicians with an instrument
easy to use in clinical practice that would increase
reliable identification of diagnostically important
mood and anxiety symptoms. This is especially
important given the fact that many experts believe
these ‘internalizing’ clinical syndromes may often be
missed in this population, because of characteristic
limitations in expressive language skills.
Method To establish validity, the Mood and
Anxiety Semi-structured (MASS) Interview-derived
diagnoses were compared with clinical DSM-IV
diagnoses derived from an extensive inpatient evalu-
ation and classifications based on the Hamilton
Depression Rating Scale for 93 psychiatric inpa-
tients served on a specialized unit for people with
ID and major mental health disorders.
Correspondence: Dr Lauren Charlot, 55 Lake Avenue North,
Worchester, MA 01655, USA (e-mail: charlotl@ummhc.org).
high yielding significant kappa coefficients ranging
from 0.42 to 0.78.
Conclusions The MASS Interview, a semi-
structured interview containing behavioural descrip-
tions of DSM-IV symptom criteria, shows promise
as a potentially helpful tool in the psychiatric diag-
nostic evaluation of persons with ID and limited
expressive language skills, in the detection of mood
and anxiety disorders. The tool also yields a wide
breadth of clinical information and is easy for
mental health clinicians to use.
Keywords anxiety, depression, diagnostic
assessment, intellectual disabilities, mood disorders,
psychiatric disorders
Introduction
Psychiatric conditions among people with intellec-
tual disability (ID) are frequently misdiagnosed,
and serious psychiatric problems may sometimes go
undetected (reviews by Lowry 1998; Sovner &
Hurley 1983; Sturmey 1999; Janowsky & Davis
2005). DSM-IV-TR diagnostic criteria can be chal-
lenging to use in this population, and a prominent
source of diagnostic error derives from the fact that
clinicians typically rely on the individual’s self-
report of experiences and feelings (Sovner 1986;
Enfield & Aman 1995; American Psychiatric

© 2007 The Authors. Journal Compilation © 2007 Blackwell Publishing Ltd

 Journal of Intellectual Disability Research
822
L. Charlot et al. • Validation of the MASS Interview
Association 2000). Yet, individuals with ID often
have expressive language skill deficits that restrict
their ability to describe feelings, including symp-
toms associated with mood and anxiety disorders
(Ross & Oliver 2003).
Further, developmental factors may affect how
psychiatric symptoms are manifested by people with
ID, in ways that are analogous (though not identical)
to those described for children (Angold 1988;
Charlot 1998; Harris 1998; Rutter 1998; Luby et al.
2003). For example, people with moderate to severe
intellectual impairment appear in some ways similar
to typically developing pre-school-aged children
when depressed, e.g. both are unlikely to report guilt
or hopelessness about their future (see Harris 1998,
pp. 106–109). Also, adults with both ID and depres-
sion often present with associated conduct problems,
appear withdrawn and have an irritable mood in
addition to anhedonia (Charlot et al. 1993; Meins
1995; Charlot 1997; Reiss & Rojahn 1993; Tsiouris
2001). Similar observations have been reported with
respect to depressed children without ID (Angold
1988; Carlson & Kashani 1988; Shafii & Shafii 1992).
This is not surprising, as researchers have noted that
many individuals with ID pass through the same
stages of development, in the same sequence, as their
peers who do not have cognitive disabilities (Harris
1998; Hodapp et al. 1990).
Psychiatric diagnostic assessment of individuals
with ID might be improved upon by focusing on
the impact of developmental features on the symp-
toms of psychiatric disorders, while maintaining use
of the standard criteria at the core of the DSM-IV.
This tactic has already been employed for assess-
ment of children without ID in DSM-III-R,
DSM-IV and DSM-IV-TR; age-related features of
many disorders are described, while adult-based
diagnostic criteria are essentially retained (Ameri-
can Psychiatric Association 1987, 1994, 2000).
To evaluate individuals with ID, we have adopted
behavioural descriptions of the DSM-IV-TR
symptom criteria that are formalized within a new
instrument, the Mood and Anxiety Semi-structured
(MASS) Interview, outlined in Table 1. In this
interview, informants are queried whether or not
the patient has displayed symptoms over the last
month. Informants are further instructed to report
only significant problems – ones that represented a
deviation from usual behaviour for the individual.
© 2007 The Authors. Journal Compilation © 2007 Blackwell Publishing Ltd
volume 51 part 10 october 2007
Subsequently, behavioural descriptions are provided
to concretely illustrate ways in which the symptom
might be manifested by a person with ID. For
example, with regard to depressed mood, the clini-
cian would prompt the informant: ‘Has the patient
had a sad facial expression? Has he been crying fre-
quently, or has he been smiling and laughing much
less than before?’ If informants reported that the
patient displayed five or more symptoms of a
depressive episode that have been intense and per-
sistent, with at least one symptom being anhedonia
or depressed mood (meeting the current DSM-
IV-TR criteria for an episode of major depression),
the clinician would note the possible presence of a
major depressive disorder. A similar approach was
followed to determine if evidence of an anxiety dis-
order or manic episode was present. In all cases,
DSM-IV-TR criteria are followed without altering
these criteria. The critical new approach in the
MASS Interview is that several possible manifesta-
tions of each symptom criterion are given to the
informant as examples of what the individual with
ID might say or do to indicate the symptom was
present.
The behavioural descriptions were derived from
multiple sources including first, the model devel-
oped by Sovner & Hurley (1982a,b) and Lowry &
Sovner (1992) in which behavioural descriptions of
each DSM symptom criterion were developed to
help clinicians better recognize symptoms in their
patients with ID who had limited or no expressive
language abilities. For example, these authors listed
all of the DSM-IV-TR criteria for a major depres-
sive episode. Then, using behavioural terms,
descriptions were provided of what an observer
might see a person with ID does or says to suggest
that the given symptoms were in fact occurring (i.e.
crying much of the time or absence of usual
amount of smiling as possible signs of depressed
mood).
Behavioural descriptions from DSM-IV-TR were
also used in the MASS Interview. In the DSM-IV-
TR, the ways in which clinical features of various
syndromes might present differently in children are
elaborated. For example, DSM-IV-TR states that
children ‘may express anxiety by crying, tantrums,
freezing or clinging’. Also, DSM-IV-TR recognizes
that it may be more common for children to
present with irritable rather than a more ‘classic’
 Journal of Intellectual Disability Research volume 51 part 10 october 2007
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L. Charlot et al. • Validation of the MASS Interview

Table 1 Mood and Anxiety Semi-structured (MASS) Interview*: behavioural descriptors for DSM-IV symptomatology

Excessive anxiety and worry

Appears anxious much of the time (has a fearful expression, never seems relaxed)
Apprehensive about events or activities (school, work, family)
‘Needy’, clinging
Nightmares (associated with anxiety, fear)
‘Freezing’
Crying, or whimpering in a fearful manner
Easily fatigued
Often looks tired, seems to have low energy
Napping during the day
Frequently tries or asks to go to bed
Reports feeling tired
Dark circles under eyes
Difficulty concentrating
Less able to focus attention and to concentrate in general – this is different from usual
Increase in or onset of a memory problem that ‘comes and goes’
Skill loss or failure to make expected learning gains (e.g. incontinent, formerly continent)
Decreased productivity at school or work/day programme (a change from baseline abilities)
More distractible at work/programme – increased off task behaviour
Decreased hygiene b/c of failure to complete ADLs (a change from baseline)
Seems stressed or agitated by demands that require concentration
Skipping from activity to activity – just can’t stay on task
More easily distracted by external stimuli, noise – gets off task much easier than before
Noise or chaos in the environment provokes agitation and this is new or worse
Depressed mood (profound state of dysphoria, present most of the day each day for at least 2 weeks)
Has a sad appearance (this person looks sad, miserable) moping, downcast
Smiling less, stopped smiling, smiles and laughs much less than before
States ‘I’m sad’
States ‘I don’t care’
Cries frequently
Anhedonia (persistent, daily, at least 2 weeks)
No longer cares about or enjoys things he/she used to enjoy, can’t seem to have any joy
Refuses or shows little interest in formerly preferred activities
Previously reinforcing things are no longer motivating
Engaging in escape and avoidance-based aggression or SIB at a higher rate
Withdrawn behaviour – spending lots of time alone, isolating self, decreased social behaviour
Sudden worsening in hygiene, doesn’t care about appearance any more

* Table 1 provides example items. The full MASS Interview contains 35 symptom item questions each with behavioural descriptions.
ADL, activities of daily living; SIB, self-injurious behavior.

sad appearance when depressed. Third, the behav-
ioural descriptions were also derived from hundreds
of intake interviews conducted by one of the
authors (Charlot) in which caregivers were asked
what had caused them to suspect that an individual
with ID was, for example, depressed, anxious, expe-
riencing panic or other psychiatric problems.
Prior to 1990, there were a handful of reports
describing DSM symptom criteria in people with
ID with presumed mood disorders ( Janowsky &
Davis 2005; Sovner & Hurley 1983; Sovner & Pary
1993). Studies in which the phenomenology of
mood syndromes was examined in subjects with ID
had many methodological weaknesses, including
lack of control groups, non-representative sample
selection techniques and highly varied approaches
for establishing cases. In some instances, symptom
substitutes were employed without empirical basis
(Clarke & Gomez 1999). Despite these concerns,
there was remarkable agreement among common
features of depression and mania (e.g. Vanstraelen
& Tyrer 1999; King et al. 2000; Smiley & Cooper

© 2007 The Authors. Journal Compilation © 2007 Blackwell Publishing Ltd

 Journal of Intellectual Disability Research
824
L. Charlot et al. • Validation of the MASS Interview
2003; Lunsky & Palucka 2004). Investigators con-
cluded that, in general, patients with ID could be
validly diagnosed with a mood disorder using the
standard DSM criteria. However, it is often neces-
sary to condition on intellectual ability or age for
some symptoms (Luby et al. 2003). For example,
Luby et al. found it necessary to alter symptom
items in their Preschool Feelings Checklist to take
into account the fact that pre-school-aged children
might not verbalize their fears but rather act them
out in their play (Luby et al. 2004).
It has been noted in the literature that individuals
with ID were less likely to self-report alterations in
affective states. Rather, caretakers observed and
reported these mood changes (crying or the
absence of smiling) (Sovner & Hurley 1983).
Changes in vegetative symptoms were seen and
described by caregivers, including changes in sleep,
appetite, weight and motor activity. Aggression and
other challenging behaviours were viewed as state-
dependent features that covary with the episodic
occurrence of core features of mood syndromes
(Lowry & Sovner 1992). Aggression and other
externalizing behaviours seem to represent a final
common pathway for a wide range of phenomena
that cause distress (Charlot et al. 1993; Tsiouris
et al. 2003).
Less has been written about the assessment of
anxiety disorders, but many researchers feel the
problem is under diagnosed (Khreim & Mikkelsen
1997; Charlot 1998; Esbensen et al. 2002; Hurley
et al. 2003). Several investigations have found that
individuals with mild to moderate ID express quali-
tatively similar fears than people without cognitive
impairment but do so with a greater intensity
(Gullone et al. 1996; Derevensky 1979), similar to
those of mental age-matched controls (Sternlicht
1979; Duff et al. 1981). Although rates and types of
fears expressed by people with ID have been
studied, little has been explored with regard to
anxiety syndromes per se, and the literature address-
ing phenomenology consists primarily of a limited
series of case reports (Khreim & Mikkelsen 1997;
Bailey & Andrews 2002).
Individuals with mild cognitive impairments can
often be assessed using tools that have been devel-
oped for people without ID (Beck et al. 1987).
However, there has been very little agreement
among investigators as to the best way of diagnosing
© 2007 The Authors. Journal Compilation © 2007 Blackwell Publishing Ltd
volume 51 part 10 october 2007
anxiety disorders, depression, mania or other syn-
dromes, in people with more severe cognitive impair-
ments (Ross & Oliver 2003). This lack of agreement
may derive in part from the adequacy of informant
reports within these assessments. For people with
more severe cognitive disabilities, much of the data
for assessment are derived from informant reports,
which must be validated prior to use (Cantwell 1996;
Rojhan et al. 1994). How do we establish symptom
criteria using third-party reports?
In our experience with inpatients with ID and
acute psychiatric disorder, we have found that infor-
mants more commonly report their own formula-
tions rather than observations of specific symptoms.
For example, caregivers will state that the patient
has been ‘manic’. With further questioning, it may
be revealed that the patient had motor restlessness
but no other symptoms of mania. Further, when
queried whether the individual with severe ID has
been anxious recently, informants may report ‘no’;
but when asked if the patient has displayed fearful
facial expressions, clinging to caretakers, or report-
ing that they are frightened; informants may then
recall that they have indeed observed these behav-
iours. Without the prompting provided by the inter-
view, informants tended to focus much of their
discussion on describing externalizing behaviours.
Although some psychopathology rating scales
have been developed and validated for use with
people with ID, most do not contain a full set of
criteria for mood and anxiety symptoms. Esbensen
et al. (2002) developed the Anxiety Depression and
Mood Screen (ADAMs), an informant-based scale
assessing symptoms of depression, mania and
anxiety with a three-factor structure corresponding
to the three diagnostic areas. The rating scale, like
many similar instruments, includes items such as
‘nervous’ and ‘depressed mood’. Unfortunately,
raters often interpret these clinical terms in differ-
ing ways. In contrast, a semi-structured interview
format can be a more effective strategy to increase
confidence that symptom terms are clearly under-
stood, and that accurate information about symp-
toms is elicited.
In the present retrospective study, exploratory use
of a semi-structured interview containing behav-
ioural descriptions for DSM-IV diagnostic criteria
was investigated in inpatients with ID. The study
was retrospective in that previously collected data
 Journal of Intellectual Disability Research
825
L. Charlot et al. • Validation of the MASS Interview
regarding inpatients served in the past were
reviewed. The focus in present study was on
symptom criteria for anxiety disorders, major
depressive episode and manic episode. The MASS
Interview, containing diagnostic criteria with behav-
ioural manifestations for each criterion, was initially
developed to be a practical but comprehensive clini-
cal tool for intake evaluations conducted on the
inpatient psychiatric service specializing in the care
of persons with ID.
Other psychopathology instruments developed for
use with individuals with ID that were readily avail-
able in the United States were considered, but
found to lack some key components to meet the
clinical needs of our programme. One drawback to
these instruments was that none contain full com-
pliments of DSM diagnostic criteria. For example,
in the assessment of depression, consider the Reiss
Screen for Maladaptive Behaviour (RSBM), one of
the most widely used instruments for people with
ID (Reiss 1988). The RSBM has two depression
scales. Even when items from both of these scales
are compiled, the nine DSM-IV-TR diagnostic cri-
teria for a major depressive episode are not present.
A key goal in our evaluation process was to look
for the presence or absence of all of the DSM-
IV-TR symptom criteria for the most common dis-
orders. The assessment tools that are most similar
to the MASS Interview are the PIMRA and the
DASH, both of which have an informant-based
semi-structured interview (Matson et al. 1991;
Matson 1997). However, neither of these instru-
ments contains items corresponding to all of the
DSM-IV-TR criteria for major depressive episode
nor for a manic episode. The PAS-ADD has a semi-
structured interview form with items corresponding
to ICD-10, but requires specialized training and it
is not widely available in the United States in clini-
cal settings (Moss & Goldberg 1991; Moss et al.
1996). The goal was to develop an assessment tech-
nique for use with individuals with ID that could be
incorporated into clinical practice easily, which
would provide comprehensive psychiatric clinical
information based on informant interviews. The
MASS Interview was created to meet this need.
Another concern was that the most commonly
employed psychopathology instruments for use with
people with ID do not employ the method piloted
by Sovner & Hurley (1982a,b) and Lowry & Sovner
© 2007 The Authors. Journal Compilation © 2007 Blackwell Publishing Ltd
volume 51 part 10 october 2007
(1992) of identifying multiple detailed behavioural
descriptions for each DSM symptom criterion
(Einfield & Tongue 1999). It was felt that these
clinical details would be most useful when trying to
improve diagnostic accuracy as well as providing a
way to gather as much clinical detail from infor-
mants as possible, in a quick and efficient manner.
The ‘gold standard’ for psychiatric diagnosis was
the discharge DSM-IV diagnosis based on a com-
prehensive clinical evaluation that covered the dura-
tion of the inpatient stay which averages 18 days.
Methods
Subjects
Interviews were conducted with informants report-
ing on symptoms at the time of admission to the
University of Massachusetts Memorial Health Care
Neuropsychiatric Disabilities Unit (n = 93). This
facility is a secured, short-stay inpatient psychiatric
unit specializing in the care of individuals with
mental illness and ID (Charlot et al. 2002). Infor-
mants included direct-care providers, family
members and case managers who attended the mul-
tidisciplinary admissions meeting for the individual.
A subset of these inpatients (n = 47) was also evalu-
ated using the Hamilton Depression Rating Scale
(HDRS).
All of the 93 psychiatric inpatients carried a
DSM-IV axis III diagnosis of ID in addition to
their psychiatric diagnoses. The majority of the
inpatients were males (60%). While 52% of the
sample had diagnoses of mild ID, 35% carried a
diagnosis of moderate ID and the remaining 13%
severe or profound ID. The mean age of these inpa-
tients was 38.6 years. These figures were consistent
with data that had been compiled for 100 consecu-
tive admissions during the year prior, and the pilot
sample appeared to be representative of inpatients
on this unit.
Psychiatric diagnosis at the time of discharge was
compared with the diagnosis based on use of the
semi-structured interview tool that was adminis-
tered at the time of admission, as a first step
towards establishing concurrent validity. The main
goal was to examine whether or not the clinical data
gleaned from such an interview, using behavioural
descriptions for the DSM symptom criteria, would
 Journal of Intellectual Disability Research
826
L. Charlot et al. • Validation of the MASS Interview
yield a diagnosis in agreement with diagnoses given
after a lengthy and comprehensive evaluation, based
in large part on direct clinical observation of the
patient. Discharge psychiatric diagnoses on the
inpatient unit were given by the attending psychia-
trist or psychiatric resident, based on an interview
with the patient, laboratory data, chart review, dis-
cussion with key informants and many observations
of the individual within the inpatient milieu. The
Neuropsychiatric Disabilities Unit (NDU) attending
psychiatrist has extensive clinical experience with
individuals with ID and psychiatric disorder, and he
provides training and supervision to the psychiatric
residents.
The MASS Interview was administered by the
unit psychologist or nurse-prescriber (RNCS) and
required 30–60 min to complete. The psychologist
and the RNCS also have long-term experience in
mental health settings in the evaluation of clinically
referred individuals with ID. All interviews were
conducted with two or more familiar informants,
who were aware of the patient’s behaviour prior to
admission. To initiate the interview, the clinician
explained that he or she would be asking about the
presence of symptoms or behaviours evident mainly
in the past month leading up to the admission. The
clinician then asked the informants to try to focus
on what they have seen the patient do or heard the
patient say, and to only report things that were
clearly evident, serious and significant.
Instrument
The MASS Interview includes all DSM-IV
symptom criteria for each of the listed diagnostic
categories, with multiple examples of possible
behavioural manifestations for each symptom crite-
rion (Table 1). These possible behavioural manifes-
tations were ones identified by Sovner & Hurley
(1982a,b) and Lowry & Sovner (1992), as well as
those generated in diagnostic interviews conducted
over a 2-year period during which the interview
tool was being used for the inpatient unit intakes.
As noted, some of these behavioural descriptions
were ones listed in DSM-IV under the sections
describing age and cultural influences on clinical
manifestations of mood and anxiety syndromes. A
review of the developmental psychopathology lit-
erature also provided additional behavioural
© 2007 The Authors. Journal Compilation © 2007 Blackwell Publishing Ltd
volume 51 part 10 october 2007
descriptions of mood and anxiety symptoms seen
in young children (Angold 1988; Wozniak et al.
1997; Charlot 1998; Rutter 1998). The clinician
conducts the MASS Interview with a group of
informants who are interviewed at the same time
(as this is the usual practice when a caretaking
team refers an individual with ID for a psychiatric
evaluation). Symptoms were deemed present by
the clinician based on whether or not one or more
of the informants observed the symptom or
problem, and also that the symptom or problem
had occurred frequently, was of clinical concern
(caused impairment) and represented a departure
from usual behaviour.
Intensity and duration criteria
Only symptoms that were described as severe and
persistent by informants during the semi-structured
interview were recorded as present. For each
symptom, duration and intensity criteria as
described in DSM-IV were employed. Informants
were instructed to report only symptoms that
occurred daily and interfered with routine function-
ing (causing impairment in usual functioning). Also,
informants were asked to describe symptoms that
were evident over the past month. For example,
depressed mood was listed as a positive finding for
individuals when noted for a period of at least
2 weeks and symptoms of mania for 1 week. Symp-
toms described by informants as present but as
chronic, mild and not significant were not endorsed
as present.
A critical concern when using the MASS Inter-
view was that a behaviour or symptom constituted a
deviation from usual behaviour for the person,
either because the symptom was new or much more
intense than was usually observed. It was also
important to determine that the symptom was
observed frequently (nearly every day for a period
of at least 2 weeks) and that it posed a concern or
was a problem in this individual’s life. These criteria
were emphasized during the interview process.
These criteria are also taken directly from the
DSM-IV-TR. For example, a common situation has
been that informants report that a person has a dis-
turbed sleep pattern. Then it is revealed that the
sleep pattern has been a lifelong pattern, and that it
has nothing to do with recent concerns that
 Journal of Intellectual Disability Research
827
L. Charlot et al. • Validation of the MASS Interview
brought the individual to clinical attention. Or,
informants report that the individual has been
crying. However, on further questioning, it is
revealed that the crying only occurred two times in
the past month. In these cases, clinicians adminis-
tering the MASS Interview would not record these
symptoms as contributing to a diagnosis of
depression.
Clinical evaluation
As noted, the clinical evaluation of the inpatients
consisted of multiple components extending over
the course of the hospital stay. The psychiatrist who
assigned a final, discharge diagnosis did not have
access to the diagnostic conclusions derived from
the MASS. The final, discharge diagnoses were
assigned on the day of discharge. In addition to
obtaining information from informants, the psychia-
trist reviews records provided by the community
team and the case managers. These records are
typically extensive. Additional clinical information is
gathered from the outpatient psychiatric clinician.
The patient is interviewed daily, and observations
made by the nursing staff, clinical social worker,
behaviourist, occupational therapist and other inpa-
tient team members are shared at daily rounds.
Additional data may be derived from laboratory and
imaging studies, as indicated. Further information
from family members and professional informants
not present at the intake is also elicited by the clini-
cal social worker. The discharge psychiatric diagno-
sis is based on all of the above, as well as the
psychiatric clinician’s observation of the patient’s
response to multimodal treatment interventions,
over the entire course of the individual’s inpatient
stay which is an average of 18 days.
The HDRS
The HDRS has been widely used in the assess-
ment of depression in people without ID (Hamil-
ton 1967) but has also been used in reports
examining depression in persons with ID. Rey-
nolds & Baker (1988), for example, assessed the
psychometric properties of their Self-Report
Depression Questionnaire (SRDQ), a 32-item self-
report measure of depressive symptoms in persons
with ID, and reported a significant correlation
© 2007 The Authors. Journal Compilation © 2007 Blackwell Publishing Ltd
volume 51 part 10 october 2007
between the SRDQ and individual clinical inter-
views using the HDRS (r = 0.67, P < 0.001). The
HDRS was also used in two other clinical reports
(Howland 1992; Charlot 1997) and was described
as a useful clinician administered rating scale in
the assessment of depression. Charlot found that
people with severe ID had lower scores than
people with mild ID, and that this appeared to be
because people with severe ID tended not to show
evidence of the cognitive symptoms of depression
(guilt, hopelessness, suicidal ideation). However,
even individuals with severe ID and depression
usually had HDRS scores suggesting a clinically
significant depression using the ‘mild depression’
cut-off score.
Cut-off scores for the HDRS have been recom-
mended. For example, at minimum, an individual
should have a score of at least 11 to receive a rating
of mild depression. Charlot (1997) used the HDRS
to assess people with major depressive disorders
and ID, and found that HDRS scores were consis-
tently lower for subjects with severe ID because
they were rarely noted to show evidence of any of
the cognitive items in the scale. It was suggested
that inpatients with depression and ID who have
DSM-IV diagnoses of profound, severe, or moder-
ate ID will have lower HDRS scores than those
suggested as standard cut-off for depression. The
HDRS has been used by others to assess people
with ID (Kazdin et al. 1983).
The rate of agreement between the HDRS and
the semi-structured interview diagnosis was calcu-
lated for the pilot cases for whom both evaluations
were completed (n = 47). Cases were seen as posi-
tive for depression with an HDRS score ⱖ11.
Agreement between the diagnosis yielded by the
semi-structured interview and the discharge diag-
nosis (based on clinical evaluation) was also calcu-
lated to establish degree of convergent validity. Of
special interest was the extent to which the diag-
nosis based on informant reports of recently
observed behaviours at the time of the patient’s
admission, agreed with clinical diagnosis, based in
part on actual observation of the patient on the
unit. When informants are questioned about spe-
cific observable behaviours, does this correspond
reliably with what clinicians actually see when an
individual with ID is evaluated during their inpa-
tient stay?
 Journal of Intellectual Disability Research
828
L. Charlot et al. • Validation of the MASS Interview
Analysis
We computed measures of agreement between
derived diagnoses using the MASS Interview and
those assigned clinically at discharge from the inpa-
tient unit (clinical diagnosis) and those derived
from the HDRS (using the cut-point described
above). The data analysis for this paper was gener-
ated using the SAS/STAT software, Version 9.1 of
the SAS System for Windows XP. (Copyright ©
2005, SAS Institute Inc. SAS and all other SAS
Institute Inc. product or service names are regis-
tered trademarks or trademarks of SAS Institute
Inc., Cary, NC, USA.) We computed the following
measures (Landis & Koch 1977; Fleiss 1981):
• sensitivity (probability of a positive diagnosis based
on the MASS Interview among patients with diagno-
sis as derived from clinical diagnosis or HDRS);
• specificity (probability of a negative diagnosis
based on the MASS Interview among patients
without that diagnosis, as determined from clinical
diagnosis or HDRS);
• overall percentage of agreement (agreement
between MASS Interview and clinical diagnosis and
HDRS, calculated over all paired ratings);
• kappa coefficient (indicating the proportion of
non-random agreement, i.e. the achieved beyond-
chance agreement as a proportion of possible
beyond-chance agreement).
The extent of agreement between the different
diagnostic methodologies (semi-structured inter-
view, clinical diagnosis, HDRS score ⱖ11) was cal-
culated by means of kappa coefficients. These
coefficients were based on dichotomous data,
© 2007 The Authors. Journal Compilation © 2007 Blackwell Publishing Ltd
volume 51 part 10 october 2007
whether or not the patient was classified as a ‘case’
by a particular assessment method.
Results
Sensitivity and specificity of the semi-structured
interview tool was calculated and the analysis and
results are summarized in Figs 1–5. There was a
significant degree of agreement between diagnoses
of generalized anxiety disorder (GAD), any anxiety
disorder, major depressive episode, or manic
episode based on the semi-structured interview and
these diagnoses based on clinical evaluation at dis-
charge (P < 0.01 for all three contrasts). There was
also a significant level of agreement between a diag-
nosis of major depression based on the semi-
structured interview and having an HDRS score
ⱖ11, 47 of whom met this criterion. All kappa coef-
ficients reported in Figs 1–5 were significant
(P < 0.01), and remained so after Bonferroni cor-
rection for multiple comparisons.
Additionally, rates for the individual symptoms
were reviewed for three subgroups (Table 2), includ-
ing patients who had a discharge diagnosis of (1)
major depression or depressive disorder not other-
wise specified, with or without comorbid anxiety dis-
order diagnoses; (2) patients diagnosed with any
anxiety disorder (GAD, panic disorder, obsessive
compulsive disorder or anxiety disorder NOS), and
with or without comorbid depression; and (3)
patients diagnosed with bipolar disorder. These
groupings were chosen because of the high rate of
overlap of anxiety and depression. We provide these
Figure 1 Frequency counts for
sensitivity and specificity calculations for
generalized anxiety disorder.
 Journal of Intellectual Disability Research
829
L. Charlot et al. • Validation of the MASS Interview
data for descriptive purposes, and do not include
inferential tests, owing to the multiplicity of con-
trasts. It is noteworthy that anxiety, restlessness,
fatigue, decreased concentration, irritability were all
common features among these diagnostic categories.
The most common vegetative sign among these
© 2007 The Authors. Journal Compilation © 2007 Blackwell Publishing Ltd
volume 51 part 10 october 2007
Figure 2 Frequency counts for
sensitivity and specificity calculations for
any anxiety disorder (GAD, panic
disorder, OCD or anxiety disorder
NOS). GAD, generalized anxiety
disorder; OCD, obsessive compulsive
disorder; NOS, not otherwise specified.
Figure 3 Frequency counts for
sensitivity and specificity calculations
major depressive episode.
Figure 4 Frequency counts for
sensitivity and specificity calculations for
manic episode.
categories was weight change, which was markedly
elevated in these samples.
Rates of symptoms reported for patients diag-
nosed with an anxiety disorder alone and depres-
sion alone are not presented here, because the
numbers for the depression alone subgroup are
 Journal of Intellectual Disability Research volume 51 part 10 october 2007
830
L. Charlot et al. • Validation of the MASS Interview

Figure 5 Frequency counts for

sensitivity and specificity calculations for
Hamilton Depression Rating Scale.

Table 2 Symptoms identified as present

MDD+ Anxiety disorder+ Bipolar using the MASS Interview for inpatients,
n = 41 n = 56 n = 12 contrasted against discharge diagnoses of
major depressive disorder either with or
without comorbid anxiety disorder diag-
Anxiety 59 75 58 noses (MDD+), any anxiety disorder
Difficult to console 49 54 46 diagnosis with or without depression
Restless/tense 68 64 50 diagnosis (anxiety disorder+) and bipolar
Fatigue 95 61 50 disorder (bipolar)
Decreased concentration 66 64 83
Irritable 78 75 67
Obsessive 54 57 33
Compulsive 39 55 33
Depression 61 43 33
Anhedonia 71 52 67
Panic 24 16 25
Decreased appetite/weight 41 34 42
Increased appetite/weight 20 23 25
Weight change 61 57 67
Decreased motor activity 32 20 25
Increased motor activity 39 48 75
Increased sleep 22 16 0
Decreased sleep 61 46 92
SI/morbid ideas 27 23 17
Excessive guilt 20 30 8
Elated mood 15 18 42
Rapid speech 17 18 50
Overactivity 10 14 25
Hypersexual 5 20 33
Grandiose 7 13 33
Mood swings 41 45 83
FOIs 2 7 42
Tics 5 13 33
Assaults 56 75 92
SIB 51 59 42
Episodic course 32 25 58

Symptom items endorsed for >50% of patients within these diagnostic categories are in
bold type.
MASS, Mood and Anxiety Semi-structured; MDD, major depressive disorder; SI, suicidal
ideation; FOI, flight-of-ideas; SIB, self-injurious behavior.

© 2007 The Authors. Journal Compilation © 2007 Blackwell Publishing Ltd

 Journal of Intellectual Disability Research
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L. Charlot et al. • Validation of the MASS Interview
modest, highlighting the fact that many of these
inpatients with ID showed a pattern of comorbidity
of depression with anxiety.
Discussion
The degree of agreement was high between diag-
nostic categories using this Interview, in comparison
with discharge diagnoses using DSM-IV criteria,
with kappa coefficients ranging between 0.42 and
0.78; this level of agreement is judged to be moder-
ate to substantial, using the criteria of Landis &
Koch (1977). The same is true for agreement
between the MASS Interview depression diagnoses
and those obtained through classification using the
HDRS. Moreover, sensitivity and specificity levels
were also moderate to substantial (ranging between
69% and 100%). The Mass Interview tended to be
more sensitive than specific for most of the diag-
noses examined, the exception being that of manic
episode.
These data support the use of a semi-structured
interview containing behavioural descriptions of
DSM-IV symptom criteria to identify patients with
ID who are more likely to be experiencing an
anxiety or mood disorder, although more research is
needed to further assess validity and reliability of
the interview. With respect to the former, it would
be useful to obtain ratings that cover identical time
periods. Further, it will be necessary to establish
interrater and test–retest reliability.
The proposed semi-structured interview
employed here is intended for use as a tool within a
more comprehensive and complete diagnostic evalu-
ation, and to be used by clinicians with experience
in mental health assessment using the DSM-IV-TR
nosology. We anticipate that mental health clinicians
with a background in the field of ID will be able to
use this instrument with a minimum of training.
The MASS Interview may find utility in identifying
putative mood or anxiety disorders, although it
would not be recommended as a definitive method
for establishing a diagnosis. Rather, the interview
tool may provide a means of insuring that clinical
information about each relevant symptom criterion
is elicited from informants. The structure of the
interview is such that informants are prompted to
report more carefully what they observed rather
© 2007 The Authors. Journal Compilation © 2007 Blackwell Publishing Ltd
volume 51 part 10 october 2007
than their thoughts about what might be wrong.
Also, the use of multiple behavioural descriptions
can reduce differences that might arise because cli-
nicians interpret terms such as anxiety in different
ways. From a practical standpoint, the interview is
not lengthy, and can be used under ordinary clinical
conditions.
Another potential advantage of the semi-
structured interview used in the current pilot study
is that all behavioural descriptions are linked
directly to DSM-IV symptom criteria. As a result, a
significant degree of content validity is ‘built in’,
because the validity of DSM-IV symptom criteria
for mood and anxiety syndromes has been estab-
lished. Although the validity of behavioural descrip-
tors selected for use must be established, most have
a high degree of face validity (i.e. crying as an indi-
cation of sadness, angry outbursts as an indication
of irritability). It seems likely that clear descriptions
of DSM-IV symptom criteria developed specifically
for use with individuals with ID will increase
symptom recognition (Charlot 2003). When clini-
cians want to be certain that informants have been
asked about each and every DSM-IV-TR symptom
criterion, the Mass Interview is unique in its cover-
age of all of the necessary items.
In the present investigation, psychiatric inpatients
were evaluated. Generalizability of the results
obtained is limited because of the lack of inclusion
of other groups of people with ID (individuals
without presumed psychiatric disorder and people
referred for outpatient care). However, many of the
hospitalizations of persons included in the present
investigation were planned, and not all of the
patients were severely ill. Future investigations using
the MASS Interview will include other groups of
individuals with ID.
The MASS Interview’s behavioural descriptions of
mood disorder symptom criteria are the same ones
as those described in the National Association for
the Dually Diagnosed and American Psychiatric
Association-sponsored DSM-IV-TR companion
guide chapter on mood disorders, currently in
development.
In subsequent investigations, additional methods
will be employed to establish reliability and validity
of the semi-structured interview, including taped
interviews to assess interrater reliability and evalua-
tion of agreement with diagnostic yield from other
 Journal of Intellectual Disability Research
832
L. Charlot et al. • Validation of the MASS Interview
semi-structured informant interview tools with pre-
viously established reliability and validity. Individu-
als with ID with similar demographic profiles who
are receiving outpatient services, and individuals
who have not been referred for any psychiatric ser-
vices will also be evaluated using the MASS Inter-
view in this investigation, which is currently
underway.
Acknowledgements
This work was funded in part by NICHD grants to
Dr William J. McIlvane (PI; R01 HD42807, P30
HD04147) and by the Commonwealth of
Massachusetts.
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Accepted 27 March 2007

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