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. 2018 Mar;6(2):243-265.
doi: 10.1177/2167702617741845. Epub 2017 Dec 8.

Evidence-Based Assessment from Simple Clinical Judgments to Statistical Learning: Evaluating a Range of Options Using Pediatric Bipolar Disorder as a Diagnostic Challenge

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Evidence-Based Assessment from Simple Clinical Judgments to Statistical Learning: Evaluating a Range of Options Using Pediatric Bipolar Disorder as a Diagnostic Challenge

Eric A Youngstrom et al. Clin Psychol Sci. 2018 Mar.

Abstract

Reliability of clinical diagnoses is often low. There are many algorithms that could improve diagnostic accuracy, and statistical learning is becoming popular. Using pediatric bipolar disorder as a clinically challenging example, we evaluated a series of increasingly complex models ranging from simple screening to a supervised LASSO regression in a large (N=550) academic clinic sample. We then externally validated models in a community clinic (N=511) with the same candidate predictors and semi-structured interview diagnoses, providing high methodological consistency; the clinics also had substantially different demography and referral patterns. Models performed well according to internal validation metrics. Complex models degraded rapidly when externally validated. Naïve Bayesian and logistic models concentrating on predictors identified in prior meta-analyses tied or bettered LASSO models when externally validated. Implementing these methods would improve clinical diagnostic performance. Statistical learning research should continue to invest in high quality indicators and diagnoses to supervise model training.

Keywords: Bipolar disorder; diagnostic accuracy; evidence-based assessment; sensitivity and specificity.

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Figures

Figure 1
Figure 1
Back to back histograms of PGBI10M score distributions for youths with a BP diagnosis versus no BP diagnosis in both Academic (N=550) and Community (N=511) clinic settings.
Figure 2
Figure 2
Calibration plots. Note. Perfect calibration is represented by the diagonal line. The vertical lines represent the Wait-Test decision threshold (solid green) and Test-Treat threshold (dashed red) in an EBA approach to clinical decision-making. The values of 20% and 80% were chosen as an approximation for heuristic purposes, not as a set threshold. Predicted probabilities below 20% would result in a clinician ruling out the diagnosis, “waiting” until other findings raised the probability again. Probabilities between 20% and 80% would be in the “assessment zone,” suggesting more intensive evaluation, and probabilities above 80% would be in the “treatment zone.” Most models over-estimate the probability of bipolar disorder in external validation.

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