Essential Science Indicators from
Clarivate, the paper, "The
Mini-International Neuropsychiatric Interview (MINI):
the development and validation of a structured
diagnostic psychiatric interview for DSM-IV and
ICD-10," (Sheehan DV, et al., J. Clin.
Psychiat. 59: 22-33, suppl. 20, 1998) has been
cited 926 times. At present, it is the #2 Highly Cited
paper in the field Psychiatry & Psychology.
Dr. David Sheehan is the lead author of this paper.
His record in the database includes 18 papers cited a
total of 1,887 times between January 1, 1997 and
December 31, 2007 in the field of Psychiatry &
Currently, Dr. Sheehan is Professor of Psychiatry and Behavioral
Medicine and Director of the Depression and Anxiety Disorders Research
Institute at the University of South Florida College of Medicine, as well
as Professor of Psychology at the University of South Florida College of
Arts and Sciences.
In the interview below, he talks with
ScienceWatch.com correspondent Gary Taubes about his
work on the MINI project.
What prompted you to develop the Mini-International
Neuropsychiatric Interview (MINI) and your highly cited 1998
Journal of Clinical Psychiatry paper?
Back in the early 1990s, I was asked to help set up studies, mainly in
Europe, on anxiety disorders. One pharmaceutical company in particular
wanted to recruit patients with panic disorder. I recommended it use a
structured diagnostic interview so that the company could be sure that all
of the patients it enrolled had this specific disorder. Several of the
European researchers, however were hesitant about the need for a structured
diagnostic interview. It was their impression that structured interviews
were too long and were a burden on the efficient implementation of a
treatment study. They didn’t have the time, the resources or the
staff, they said, to do all these complicated screenings. Wasn’t
there an easier way of accomplishing the same goal?
I agreed that that the existing structured diagnostic interviews were long
and difficult to navigate. The company wanted to know if I could make a new
interview that was shorter, easier to navigate, and more elegant. I said,
"Yes, that’s possible." Another person in that advisory group, Yves
Lecrubier, said, "I agree with David. There should be a way to make a
shorter, more elegant one." The medical director for the drug company asked
if I would go ahead and develop such an instrument. In a weak moment, I
said, "Yes, why not." And I added, "Yves also seems interested. Maybe the
two of us can get together this evening and report back in the morning."
able to show that our diagnostic
interview had very similar
psychometric properties to the
others, but was much easier to use
and considerably shorter."
So Yves and I had dinner. We sketched out how we could create a new
interview that would be a fraction of the size of the existing one, and we
talked about how to make it much more user-friendly— so that it could
be used in non-research clinic settings as well as in research. We reported
back, saying that it seemed this project could be done, and we’d be
happy to do it. And the company then said they’d be interested in
funding us to do a validation study if we developed the structured
How did it proceed from there, particularly since you
and Dr. Lecrubier work on different sides of the Atlantic?
We corresponded back and forth and met together. Yves is at INSERM in Paris
(France’s National Institute for Health), and he’s also an
expert in psychiatric diagnosis and psychopharmacology. It took us a while,
but we developed our first draft and the company gave us the funds to do a
validation study, to see how it stacked up against the two other most
widely used structured diagnostic interviews. The long and the short of it
is that we were able to show that our diagnostic interview had very similar
psychometric properties to the others, but was much easier to use and
considerably shorter. The MINI was developed to assist in the precise
diagnosis of the 16 most common psychiatric disorders, conditions like
major depression, bipolar disorder, panic disorder, psychotic disorders and
substance use disorders.
Was that a surprise to you—that it performed just
Not really, because we were able to build on the shoulders of giants, so to
speak. We knew what the weaknesses of the other interviews were. That meant
that we could make the MINI strong where the others were weak. For example,
if one of the then current interviews was strong on anxiety disorders but
weak on psychotic disorders and bipolar depression, and the other was
strong on the more severe psychiatric disorders, we tried to capture the
strengths of each and circumvent the weaknesses. So, in that sense, the
study showed that it came out exactly as we had planned. The MINI was
strong where each of the others were weak.
That study then was the subject of several publications. Probably the most
important one was the one in the Journal of Clinical Psychiatry,
which is the highly cited paper. That paper came out years after the study
was actually done - because it took a large number of patients, with
several hundred thousand datapoints of information, to collate and analyze.
It was an arduous task.
What did you do after that first validation study and
the collating job?
Subsequently we did other validation studies in Europe, in the Middle East
and in Asia, where we tested the MINI against expert opinion. People then
approached us to translate the MINI into other languages. We co-opted a
group of wonderful, bright, highly experienced diagnosticians from all over
the world to help us in the translation efforts. Then we got one of the
companies to fund a big international meeting where all these translation
teams came together. This was about a decade ago, and we tried to get
everybody on the same page so that all of the translations captured the
spirit of the MINI and were not just literal translations of words.
Can you give an example of what you mean by
Here’s one. I don’t think that this particular item is in the
MINI anymore in the exact same way. Still, it’s a good illustration.
Let’s say that you’re asking a patient in a southern state,
"Are you feeling down-hearted, blue?" The individual may respond, "Yeah,
sure, I feel down-hearted, blue" quite a lot of the time. If you translate
those words literally into French, the patient is likely to look at you and
ask, "What do you mean? My heart is down and I’m feeling the color
blue?" There’s a great deal lost in the translation. Many languages
have no word for depression. In others—Arabic, for
instance—there are multiple words for depression. In Pashto, a
language used in Afghanistan and western Pakistan, they use the same work
for both anxiety and depression.
The issue for us was how to capture all these subtle nuances from one
language to the next, not just the experience of the disorder, but also the
experience of the patient, and try to get that constant across all the
languages. That way everybody can understand the spirit of each question
and the experience at a level almost beyond language.
This conference must have been a unique
Absolutely! I’ve given lectures and attended in conferences in 65
countries around the world, but this was the most fascinating conference
I’ve ever attended. Nothing else was ever like it. What we began to
realize was that in translating the MINI we were harnessing the research
and academic experience of psychiatrists all over the world. Prior to this,
clinicians and researchers used different diagnostic systems. We were
bringing them all onto the same page and pointing them all to magnetic
north at a very practical level. In the collaboration, we were providing
each other with a practical recipe for psychiatric diagnosis in a way that
everyone could use in their everyday work and in a way that they could all
understand. That in turn greatly increases the level of input and expertise
you bring to solving the puzzles of these psychiatric disorders. At the
same time you are harnessing all this international energy and getting them
all to speak a common diagnostic language so that they can collaborate
together. This sets the stage for giant international collaborations in
solving these illnesses and finding better treatments.
Do you think this contributes to the huge influence your
paper and the MINI have had?
Yes. If you look at the structured interview itself, the MINI, you’d
say maybe anybody could have done that. But as the first very widely
translated, global, psychiatric interview, it was bringing everybody into
the same diagnostic system. Everybody had to be part of it, and everybody
had to communicate with each other at international meetings. Somebody
could come to a big meeting in the US and say, "I did a study with 500
people with bipolar depression and 200 with major depressive disorder, and
we’re doing it the exact same way that you’re doing it."
given lectures and attended in
conferences in 65 countries around
the world, but this was the most
fascinating conference I’ve
So it allowed everybody to take everybody else’s work seriously, and
it allowed the world’s regulatory agencies, like the FDA, to be able
to use research from other countries, because they’re all using the
same system. And, hopefully, this also decreases the cost of psychiatric
medical research, because now we can pool resources. We don’t have to
replicate everything in every country. So this brought everything and
everybody together, and that’s been very exciting. The reason people
now use the MINI so much is that it allows everybody in every country to be
able to participate in this common enterprise.
Was this a deliberate plan from the beginning, or
something you realized as the project evolved?
We tried from the get-go to make this more than just a U.S. system. We
realized that we were at the dawn of global medical research and this would
require international collaboration and harmonization. This was a
deliberate plan. We were trying to bring everybody together with the MINI.
And we always said this is not a completed product. It is an exercise in
progress, and we will continue to refine and tweak and improve it with
continued input from people and data from studies all over world to make it
better and better. We have relentlessly and ceaselessly done that.
What was the hardest or most challenging aspect of the
The interesting thing, I have to say, is that it never has really felt like
work. The pleasure we have had in collaborating on this venture has far
outweighed the challenges. Yves and I have both worked on the MINI mainly
at night and on weekends. We don’t have time during the day to work
on it. Accepting that the development of the MINI is not a destination but
a process has made the challenge easier to manage. It is an exercise in
paying attention to fine, tiny little details, subtle nuances most people
would totally miss on first reading. We tried to capture the essence of the
experience of each of the key symptoms and signs of these psychiatric
disorders. There are layers of these in the MINI structured diagnostic
You said originally that you set out to incorporate the
strengths of the other structured diagnostic interviews, while
simultaneously making it considerably shorter. How did you go about
When we looked at the existing structured interviews, Yves and I both
realized very quickly that not all questions had equal weight. Some are
more potent at hitting the bull’s eye right off the bat than others.
Many of the questions in other interviews are just frill, icing on the
cake. They’re not relevant to making clinical decisions.
Our task was to cut everything down to the essentials so that the MINI
could make a valid and accurate diagnosis with as few questions as
possible. This is important for researchers and clinicians who have to make
a clinical decision—for example include or exclude an individual from
a study or to start treatment. You look for the items that are loaded up
most heavily toward that end. Some are very potent; some are very weak. We
used what’s called decision tree logic: if you ask one or two screen
questions and the answer is no, then you skip over the next items and go to
the next disorder, much as clinicians with all illnesses in their busy
Is there one last point you’d like to make about
the MINI or your work in general?
About the MINI, when I’m training people on it, I always emphasize a
lesson I learned from classical music. I have a great interest in music,
and there’s a famous quote by Isaac Stern, who said that it’s
not the notes that count, it’s the pauses between the notes.
When you are reading the MINI questions to a patient and administering the
interview, don’t just read off the words—blah, blah, blah, in
this flat way—you have to present the information in the question,
pausing appropriately between phrases, while you watch the patient digest
what you’ve said. This is all about cadence and using language.
One of the things people occasionally spot with the MINI is that many of
the questions in English are phrased in such a way that they flow in a
musical sense. They have a rhythm and a cadence to them. And that rhythm is
there to help the patient get it and digest it and not be overwhelmed all
at once by too much detail.
I have to say, we didn’t dream all this up in one night. It came from
years of thinking about it, and fiddling with it, always improving it.
David V. Sheehan, M.D. MBA
Professor of Psychiatry and Director,
Depression and Anxiety Disorders Research Institute
University of South Florida College of Medicine
Tampa, FL, USA
Sheehan's most-cited paper with 926
cites to date:
Sheehan DV, et al., “The Mini International
Neuropsychiatric Interview (MINI): The development and
validation of a structured diagnostic psychiatric interview
for DSM-IV and ICD-10,” J. Clin. Psychiat.
59: 22-33, Suppl. 20, 1998. Source:
Essential Science Indicators