text:
Nice one. Congrats...
Nice one. Congrats...
RE: where did you get him?
central iowa. weve got alot of big deer again this year. i guess iowa is a pretty good state to hunt deer.
why is it called a 10 point? not allowed to hunt in the uk.
a ten point would have ten points on the antlers. some people dont count the brush tines though, so they would call it an 8 point. i dont know what this particular buck scores yet. my freind thats scores them is away on a fishing trip.
EDIT: anyone got a guess on what he would score?
EDIT2: i uploaded a pic from the feild and updated my first post. much better quality!!
EDIT3: and the "score" (not having much to do with the points) has something to do with total antler length, width and height. idk for sure
Last edited by justin; 10-31-2010 at 11:59 AM.
Congrade. Nice trophy. Also nice shot placement. What broadhead did you use?
lol you see where i shot him? it wasnt exactly an ideal shot but i was close, it was a 22 yard shot straight on. i was grouping under 2 inches at that range that afternoon so took the shot. the broadhead i was using was a nap shockwave. but i wish i had a fixed blade knocked for a straight into the chest shot. my aarow buried to just before the flech though. he got about 75 yards dumping lots of blood. it was a quick kill. i did a rough score tonight too and came up with 137. not so bad for my first deer.
EDIT: i apoligise for the blood and the tounge hanging out.
Last edited by justin; 11-06-2010 at 06:34 PM.
Lol don't think there would have been any chance of a past throw from that position. Very nice Trophy. Any deer killed with a bow is a trophy. But thats a nice deer all the way round.
yeah its nice! but i saw some pictures of some real monsters taken in a muzzleloader youth season. omfg.
a guy i work with shot a 168 this year.... another guy i know shot a 157 last year......... iowa is full of monster bucks!!!!
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Choke: A Novelby Chuck Palahniuk
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Victor Mancini, a medical-school dropout, is an antihero for our deranged times. Needing to pay elder care for his mother, Victor has devised an ingenious scam: he pretends to choke on pieces of food while dining in upscale restaurants. He then allows himself to be "saved" by fellow patrons who, feeling responsible for Victor's life, go on to send checks to support him. When he's not pulling this stunt, Victor cruises sexual addiction recovery workshops for action, visits his addled mom, and spends his days working at a colonial theme park. His creator, Chuck Palahniuk, is the visionary we need and the satirist we deserve.
"Few contemporary writers mix the outrageous and the hilarious with greater zest....Chuck Palahniuk's splenetic, anarchic glee makes him a worthy heir to Ken Kesey." Newsday
"Sheer, anarchic fierceness of imagination....[A] raw and vital book." The New York Times
"In the course of his three novels, Palahniuk has become a master of depicting the dark and depraved underbelly of our society through the voices of mordantly existential protagonists. Choke is no exception." Library Journal (Starred Review)
"Puts a bleakly humorous spin on self-help, addiction recovery, and childhood trauma....
"Palahniuk is a cheerful nihilist with a mordant wit and a taste for scatological humor. Fair warning: some may find his language and imagery offensive." Kirkus Reviews
"Victor is even more pathetic than Palahniuk's previous antiheroes....Still, the novel showcases the author's powers of description, character development and attention-getting dialogue handily enough to give this dark meditation on addiction a distinctive and humorous twist." Publishers Weekly
"As with his previous novels, this one lacks subtlety, but it will have great appeal with the legions of disenfranchised who flocked to see Fight Club in the theater." John Green, Booklist
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On April 4, 2012, while en route to a shots fired call, Bartow County Sheriff's Office Deputy Joshua Nelson encountered the suspect's vehicle on Linwood Road.
While attempting to conduct a traffic stop, Nelson began receiving fire from an AR-15 rifle. Taking cover behind his vehicle, Nelson returned fire with his service weapon, wounding the suspect.
For his actions during the encounter, Nelson this month was recognized at the local and state level as the Elks Lodge Public Safety Officer of the Year.
"All public safety agencies in Bartow County — police, firefighters, EMT, etc. — were contacted and asked to submit an outstanding member from each department for consideration as their candidate for the Cartersville Elks Lodge Public Safety Officer of the Year," said Gary Robinette, chairman of the Board of Directors of the Cartersville Elks Lodge.
Following recognition during a dinner hosted by the lodge, Nelson's qualifications were forwarded to the Public Safety Officer of the Year Committee of the Georgia Elks Association for statewide judging, where he also was selected for the state honor.
"... What makes him stand out as an officer of the year, because of this incident, is his evident vigilance, preparedness and response to self-defense training, against an armed and dangerous felon when it mattered most," Robinette said.
"It's not a big deal to me. It's a department thing, if you ask me," Nelson said. "I don't feel I really did anything special to deserve it."
A U.S. Marine Corps veteran, Nelson joined the BCSO four years ago after serving two tours of duty in Iraq.
"... I always knew I wanted to do military and then law enforcement, so I went to the military and I came back. Two weeks after I got out of the military, I got hired here," he said.
Nelson's dedication and drive make him an asset to the department, Sheriff Clark Millsap said.
"Josh, once again, is one of those I've surrounded myself with that's just dedicated to this county," Millsap said. "Josh went above and beyond, and goes above and beyond on all calls, but the one he was really recognized for was a shooting incident. He was taking fire from a person with a rifle and all he had to return fire with was a pistol, but he was able to stop the threat and he was able to keep anybody else from being injured. ... He deserved to be recognized for his heroics in that one incident."
Recognizing officers like Joshua Nelson is just one way the Cartersville Elks Lodge — and organizations across the nation — give back to the community.
"... Although each lodge is essentially autonomous, the public safety officer of the year program is encouraged by the national organization and is practiced by individual lodges across the country at the same time every year. In this manner, public safety officers across the nation can be recognized for their selfless and oftentimes sacrificial service to their communities by an organization with the status of the Benevolent and Protective Order of Elks," Robinette said. "The lodges benefit through exemplifying their service-oriented commitment to their individual communities. ...
"Any time a specific organization, of any type, and its employees can demonstrate through its leadership and training that it has set a high standard of service, and can be recognized for it, in the community that it serves is very important. This is particularly true of a public safety organization, whose men and women regularly put themselves in harm's way while performing their duties. Such recognition instills pride in the members of the organization, as well as a sense of being appreciated in the community by the people they serve and protect."
Nelson agreed.
"... I heard somebody say this before, 'You really don't want us until you absolutely need us. But then when you need us, you absolutely need us.' Personally, I don't like recognition for myself. I like recognition as a whole, for everybody," he said. "It is important to recognize public safety — fire, EMS, law enforcement, everybody. You know, somebody just stops by and says, 'Thank you for what you do.' It means a lot because we have to deal with the bad side of society, I guess you could say, and we're doing it for the good side of society."
BCSO, captain recognized by GOHS program
Earlier this month, Bartow County Sheriff's Office and Uniform Patrol Division Capt. Lee Fletcher also took home state honors from the Governor's Office of Highway Safety.
During the Mountain Area Traffic Enforcement Network (M.A.T.E.N.) meeting, BCSO was named Agency of the Year for the district, and Fletcher was recognized as Officer of the Year for M.A.T.E.N.
M.A.T.E.N. is one of 16 regional traffic enforcement networks across Georgia, according to a press release. The M.A.T.E.N. that includes Bartow also involves 10 other counties north and west of Bartow. The regional networks are open to all sworn law enforcement officers and prosecutors, and are designed to enhance traffic enforcement activities through networking, training and legislation.
"All the agencies inside that network, which is 40-something agencies, selected [BCSO] because of their dedication to traffic safety, everything they do to enforce the traffic laws and they've just done a tremendous job in that regard," said John Gardner, GOHS Northern Region Law Enforcement Liaison.
An "ecstatic" Millsap said the award is indicative of the officers within his agency.
"... I am so proud ... [of] what these officers have done. I had an old sheriff tell me when I first got elected, 'Surround yourself with the best people you can find.' I have done that," he said. "This award is just a prime example of the dedication that these men and women that work here have got for this county and for this state. We participate in this Governor's Office of Highway Safety program not only here in Bartow, but we lend our officers to other counties as well. It's all a part of keeping this state and our roads as safe as possible."
Fletcher echoed the sheriff's comments.
"I think [the award is] great because we participate in every MATEN II meeting. We always send three or four deputies; they stay the entire time with the agencies, help them out with their road checks," Fletcher said. "The sheriff is generous enough to make sure we have our own drinks on board, which are provided to other agencies when we are out and it's hot. We provide the B.A.T.-mobile, which is the blood alcohol transport unit, and it goes along with these guys."
The GOHS also looked at Fletcher's contributions to the traffic enforcement program.
"Capt. Fletcher shows his dedication to traffic safety by ensuring that his agency is represented at the regional meetings and that Bartow County participates in the various GOHS traffic enforcement campaigns, such as Operation Zero Tolerance," a press release state. "Capt. Fletcher is considered an asset to the Bartow County Sheriff's Office and is instrumental in providing training, scheduling, and participation in the M.A.T.E.N. for his agency."
For the 23-year BCSO veteran, the award was unexpected.
"I'm at a loss for words because out of 16 counties there's a lot of agencies that participate in this. I didn't see it coming," Fletcher said.
"Lee Fletcher is a dedicated individual whose main objective is to make Bartow County one of the safest places to drive your vehicle. ... Lee takes his job serious and his duties are patrol division for the Bartow County Sheriff's Office and he is one of the best at what he does," Millsap said. "He still gets out on the street with these guys because that's what he likes to do and it's just an awesome thing for Lee to be chosen as Officer of the Year for the Governor's Office of Highway Safety for this area."


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Vegetarian Times magazine arrived today with some delicious looking tamales recipe. My son requested that I make some. (Probably will only happen once or twice because I know the traditional ones are time consuming.) All the recipes have quite a bit of fat in them. I'm familiar with the substitutes for oil and butter but not sure they will adequately hold the masa together. Anyone have experience with this?
There's also a section of brussel sprouts recipes. Lucky me! I still have half of the stalk from Trader Joe's. I do like them simply steamed with a sprinkling of nutritional yeast, though.
I lived in Chile for eight years, and often enjoyed the local version of tamales. They are called humitas there, and have always been vegan, at least with the families I know. There are a number of recipes I found quickly on line, but they seem to have milk or butter. I never saw that in Chile. This one looks like what I remember, minus the butter: http://www.chilean-wine.com/how-to-make-chilean-humitas.
The women there told me that the secret was to put the corn through a grinder, not a blender, and to chop the onion very very fine.
madeline yakimchukDirector: MEET IRENE - An Unlikely VeganGRYPHON media productions
Forgot to mention... they would have used what we call here a yellow banana pepper rather than a green chili; that is rather Mexican, and olive oil would be used over butter.
- madeline
I have a recipe I haven't tried yet. It is from the drmcdougall.com website, from a newletter. The recipe is by Alex Bury, and uses water, or stock, or stock, or some combo of them instead of the fat. I have also seen one that uses mashed potatoes instead of the fat/lard. I think that was also at mcdougall. There are a lot of good recipes there from newsletters. There is a list of them sorted by category - I think that is under quick links.
Is the following recipe any help ? I can't tell if it's the same thing you're talking about:
Recipe By: Susan VoisinServing Size: 6
1 medium onion — chopped1 green bell pepper — chopped2 cloves garlic — minced16 ounces refried beans, fatfree — (1 can)30 ounces pinto beans, canned — (2 cans)1 cup frozen corn kernels3/4 cup salsa2 teaspoons chili powder1/2 teaspoon cumin1 teaspoon salt — optional1 tablespoon nutritional yeast
Cornmeal Crust1 cup cornmeal1 teaspoon salt1 tablespoon agave nectar — or other liquid sweetener*1 cup boiling water
Preheat oven to 400 degrees. In a large nonstick skillet over medium-high heat, sauté the onion until it is just beginning to brown, stirring constantly. Add the green pepper and stir for 2 minutes. Add the garlic and sauté for one more minute. Add the remaining ingredients, except for the nutritional yeast and crust ingredients. Mix well and pour into a 2-quart baking dish. Sprinkle with nutritional yeast.
Mix cornmeal with salt and stir in agave nectar. Beat in boiling water until mixture is smooth. Drop by spoonfuls over nutritional yeast and beans and spread to cover the surface.
Bake for 25 to 30 minutes, or until crusty.
*Any mild-tasting liquid sweetener will do–including rice syrup, corn syrup, or barley malt syrup.- – - – - – - – - – - – - – - – - – -
Per serving: 331 Calories (kcal); 1g Total Fat; (3% calories from fat); 16g Protein; 65g Carbohydrate; 0mg Cholesterol; 1729mg Sodium
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Madeline- Your Chilean tamales sound yummy. I might try them modified - without the butter or oil. I've been trying to eat fat free.
loveheart - I should have thought of the McDougall website - always fat free.
theodore - thanks, that sounds what I'm looking for since it's from the Fat Free Vegan right? Have you tried it?
A favorite vegetarian Mexican restaurant in Houston, Radical Eats, serves delicous Spinach and Corn Tamales. Their chef generously shared her recipe (although not fat free) If anyone is interested -
You all are so helpful. I'll let you know how my tamales turn out.
My sweetheart wants to make fat free vegan tamales. Did you have luck with any particular receipe?
I used to love the tamales from Radical Eats but after I started eating fat free I would rather have them that way.
Karoline in Houston
I still haven't tried to make the tamales but was thinking about it the other day. If this week is a little quieter, I think I'll try a recipe I found in the McDougall newsletter index. I'll have to search for it again.
I've found vegan tamales in HEB but loaded with fat - put them back down. Do you have a favorite vegan restaurant in Houston? Field of Greens is a good one. No tamales on the menu, though.
I sort of gave up on restaurants. I go to be with people. Most of the time, I eat a salad with vinegar. Last time at Baba Yega's, I ordered plain pasta and guacamole. The guacamole is enough for 2 orders of pasta but the combo was rather tasty - admittedly still on the calorie-dense side.
We, or better said my sweetheart, cook a lot from pizza to dosas. If you are interested in dosas, I'll get you the receipe. We bake them on flat non-stick pan without oil. Maybe not as crisp as with using oil but still tasty and decidedly healthy. For toasting the spices we use a few drops of oil.
For the tamales, I found one McDougall receipe: http://www.drmcdougall.com/misc/2007nl/aug/recipes.htm
And one making a bean & masa dough - no filling described: http://www.fatfree.com/recipes/mexican/maya-tamales
I sure hope that we'll be trying it out soon. Let me know if you get to it first and how it went!
Yes, that's how I feel about restaurants too unless I'm with my son who eats mostly vegan also. I'm just there to be with the people. Most restaurants that the family goes to have only one or two things that work. Have never tried Baba Yega but it looks nice - I was looking at the website. The vegetarian plates sound delicious. The patio area reminds me of the Gardens of Bammel Lane where we attended a wedding reception recently.
No rush if you have to type up the dosa recipe but when you have time, I'd be interested in it. I like the dosas at Madras Pavillion but I'm sure they're cooked in oil. Never tried to make them.
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Michelangelo said the best way to judge the essential elements of a sculpture is to throw it down a hill and the unimportant pieces will break away. Sometimes life is like that. It tosses us down a hill. But when we reach the bottom and only the important things are left, that's when our vision clears. That's when we hold on tight to what we know, while hope stirs inside us. It's all a matter of perspective.
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text: i just got my rytera alien x back from the bowshop today. had new limbs put on it. only had to wait 2 weeks minus 1 day. not to bad for the limbs coming from wash state to Pa. by the looks of the limbs rytera must be using martins new powertuff limbs and not the barnsdale limbs anymore. the limbs have the slot cut in the limb where the limb bolt goes thru, just like all the other martins. i hope they will hold up as good as the barnsdales.


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"We have two sections, it's only for fourth and fifth graders, and they are chosen by their teachers at their school to come and participate," Emerson Elementary School Principal Robb Kittle said.
The top six math students from fourth and fifth grade were chosen to compete in the competition, which was broken down into two sections.
"The Math Fest side of the competition is [done with] paper and pencil and we give them questions with multi-step problems where they have to work through our Common Core State Standards ... they'll present their answers to the group and they get three chances and if they miss three times, they're out of the competition and the school who lasts the longest wins that side [of the competition]," Kittle said. "On the flip side, on the other side of the gym we have a Math Trail, which is a team effort where you're working together to solve four different problems and you rotate stations."
He said the event is a fun way for students to work through all the elements of the Common Core State Standards.
"Math has been a Bartow County system focus for the last few years; we've pushed ourselves in reading and language arts and we've gotten better each and every year, but math was kind of on the back burner a little bit, so when the schools created the Math Fest five years ago, we wanted to put that focus back on math and math success ..., so we felt like this was a good way to get kids excited about doing math," Kittle said.
He said the system also works to provide opportunities like Math Fest so parents can become more involved in their child's academic endeavors, even if the parent is not necessarily strong in the subject at hand.
"I think as a community of schools we try to do more things with math, like math nights and Math Fest, where parents can come out and see the work we're doing with math and can become more comfortable with the terminology we use and the process we do to solve the problems and so by doing community events like this where they can see their kids learning and how they're learning, they become more comfortable with the atmosphere," Kittle said.
Clear Creek Elementary School student Bryanna Candelaria placed first in the individual Math Fest competition for fifth-grade students. She said she enjoyed both the teamwork and individual work required during Math Fest.
"At first they put us in the Math Trail where we do a lot of games, and our team work was pretty good," Candelaria said.
While Candelaria said Math Fest was a fun experience, it required hard work outside of school.
"Usually I do a lot of practice at home, go over it, and make sure the answers are logical," Candelaria said.
Schools participating in this year's Math Fest are Adairsville Elementary, Allatoona Elementary, Clear Creek Elementary, Cloverleaf Elementary, Emerson Elementary, Euharlee Elementary, Hamilton Crossing Elementary, Kingston Elementary, Pine Log Elementary and White Elementary.
Fourth-grade individual Math Fest winners are, first place, Delana Prince, Allatoona Elementary; second place, Skyler Blalack, Allatoona Elementary; third place, Jillian Boyter, Euharlee Elementary; fourth-grade Math Fluency winner, Kayla Cantor, Allatoona Elementary; fourth-grade Math Fest Team winner, Allatoona Elementary; and fourth-grade Math Trail Team winner, Euharlee Elementary.
Fifth-grade individual Math Fest winners are first place, Bryanna Candelaria, Clear Creek Elementary; second place, Lexi Atilano, White Elementary; third place, Frances Runyon, Emerson Elementary; fifth-grade Math Fluency winner, Anthony Rodriguez, Kingston Elementary; fifth-grade Math Fest Team winner, Emerson Elementary; and fifth-grade Math Trail Team winner, Clear Creek Elementary.


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Dr. Mościcki, Dr. Clarke, Dr. Kuramoto, Dr. Narrow, and Dr. Regier are affiliated with the Division of Research, American Psychiatric Association, 1000 Wilson Blvd., Suite 1825, Arlington, VA 22209 (e-mail: email@example.com). Dr. Kraemer is with the Department of Psychiatry and Behavioral Sciences, Stanford University, Palo Alto, California. Dr. Kupfer is with the Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania. Parts of this article were presented at the annual meetings of the American Psychiatric Association, Philadelphia, May 5–9, 2012, and the New Clinical Drug Evaluation Unit, Phoenix, Arizona, May 29 to June 1, 2012.
Copyright © 2013 by the American Psychiatric Association
This article describes the clinical utility and feasibility of proposed DSM-5 criteria and measures as tested in the DSM-5 Field Trials in Routine Clinical Practice Settings (RCP).
RCP data were collected online for six months (October 2011 to March 2012). Participants included psychiatrists, licensed clinical psychologists, clinical social workers, advanced practice psychiatric–mental health nurses, licensed counselors, and licensed marriage and family therapists. Clinicians received staged, online training and enrolled at least one patient. Patients completed self-assessments of cross-cutting symptom domains, disability measures, and an evaluation of these measures. Clinicians conducted diagnostic interviews and completed DSM-5 and related assessments and a clinical utility questionnaire.
A total of 621 clinicians provided data for 1,269 patients. Large proportions of clinicians reported that the DSM-5 approach was generally very or extremely easy for assessment of both pediatric (51%) and adult (46%) patients and very or extremely useful in routine clinical practice for pediatric (48%) and adult (46%) patients. Clinicians considered the DSM-5 approach to be better (57%) or much better (18%) than that of DSM-IV. Patients, including children age 11 to 17 (47%), parents of children age six to ten (64%), parents of adolescents age 11 to 17 (72%), and adult patients (52%), reported that the cross-cutting measures would help their clinicians better understand their symptoms. Similar patterns in evaluations of feasibility and clinical utility were observed among clinicians from various disciplines.
The DSM-5 approach was feasible and clinically useful in a wide range of routine practice settings and favorably received by both clinicians and patients.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) was primarily developed to enhance communication and provide reliable diagnostic guidelines in clinical practice. Since the first edition of DSM in 1952, each of the four revisions over the past 45 years introduced changes in the description of mental disorders or diagnostic criteria that reflected contemporary advances in the science and understanding of mental disorders (1). Improved diagnostic reliability has been achieved by adding explicit criteria for mental disorders that provide descriptive information about signs, symptom expression, symptom duration, and consequences of these syndromes (2).
Similarly, proposed changes to DSM-5 were developed to capture the latest scientific advances and to enhance the reliability of diagnostic criteria while also addressing the need for improved clinical utility. The process of revising DSM-IV provided an opportunity to better integrate relevant mental health research findings that have emerged over the past two decades. DSM-5 introduces a more dimensional spectrum approach to several disorders, including autism spectrum disorder (ASD), learning disorders, substance use disorders, and somatic symptom disorders. Substantial modifications were also made to criteria for such disorders as schizophrenia, schizoaffective disorder, bipolar disorder, posttraumatic stress disorder (PTSD), and obsessive-compulsive disorder. The major revisions incorporated in DSM-5 have been summarized elsewhere (3–5) and are described in greater detail on the American Psychiatric Association's (APA's) online resource page for DSM-5 (www.psychiatry.org/dsm5). [A table listing key changes in the diagnostic criteria for several disorders is available in an online supplement to this article.]
DSM-5's introduction of patient-reported symptom and disability measures (5) and changes to select diagnostic criteria underscored the need for field testing, which has been a regular part of the DSM revision process since the third edition (6–10). One set of field trials for DSM-5, conducted at high-volume academic and research centers (3–5,11), tested the reliability of diagnoses, or the degree to which two clinicians could agree on diagnoses in separate examinations of the same patient when using DSM-5 diagnostic criteria and clinical assessment measures. Most of the diagnoses that were adequately tested had good to very good test-retest reliability with representative clinical populations (4), and there was generally good to excellent reliability for patient-reported symptom measures (5). However, because most clinical practice takes place outside academic and research centers (12,13), it is important to know whether the criteria that are used in such settings are feasible and clinically useful in routine clinical practice settings. A second set of DSM-5 field trials was planned specifically for this purpose. This article presents results from the DSM-5 Field Trials in Routine Clinical Practice Settings (RCP), which addressed the feasibility and clinical utility of the proposed criteria revisions in these settings.
The DSM-5 RCP Field Trials were conducted in a wide range of practice settings in the United States, including Alaska, Hawaii, and Puerto Rico, and in Canada, Australia, and the United Kingdom. Data collection took place over a six-month period from the fall of 2011 through early 2012.
Study participants included mental health professionals and their patients. Clinicians included psychiatrists, licensed doctoral-level clinical psychologists, clinical social workers, advanced practice psychiatric–mental health nurses, licensed counselors, and licensed marriage and family therapists. Clinicians were recruited from two groups, a random sample of 9,460 psychiatrists drawn from the American Medical Association (AMA) Physician Masterfile (14) and a volunteer sample of more than 5,600 mental health clinicians, recruited primarily on the DSM-5 Web site (www.dsm5.org).
Clinicians were eligible to participate if they were licensed to independently make DSM diagnoses; treated at least one new patient per month; had access to a computer with an Internet connection in the setting where field trial patients would be seen; were willing to provide computer access for both patient and clinician use during the study visit; could complete several hours of formal online training; and were able to enroll at least one patient in the study, conduct a diagnostic assessment of the patient, and provide patient data using the proposed DSM-5 criteria and related measures. Clinicians who were DSM-5 Task Force or DSM-5 Work Group members or who were otherwise involved with the DSM-5 development process were excluded from RCP Field Trials participation to reduce the chance of real or perceived bias.
After exclusion of residents, nonpsychiatrists, psychiatrists not involved in direct patient care, and those with invalid addresses, 2,679 of 8,953 psychiatrists (30%) completed the eligibility survey. Of these, 1,299 (48%) met eligibility criteria, and of this group, 472 submitted written consent forms, and 110 completed all online training and provided patient data. Therefore, about one-fourth of those submitting consent forms completed the study.
A total of 12,797 individuals volunteered for the DSM-5 RCP Field Trials through the DSM-5 Web site. Of these volunteers, 5,647 completed the eligibility survey, and 3,841 mental health clinicians (68%) met eligibility criteria. Of this group, 2,034 submitted written consent forms, and 511 completed all online training and provided patient data. Again, about one-fourth of those submitting consent forms completed the study.
Because the participation rate of the random sample was low, this sample was considered a sample of convenience and was combined for analyses with the volunteer sample of psychiatrists. The full sample of 621 participants included 154 psychiatrists, 77 licensed doctoral-level clinical psychologists, 111 clinical social workers, 33 advanced practice psychiatric–mental health nurses, 126 licensed counselors, 113 licensed marriage and family therapists, and seven licensed master's-level psychologists.
Each clinician was asked to report on at least one patient randomly sampled from his or her active caseload. Eligible patients or their parents or legal representatives had to be able to read and communicate in English. Patients had to be symptomatic at the time of enrollment and had to be at least six years of age, but otherwise no patient was excluded on the basis of age or cognitive impairment. The 621 participating clinicians provided data on 1,269 patients. Among these clinicians, 536 reported on the patient enrollment process, from which we estimated a patient participation rate of 32% (3,317 patients invited to participate, of whom 1,071 agreed). The remaining 85 clinicians enrolled 198 patients.
Both patients and clinicians completed computer-assisted assessments as part of the study. The measures have been described in detail elsewhere (3,5). Briefly, they included patient-completed assessments of 13 psychological "cross-cutting" symptom domains and disability (5) and clinician-completed diagnostic checklists, severity measures, relevant clinical and family histories, and patient and clinical utility questionnaires.
With rare exceptions—for example, in correctional settings where patient computer access was forbidden—study measures were electronically administered. Data were collected using the Research Electronic Data Capture (REDCap) system, an encrypted, HIPAA-compliant electronic database system developed by investigators at Vanderbilt University and supported by the National Institutes of Health (NIH). REDCap is a suite of Web-based tools designed to support data capture and dissemination (15), which was modified to meet the specific needs of the DSM-5 field trials (3).
Eligible clinicians submitted written informed consent and completed a rigorous, staged, online training program that included an overview of the RCP Field Trials, a self-directed review of the proposed DSM-5 criteria that had been posted on the DSM-5 Web site (www.dsm5.org), an introduction to REDCap, practice using the REDCap system with mock patients, and instructions on how to enroll patients and obtain written informed consent.
On the basis of a modified Kish procedure (16,17) that randomly assigned a start day and time, clinicians invited consecutive patients from their active caseload for field trial participation and entered all subsequent patients on a log until consent was obtained from one or more patients. Clinicians were asked to report on at least one existing or one new patient; the number of patients seen by individual clinicians ranged from one to eight, with a median of two patients per clinician. For the study visit, the patient or proxy completed the patient measures and a brief set of questions about his or her impression of the measures before meeting with the clinician. The results and interpretation of the patient-reported measures were transmitted to a database for clinician review before patient evaluation. The clinician then conducted a diagnostic interview and completed one or more relevant DSM-5 diagnostic checklists and severity measures, any additional indicated measures, and the clinical utility questionnaire. All required clinician forms were completed in REDCap.
Human subjects protection training was provided for clinicians who did not have current certification. All RCP Field Trials procedures and forms were reviewed and approved by the institutional review board (IRB) of the American Psychiatric Institute for Research and Education. Additional IRB review and approval were obtained by participating RCP Field Trials clinicians who were affiliated with institutions that required local IRB approval. A Certificate of Confidentiality was obtained from NIH to protect sensitive patient information.
Remuneration was provided to clinicians in the form of continuing medical education (CME) units. Clinicians who completed a study visit and provided patient diagnostic data received recognition as Collaborating Investigators and were offered a complimentary DSM-5.
Responses to specific questions in the clinical utility questionnaire and the patient feedback questionnaire were used to examine feasibility, clinical utility, clinician comparison of DSM-5 with DSM-IV, and patient impressions of the helpfulness of the patient measures. All analyses were conducted with SAS, version 9.3, statistical software. Descriptive statistics were generated for study population patients and clinicians; clinician and patient responses were examined separately for diagnostic categories that included 20 or more patients.
The findings presented here reflect data reported by 621 clinicians who completed a study visit and provided diagnostic data for 1,269 patients.
Table 1 shows the frequency of primary DSM-5 diagnoses among patients randomly selected for a study visit. The most frequent primary diagnoses among the 164 pediatric patients were attention-deficit hyperactivity disorder (ADHD) (27% of patients age six to 17 years), followed by major depressive disorder (8%) and ASD (7%). The most frequent primary diagnoses among 1,105 adult patients were major depressive disorder (19%), generalized anxiety disorder (10%), and bipolar I disorder (8%).
Clinicians reported that the overall DSM-5 approach was generally easy to use and that the proposed criteria and cross-cutting measures were clinically useful. Responses to the specific questions about overall feasibility and clinical utility of the proposed diagnostic criteria and cross-cutting measures are summarized for all disorders in Table 2. For more than 80% of patients, clinicians indicated that the overall DSM-5 approach to diagnostic assessment, including use of the patient-reported cross-cutting assessment measures, diagnostic criteria, and severity measures, was moderately to extremely feasible to apply in their clinical practice. Similarly, for approximately 80% of patients, clinicians reported that the DSM-5 criteria were moderately to extremely useful for the primary diagnosis compared with DSM-IV criteria. Thus the proportion of physicians giving ratings of "very" or "extremely" greatly exceeded the proportion giving ratings of "not at all" and "slightly," which discounted any central tendency for reporting. Large proportions of clinicians also reported that the patient-reported, cross-cutting measures were very or extremely useful.
a Number of patients for whom responses were provided on the clinical utility questionnaire
b For patients with comorbid DSM-5 diagnoses, clinicians were asked to evaluate proposed criteria separately for each diagnosis.
Figures 1 and 2 present more detailed data—by specific diagnoses and patient age group—on clinicians' impressions of the DSM-5 approach to patient assessment compared with DSM-IV. Of the clinicians with pediatric patients, more than 75% responded that the DSM-5 approach for all disorders was better (60%) or much better (16%) than the DSM-IV approach to the diagnosis of a mental disorder. Nearly 85% of those treating patients with ADHD rated the approach to ADHD better (71%) or much better (13%) (Figure 1). Similarly, approximately 75% of the clinicians with adult patients reported that the DSM-5 approach for all disorders was better (57%) or much better (18%) than DSM-IV for assessment of adult patients (Figure 2). The most favorable ratings were reported for PTSD, personality disorders, bipolar II disorder, substance use disorders, and somatic symptom disorder.
aADHD, attention-deficit hyperactivity disorder
Figure 3 shows clinician responses by discipline, summarized for all disorders. Regardless of discipline, most clinicians participating in the DSM-5 RCP Field Trials considered the DSM-5 assessment approach to be better or much better than DSM-IV. Ratings ranged from a cumulative 69% for psychiatrists (better, 55%; much better, 14%) to a cumulative 81% for licensed counselors (better, 60%; much better, 21%).
aPsychiatrists: 154 clinicians and 303 patients; licensed doctoral-level clinical psychologists: 77 clinicians and 153 patients; clinical social workers: 111 clinicians and 227 patients; advanced practice psychiatric–mental health nurses: 33 clinicians and 54 patients; licensed counselors: 126 clinicians and 244 patients; licensed marriage and family therapists: 113 clinicians and 228 patients. Total: 621 clinicians and 1,226 patients. Total includes responses not shown separately from seven licensed master's-level psychologists reporting on 17 patients.
Fifty-one pediatric patients age 11 to 17 years and 111 parents of patients age six to 17 years responded to the questions about the helpfulness of the patient cross-cutting measures (Figure 4). In general (for all disorders), among patients and parents who provided feedback, a higher proportion of parents than patients reported that they thought the questions would be helpful (response of "yes") to the clinician in understanding their child's symptoms (parents of children age six to ten, 64%; parents of children age 11 to 17, 72%; children age 11 to 17, 47%).
Among adult patients, consistently large proportions indicated that they thought the questionnaires would help the clinician better understand their symptoms (Figure 5). The two diagnostic categories with the highest proportion of "yes" responses were substance use disorders (73%) and bipolar I disorder (66%). Somatic symptom disorder (41%) and PTSD (42%) had the lowest proportion of "yes" responses; for both disorders, however, a large proportion of patients endorsed the "maybe" category (35% and 41%, respectively). Few patients indicated they thought the cross-cutting measures would not be helpful to the clinician; "no" responses ranged from 0% for substance use disorders and ADHD to 10% (N=2) for any personality disorder.
The DSM-5 RCP Field Trials examined the feasibility and clinical utility of the proposed diagnostic criteria in routine clinical practice settings. Clinicians from six mental health disciplines reported that the proposed criteria were generally easy to use in their practices and useful in patient assessment and that the DSM-5 approach was better than the DSM-IV approach. Most patients reported that they thought the patient measures would be helpful to their clinicians in understanding their symptoms.
The development of DSM-5 involved a multidisciplinary and international advisory and work group process, with three postings of draft criteria on the DSM-5 Web site (www.dsm5.org) to obtain public critiques and input. In both arms of the DSM-5 field trials, these criteria were implemented in a diagnostic assessment approach that involved computer-assisted, patient-completed assessments of commonly occurring "cross-cutting" symptoms and disabilities, a routine clinical interview rather than a structured research interview; and completion of computer-assisted diagnostic checklists and severity measures. The substantial changes in assessment procedures and in selected diagnostic criteria proposed for DSM-5 necessitated reliability testing in large academic and research settings (3–5), as well as feasibility and clinical utility testing in both the academic and RCP Field Trials. Conducting a field trial of this scope in routine practice settings required a considerable degree of training in a new approach to diagnosis, using moderately revised content and unfamiliar technology. We recognized that participation in the RCP Field Trials required clinicians' interest, time, and willingness to adjust routine clinical schedules to the field trial protocol and electronic data collection, and that many clinicians might not be able to complete all stages of the study. Despite these challenges, more than 600 clinicians successfully evaluated more than 1,200 patients and reported useful data.
Clinicians reported that they generally found the proposed DSM-5 approach to diagnosis easy to apply and clinically useful. Diagnostic criteria for PTSD, substance use disorders, bipolar disorders, and personality disorders received the most favorable clinical utility ratings from clinicians with adult patients. ADHD criteria received the highest ratings from clinicians with pediatric patients. These were among the most significantly revised disorders in DSM-5, yet the revised criteria received some of the highest ratings for their feasibility and clinical utility. This finding suggests that these DSM-5 criteria will facilitate better care for patients who suffer from these disorders.
Among the new manual's most noticeable differences from previous editions is the inclusion of patient-reported measures to identify initial clinical status and longitudinal outcome status in the DSM-5 approach to diagnostic assessment. In clinical practice, a mental disorder diagnosis is only one aspect of a clinical formulation that also includes the presenting complaint; past medical history; a mental status examination; a review of physical and mental systems; and an assessment of the patient's family, social, and cultural context, ability to perform various life activities, environmental exposures, and other risk factors. A diagnosis made in this context can benefit from the type of patient-generated information introduced in DSM-5—which is supported by the levels of patient approval reported here—and will become increasingly standardized as part of federally mandated "meaningful use criteria" for electronic health records (18). Likewise, measurement-based care models for monitoring response to treatment for both mental disorders (19) and other medical conditions have already been incorporated as "quality indicator" measures in some health systems (20). As a result, patient-generated symptom and disability measures that can be incorporated into routine clinical use without additional costs, such as those that are made available for further study with the DSM-5, are an increasingly important component of clinical practice. This underscores the value of these study findings and indicates that a measurement-based approach to mental health care may be preferable to clinicians and patients alike.
It is particularly noteworthy that the version of the criteria for personality disorders that was studied in the DSM-5 RCP Field Trials involved a trait-based system that was well received by study clinicians. Likewise, the use of cross-cutting symptom measures for patient completion before a clinical interview was rated highly by both clinicians and patients, who saw these instruments as a useful means of communicating their reasons for coming in for clinical evaluation or treatment. These measures were recommended for further study in the final APA review process and are currently placed in Section III of DSM-5 (21).
Clinicians from the various mental health disciplines exhibited similar patterns in their evaluations of the overall assessment and the proposed changes in diagnostic criteria. Regardless of any overall professional differences among disciplines in training and assessment techniques, a substantial majority, more than 75%, of the volunteer clinicians from all disciplines gave a rating of "better" or "much better" for the overall DSM-5 approach compared with the approach provided by DSM-IV.
This study had a number of limitations. First, the data came from a highly motivated and self-selected, rather than a representative, sample of clinicians. On the basis of our previous experience with sampling from the AMA Physician Masterfile and the likelihood that a substantial proportion of psychiatrists in solo or small practices might not meet the eligibility criterion of providing computer access for patients, we drew a relatively large random sample of psychiatrists in anticipation of a potentially low response rate. It is possible that clinicians who originally responded did not fully realize the challenges of the online training and the time commitment required to complete the study, which may have contributed to the final participation rates that we observed. After the randomly selected psychiatrists and the other volunteer clinicians submitted consent forms, about one-fourth of each group completed all training and contributed patient data. The findings reported here, therefore, should not be generalized to all mental health clinicians and patients. Similarly, the distributions of proposed DSM-5 diagnoses reported by the RCP Field Trials clinicians do not represent treated prevalence rates and should not be generalized.
Second, a separate evaluation of clinicians' experience with the online data collection system was not provided in REDCap. Although clinicians received an opportunity to comment on the online data collection experience when they claimed their CME credit, it is possible that some clinicians included their reactions to the online data collection rather than just to the proposed assessment instruments and diagnostic criteria. Further evaluation is needed of the implementation of more practice-based and clinician-friendly data collection technologies, as opposed to research-based technologies, for DSM-5. Third, unlike the DSM-5 Field Trials in Large Academic Settings (3–5), the RCP arm of the field trials was intended to examine the experience of mental health clinicians in a wide range of typical practice settings. However, because of small numbers of patients in some diagnostic categories and because patients were not necessarily a representative sample of all patients in the population, it was not possible to ascertain the feasibility and clinical utility of the proposed DSM-5 criteria for some diagnostic categories, especially among pediatric patients. The findings for diagnostic categories with small numbers of patients should be interpreted with caution. Fourth, our analyses focused on primary diagnoses; co-occurring diagnoses were not addressed in this study. Finally, although clinicians had the option of enrolling multiple patients, many provided data on only one patient.
The DSM-5 RCP Field Trials introduced a new component of testing that extended well beyond the previous focus on tests of reliability and disorder prevalence (8–10). Unique to both arms of the DSM-5 field trials was the inclusion of an assessment strategy that involved patient input, which could inform a diagnostic evaluation based on DSM-5 criteria by using routine diagnostic interviews. Because research interviews with highly structured instruments are not the norm for clinical practice, it was important to evaluate DSM-5 in the manner in which it would be used. Although assessing the reliability of the new diagnostic criteria is clearly important, it is equally vital to evaluate the convenience and clinical relevance of DSM-5 for mental health clinicians in the range of disciplines who will depend on it. The RCP Field Trials suggest that the DSM-5 approach is feasible and clinically useful in routine care settings and acceptable to both clinicians and their patients.
This study was funded by the American Psychiatric Association. The aggregate findings presented here include material contributed as a result of work supported with resources and use of facilities at the Huntington (West Virginia) Veterans Affairs Medical Center. The DSM-5 RCP Field Trials were conducted by a dedicated research team, the DSM-5 RCP Field Trials Technical Support Team, including Lisa Countis (field operations manager), Dr. Kuramoto, Adam Hoffberg, M.S., June Kim, M.S., Lisa Greiner, M.S.S.A., and Dr. Clarke, and with the tireless efforts of research staff and interns, including Jennifer Shupinka, Krystal Robinson, Dawn Mabry, Charlotte Morris, Anne Park, and Grace Lee. The authors are especially grateful for the contributions of Farifteh F. Duffy, Ph.D., Emily Kuhl, Ph.D., and Joyce C. West, Ph.D., M.P.P. The authors are grateful to the following organizations for help in recruiting mental health clinicians as participants in the DSM-5 RCP Field Trials: the American Psychiatric Association's leadership, components, and members; American Psychological Association; National Association of Social Workers; American Psychiatric Nurses Association; American Nurses Association; National Board of Certified Counselors; and American Association of Marriage and Family Therapists. The authors also gratefully acknowledge the efforts of Sandra E. Shaw, M.S.N., R.N. Finally, the authors thank the clinicians and their patients who generously contributed their time to participate in this historic effort.
The authors report no competing interests.
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