1. Using MMPI-2-RF Scale Cut-Offs to Screen for Depressive Disorders
Jacob Warszawski
William Menton
Yossef Ben-Porath
Kent State University

2. MMPI background The Minnesota Multiphasic Personality Inventory (MMPI)
Diagnostic clinical scales
Eventual shift to code types
The MMPI-2
Continued emphasis on code types
Heterogeneous scales (subscales needed to aid interpretation)
The MMPI-2-RF
Shift to construct-homogeneous scales
Focus on reducing general distress variance
-The MMPI is an extensive personality assessment used to assist with differential diagnosis; help develop treatment plans; help answer legal questions (e.g. forensic psychology); screen job candidates during the personnel selection process; or as part of a therapeutic assessment procedure.
-MMPI-2 continued to emphasize code types (e.g. 1-2 / 2-1 for Dep, Anx, Som.) relying on the highest scale elevations and incorporating subscales to aid in diagnosis. The heterogeniety of scales, overlapping content, and aging of the instrument called for revisions, leading to
--The current MMPI (MMPI-2-RF) is a 338 item instrument that infers psychopathology as homogenous and additive, separating overlapping content from scales, allowing for more straightforward interpretation of results.

3. Past approaches to diagnostic cut-scores
Dissertation by Lane (2001) evaluated classification accuracy of the MMPI-2 and SCL-90-R in diagnosing depressive disorders
A more recent study evaluated the diagnostic utility of the MMPI-2 and Rorschach in differentiating psychotic & non-psychotic inpatients (Dao, Prevatt, & Horne, 2008)
Wetzler, Khadivi, and Moser (1998) examined the MMPI-2 in assessing inpatients for depressive and psychotic disorders
1.) The dissertation by Lane illustrated that MMPI-2 clinical Scale 2(D) and Depression content scale (DEP) significantly differentiated between participants with depressive spectrum illnesses and participants with non-depressive diagnoses, and compared it to the SCL-90-R, finding the MMPI-2 to be more reliable. Sample size: Depressed=15, Non-Depressed=15
2.) Both the MMPI-2 and the Rorschach instruments discriminated psychosis modestly well in their respective domains, but did not address the MMPI’s ability to demonstrate its discriminative abilities by itself in contrast to a comparison instrument. It is important to note that this study combined Rorschach and MMPI-2 scale findings when calculating classification accuracy statistics
3.) Wetzler’s aim was to assess incremental utility of the MMPI-2 in assessing for each disorder cluster. Wetzler’s study found single scales to be less useful to aid in diagnosis although higher sensitivity and specificity on single scales was shown in comparison to the current study, which is likely the result of using an inpatient sample (w/more acute symptoms) and the MMPI-2 scales heterogenous nature.

4. Past research cont.
MMPI-2-RF scales as predictors of psychiatric diagnoses (Haber & Baum, 2014)
MMPI-2 Clinical Scale differences between dysthymia & major depression (Klonsky & Bertelson, 2000)
Distinguishing bipolar depression, major depression, and schizophrenia with the MMPI-2 clinical and content scales (Bagby, Marshall, Basso, Nicholson, Bacchiochi, & Miller, 2005)
Watson, Quilty, & Bagby (2011) MMPI-2-RF differentiating Bipolar from MDD
1.) Haber & Baum’s study examined the relationship between MMPI-2-RF scale scores and psychiatric diagnoses and which ones best predicted that a diagnosis would be assigned. Pertinent to our study, Haber & Baum found according to their work that RCd was the only predictor of an assignment to a depressive disorder category.
2.) Klonsky & Bertelson investigated MMPI-2 scale differences between Dysthymia and MDD. Their conclusions showed that MDD was clearly more severe than Dysthymia, and once again, single scales were less useful in differential diagnosis than multiple scales, and that while both diagnoses showed somatic scale elevations, MDD showed higher elevations on somatic/physical scales, causing their inclusion in this study.
3.) In a study by Bagby’s group in 2005, no clinical or content scale on the MMPI-2 proved to be effective in distinguishing patients with bipolar depression from patients with major depression. Bagby cites in the discussion that RC9, a newly restructured clinical scale may help future research with this problem.
4.) A study performed by Bagby in 2011 on the MMPI-2-RF’s ability to differentiate Bipolar from MDD confirmed earlier suspicions and found that 5 scales showed significant differences between patients with Bipolar and MDD. Only ACT (activation) showed strong clinical utility in differentiating the disorders.

5. The present study
Minimal past research investigating use of the MMPI-2-RF for diagnostic classification
Past research focused largely on two specific categories:
Differential diagnosis (e.g. Major Depression from Dysthymia)
Comparing the MMPI-2 to other instruments in assessing diagnostic utility
Present goal:
Evaluate usefulness of using MMPI-2-RF cut-score configurations to discriminate individuals with depressive disorders from those without

6. Method: Participants Outpatient community mental health sample
Mean age = 33 (SD = 10)
61% Female
Predominantly Caucasian (80% Caucasian, 17% African-American, 3% other)
Participants with invalid MMPI-2-RF protocols screened out
Two groups (overall n = 895)
Patients with a depressive disorder diagnosis (n = 254)
Major Depressive Disorder & Persistent Depressive Disorder (Dysthymia) with all specifiers were included
Adjustment Disorder with Depressed Mood not included in the Depressive Diagnosis group
Patients without depressive disorder diagnosis (n = 641)
I moved the demographic information to this slide

7. Methods & Procedures
Identified several scales theoretically related to Depressive Disorders
EID, RCd, RC1, RC2, MLS, HLP, SFD, SUI, RC9
Narrowed-down scale selections based on theoretical and statistical considerations (e.g., zero-order correlations)
Four scales substantially correlated with Depressive Disorder:
RCd, RC2, MLS, HLP
All correlations significant at p < .01 (2-tailed)
1.) For our methods, we selected scales theoretically related to depressive disorders. Externalizing/Internalizing dysfunction is highly correlated with DEP, but we chose to use scales highly distinctive of depressive features. Furthermore, EID, being a higher order scale, measures a broad range of features common across many disorders, so it was struck from our analyses. RCd identifies across many studies as being highly related to depression and in Dr. Ben-Porath’s book on interpreting the MMPI-2-RF referred to as a psychopathology “thermometer”, so it was included. Somatic complaints (RC1) were selected due to their frequent occurrences in depressed individuals. High cut scores on RC2 is listed in the MMPI-2-RF manual as potential for further assessment of a mood disorder, so it too was included. MLS & HLP, MLS a somatic scale and HLP an internalizing scale, were included because of their relevance in other research studies previously mentioned. Self-doubt (SFD) was not included due to its heterogeneous nature with other disorders. SUI was included for consideration because of its clear relationship with depression but was not selected for the same reasons as self-doubt. Finally, low scores on RC9 (hypomanic activation) were selected following the logic that a low hypomanic activation score could be indicative of depression.
2.) Zero-order correlations revealed that RCd, RC2, MLS, & HLP were most significantly correlated to a depressive Dx in our sample
3.) RCd, a general measure of symptomatic depression and anxiety, linked to helplessness/hopelessness, and a general sense of inefficacy. While many with Depressive Dx exhibit RCd (demoralization), many individuals scoring high on RCd can show full range of affect and experience pleasure, features contrasting with a depressive disorder. RCd was included both because of correlation and its history of association with depressed mood.
RC2 (LPE), a recognizable yet not exclusive feature of Depression, Schizophrenia, and PTSD, is linked directly with RCd as a red flag for a depressive disorder if both show elevations.
MLS, a scale falling under the somatic/cognitive domain, plays a role in somatoform symptomology. Beyond our own correlations, other studies previously mentioned identify MLS as significantly connected to depression, giving grounds for inclusion in our analysis.
HLP (helplessness/hopelessness), a demoralization related internalizing scale, conveys a message of pessimism and inability/ambivalence toward self-change. Hopelessness is a core feature of depression, even listed in the DSM as criteria for the disorder, illustrating a clear-cut purpose for its selection.
Of interest is MLS showing slightly higher correlation with our depressive group
All scales at cut scores of 55t and up were analyzed for classification accuracy. The most complex configurations analyzed all four scales at different elevations.
Bill’s notes:
I removed the full scale names to make the slide a little less busy. It would still be good to say what the scales measure.
RCd
RC2
MLS
HLP
Depressive Disorder
.32
.26
.28
.19

8. Results
All scales individually demonstrated some clinical utility in screening in or out a Depressive Disorder diagnosis
Sensitivity & specificity varied substantially between scales
MMPI-2-RF Scale
Sensitivity
Specificity
Overall Accuracy
RCd 65T
.82
.46
.51
RC2 65T
.69
.58
MLS 65T
.76
.55
HLP 65T
.53
.72
.70
RCd 70T
.61
.62
RC2 70T
.50
.74
.71
MLS 70T
.52
.68
HLP 70T
.32
.84
.77
RCd and MLS had high sensitivity, but very poor specificity
HLP had poor sensitivity, but fair specificity
These findings suggest some combination of scales may be optimal for identifying depressive disorders
For example, you could bold sensitivity >.8, specificity >.8, accuracy > base rate
*Base Rate = .28

9. Results continued MMPI-2-RF Scale(s) Sensitivity Specificity
Overall Accuracy
RCd 65T & RC2 65T
.61
.64
RCd 65T & RC2 70T
.46
.77
.73
RCd 65T & RC2 75T
.43
.83
.78
RCd 65T & RC2 80T
.31
.86
.80
MLS 65T & RCd 65T
.66
.65
MLS 65T & RCd 70T
.60
.72
.70
MLS 65T & RCd 75T
.52
.74
MLS 65T & RCd 80T
.30
.88
.81
Again MLS 65 shows high sens but poor specificity
Going up each scale (HLP 70, RC2 75, RCd 80), sensitivity is poor but overall accuracy is very good, implying the scales are very good at screening in or out for a depressive disorder
Combinations of scales show excellent specificity and overall accuracy, once again conveying that the scales are very good at screening out for a depressive disorder
*Base Rate = .28

10. Results continued MMPI-2-RF Scale(s) Sensitivity Specificity
Overall Accuracy
MLS 65T & HLP 65T
.46
.81
.76
MLS 65T & HLP 70T
.29
.88
.80
MLS 65T & HLP 75T
MLS 65T & HLP 80T
.11
.96
.85
HLP 65T & RC2 65T
.78
.74
HLP 65T & RC2 70T
.38
.84
HLP 65T & RC2 75T
.87
HLP 65T & RC2 80T
.28
.89
.82
*Base Rate = .28

11. Results continued
MMPI-2-RF Scale(s)
Sensitivity
Specificity
Overall Accuracy
RCd & RC2 & MLS (65T)
.50
.76
.69
RCd & RC2 &
HLP & MLS (55T)
.60
.64
.63
HLP & MLS (60T)
.52
.71
HLP & MLS (65T)
.37
.84
.78
RCd 85T & RC2 95T &
HLP 85T & MLS T85
.00
.99
Bill’s notes (3.4.16)
Make sure you carefully (and explicitly) orient the audience to the fact that you are using different numbers and combinations of scales as well as different scale elevations within the final configuration
Multi-scale combinations (like the first one shown) show fair sensitivity and decent specificity, but overall accuracy not beyond base rate
When all selected scales (row 3) are combined, specificity, and overall accuracy sit at excellent levels, illustrating that those without the disease will be correctly screened out.
The final 4 selected scale combinations (table column 1, row 5) simply reflect the last point
*Base Rate = .28

12. Discussion
No single- or multi-scale configuration demonstrated both high sensitivity & specificity
Many scales show high sensitivity declining over higher scale elevations
Simultaneously, specificity increases over higher scale elevations
Modest incremental improvements in overall classification accuracy for some configurations
Particularly useful in screening out non-depressed clients
…implying that the MMPI-2-RF is best used as an instrument to illustrate an individual’s personality traits as a constellation to be interpreted all at once rather than one at a time. Studies such as this one show that some scales may have more that can be extracted from than previously thought, as in the case with MLS outperforming other scales.

13. Discussion
This study additionally underscores the importance of examining all conceptually related scales (e.g., MLS) when making a diagnostic decision
As always, it is recommended to integrate test data with extra-test information before rendering diagnoses
Replication of this research in other settings is recommended, with the following aims:
Evaluating general utility and replicability of select cut-off scale configurations
Exploring utility of using the MMPI-2-RF to make other diagnostic decisions
Not all individuals present with the same symptoms, making classification accuracy very difficult when using any instrument like the MMPI-2-RF
And to reiterate…e.g. Interviews, observations, other tests, personal history and so on

14. References
Bagby, R. M., Marshall, M. B., Basso, M. R., Nicholson, R. A., Bacchiochi, J., & Miller, L. S. (2005). Distinguishing bipolar depression, major depression, and schizophrenia with the MMPI-2 clinical and content scales. Journal of Personality Assessment, 84(1),
Ben-Porath, Y. S. (2012). Interpreting the MMPI-2-RF. Minneapolis, MN, US: University of Minnesota Press.
Dao, T. K., Prevatt, F., & Horne, H. L. (2008). Differentiating psychotic patients from nonpsychotic patients with the MMPI-2 and Rorschach. Journal of Personality Assessment, 90(1), doi: /
Haber, J. C., & Baum, L. J. (2014). Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF) Scales as predictors of psychiatric diagnoses. South African Journal of Psychology, 44(4), doi: /

15. References
Klonsky, E. D., & Bertelson, A. D. (2000). MMPI-2 clinical scale difference between dysthymia and major depression. Assessment, 7(2), doi /
Lane, D. W. (2001, October). An analysis of the MMPI-2 and SCL-90-R in the diagnosis of depressive illness. Dissertation Abstracts International, 62, 2063.
Watson, C., Quilty, L., & Bagby, R. (2011). Differentiating Bipolar Disorder from Major Depressive Disorder Using the MMPI-2- RF: A Receiver Operating Characteristics (ROC) Analysis. Journal of Psychopathology & Behavioral Assessment, 33(3), doi:1.1007/s
Wetzler, S., Khadivi, A., & Moser, R. K. (1998). The use of the MMPI-2 for the assessment of depressive and psychotic disorders. Assessment, 5(3), doi: /