A few days ago, I was marveling at the tenacity of Drs. John Rush and Madhukar Trivedi in sticking to their dream of the evidence-based, measurement-based treatment of depression using algorthms to achieve full remission [a magnificent obsession…] – a dream that persisted in spite of a string of remarkably lackluster and failed implementations [TMAP, STAR*D, IMPACTS, CO-MED]. The evidence-based and measurement-based pieces involved using some kind of objective parameter the follow [and demonstrate] the patient’s response to treatment – a quantitatable instrument – a questionnaire. In their studies, they use a variety of depression rating scales: primarily the Hamilton Depression Rating Scale [HAM-D] and Rush’s own Quick Inventory of Depressive Symptomatology [QIDS]. They wanted to move this same Clinical Trial technology into the practice of primary care physicians and psychiatrists in their everyday management of patients, assuring us that it was good for us [both to follow treatment and as evidence of our work for Managed Care]. In 1995, before any of their mentioned implementations, they said:
Clinician-rated symptom measures, while time-consuming, provide a firm basis for making strategic [e.g., switching or augmenting treatment] or tactical [e.g., dose adjustments, starting side effect treatments, etc.] decisions. Thus, the routine use of clinical rating scales seems justified. The measurement of symptomatic outcome will also help clinicians inform managed care and other administrators as to whether or not ongoing continuation treatment is indicated. In addition, our own experience, having measured outcome in clinical practice for over 20 years, strongly suggests that patients are highly receptive to this brief assessment. They seem to be reassured that the clinician is attending to the symptomatology that caused them to seek treatment…
A decade later, they were both on an American College of Neuropsychopharmacology [ACNP] Task Force on response and remission in major depressive disorder [with Drs. David Kupfer and Darrel Regier, leaders of the DSM-5 Revision Task Force] that reached the same conclusion [even after the abject failure of TMAP, STAR*D, IMPACTS, and CO-MED]. So now Drs. Kupfer and Regier are carrying this evidence-based, measurement-based treatment of depression idea on in the form of Cross-Cutting Dimensional Assessment in DSM-5:
Dimensional assessments are being proposed for inclusion with existing categorical diagnoses in DSM-5 to provide a basis for measurement-based care. The principal goal is to provide additional information that assists the clinician in assessment, treatment planning, and treatment monitoring…
This idea just won’t go away. Maybe I’ve been too harsh, too critical. So I thought I’d look into what they actually had in mind. Looking at their write up, I found this:
… will use either clinician-rated measures or measures developed as part of an initiative on patient assessment underway at the National Institutes of Health. As part of a roadmap for clinical research, the NIH began an effort to produce a Patient-Reported Outcome Measurement Information System™ [PROMIS] that:
“aims to revolutionize the way patient-reported outcome tools are selected and employed … PROMIS™ aims to develop ways to measure patient-reported symptoms … across a wide variety of chronic diseases and conditions.” [http://www.nihpromis.org]
PROMIS™ has developed assessments for a number of clinical domains that have been identified by the DSM-5 Task Force as areas on which quantitative ratings would be useful for this cross-cutting assessment. One advantage for using the scales developed by the PROMIS™ initiative is that they are short. Further, the initiative has developed computerized adaptive testing methods that can be used to establish a patient’s rating by comparison to national norms with as few questions as possible.
So I went to the Promis™ instrument for depression:
I wrote the part of this post above the line this morning, and then drove into Atlanta for an old friend’s funeral and then went to the Christmas party of my former practice group. It was an emotional day, and I gave zero thought to Cross-Cutting Dimensional Assessments or the DSM-5. I guess I stopped writing this morning because I was worried that my reaction to that questionnaire was so overwhelmingly negative, somewhere around downright incredulous. Something like: You’ve been thinking about this for 16 years and this is what you come up with? eight questions that are about synonyms? and you propose that we can use such a thing to objectively follow a patient’s treatment? and you think that this will help patients "be reassured that the clinician is attending to the symptomatology that caused them to seek treatment"? and you want to actually make it part of the DSM-5? Give me a break! When I came back tonight, it was still open on my computer and I felt exactly the same way I felt this morning – How silly!…
It is silly and you are, as usual spot on. Construction of self-report inventories is a highly technical undertaking in the first place…I don’t imagine that it figures significantly in the education of medical doctors. The comment shouldn’t be taken as a diss but rather is intended to state an obvious matter of fact. This trivial 8 item inventory has virtually no redeeming contribution to make on the “face” of it. It is several steps of sophistication removed from the flawed Beck Depression Inventory which at least tried to cohere to psychometric standards. Moreover, as a “screening” tool it is useful to the clinician to save her time in formulating questions to pose and data to collect to inform her judgment. It also has the benefit of delivering standard (or z scores) that can help soften the issues of most any self-report inventory of this general type. Nothing can replace administration of a comprehensive battery of psychological tests that, taken together, can aid the clinician in developing fruitful hypotheses that might help N=1.
Among other fatal flaws, this example conflates frequency of experiencing a symptom with severity of the symptom. NIMH should know better. The template used here mirrors the old Zung depression scale. Look here for a critical analysis of that scale vis à vis the Hamilton scale.
PubMed ID # 4688625.
Existentialism has a term for the state characterized by those 8 questions. It’s called “the human condition.”