{"id":17120,"date":"2011-12-10T22:29:39","date_gmt":"2011-12-11T03:29:39","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=17120"},"modified":"2011-12-11T06:57:31","modified_gmt":"2011-12-11T11:57:31","slug":"how-silly","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2011\/12\/10\/how-silly\/","title":{"rendered":"how silly!&#8230;"},"content":{"rendered":"<div align=\"justify\">A few days ago, I was marveling at the tenacity of Drs. John Rush and Madhukar Trivedi in sticking to their dream of the<em> evidence-based<\/em>, <em>measurement-based<\/em> treatment of depression using <em>algorthms<\/em> to achieve full <em>remission<\/em> [<a target=\"_blank\" href=\"http:\/\/1boringoldman.com\/index.php\/2011\/12\/07\/magnificent-obsession\/\"><u><strong><font color=\"#200020\">a magnificent obsession&#8230;<\/font><\/strong><\/u><\/a>] &#8211; a dream that persisted in spite of a string of remarkably lackluster and failed implementations [<strong><font color=\"#200020\">TMAP<\/font><\/strong>, <strong><font color=\"#200020\">STAR*D<\/font><\/strong>, <strong><font color=\"#200020\">IMPACTS<\/font><\/strong>, <strong><font color=\"#200020\">CO-MED<\/font><\/strong>]. The <em>evidence-based<\/em> and <em>measurement-based<\/em> pieces involved using some kind of objective parameter the follow [and demonstrate] the patient&#8217;s response to treatment &#8211; a quantitatable instrument &#8211; a questionnaire. In their studies, they use a variety of depression rating scales: primarily the Hamilton Depression Rating Scale [<strong><font color=\"#200020\">HAM-D<\/font><\/strong>] and Rush&#8217;s own Quick Inventory of Depressive Symptomatology [<strong><font color=\"#200020\">QIDS<\/font><\/strong>]. 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:<\/div>\n<ul><sup><\/p>\n<div align=\"justify\">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. <strong><font color=\"#990000\">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<\/font><\/strong>&hellip;<\/div>\n<p> <\/sup><\/ul>\n<div align=\"justify\">A decade later, they were both on an American College of Neuropsychopharmacology [ACNP] <a target=\"_blank\" href=\"http:\/\/www.nature.com\/npp\/journal\/v31\/n9\/full\/1301131a.html\"><u><strong><font color=\"#200020\">Task Force on response and remission in major depressive disorder<\/font><\/strong><\/u><\/a> [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 <strong><font color=\"#200020\">TMAP<\/font><\/strong>, <strong><font color=\"#200020\">STAR*D<\/font><\/strong>, <strong><font color=\"#200020\">IMPACTS<\/font><\/strong>, and <strong><font color=\"#200020\">CO-MED<\/font><\/strong>]. So now Drs. Kupfer and Regier are carrying this<em> evidence-based<\/em>, <em>measurement-based<\/em> treatment of depression idea on in the form of <a target=\"_blank\" href=\"http:\/\/www.dsm5.org\/ProposedRevisions\/Pages\/Cross-CuttingDimensionalAssessmentinDSM-5.aspx\"><u><strong><font color=\"#200020\">Cross-Cutting Dimensional Assessment in DSM-5<\/font><\/strong><\/u><\/a>:<\/div>\n<ul>\n<div align=\"justify\"><sup>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&#8230;<\/sup><\/div>\n<\/ul>\n<div align=\"justify\">This idea just won&#8217;t go away. Maybe I&#8217;ve been too harsh, too critical. So I thought I&#8217;d look into what they actually had in mind. Looking at their write up, I found this:           <\/div>\n<ul>\n<div align=\"justify\"><sup>&#8230; 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&trade; [PROMIS] that:<\/sup><\/div>\n<ol>\n<div align=\"justify\"><sup>&ldquo;aims to revolutionize the way patient-reported outcome tools are selected and employed &#8230; PROMIS&trade; aims to develop ways to measure patient-reported symptoms &#8230; across a wide variety of chronic diseases and conditions.&rdquo; [<u><strong><a target=\"_blank\" href=\"http:\/\/www.nihpromis.org\/\"><font color=\"#200020\">http:\/\/www.nihpromis.org<\/font><\/a><\/strong><\/u>]<\/sup><\/div>\n<\/ol>\n<div align=\"justify\"><sup>PROMIS&trade;  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&trade;  initiative is that they are short. Further, the initiative has  developed computerized adaptive testing methods that can be used to  establish a patient&rsquo;s rating by comparison to national norms with as few  questions as possible.<\/sup><\/div>\n<\/ul>\n<div align=\"justify\">So I went to the <a href=\"http:\/\/www.dsm5.org\/ProposedRevisions\/Documents\/PROMIS%20v1.0%20ED-Depression%20Short%20Form%201.pdf\" target=\"_blank\"><u><strong><font color=\"#200020\">Promis&trade; instrument<\/font><\/strong><\/u><\/a> for depression:      <\/div>\n<div align=\"center\"><a href=\"http:\/\/www.dsm5.org\/ProposedRevisions\/Documents\/PROMIS%20v1.0%20ED-Depression%20Short%20Form%201.pdf\" target=\"_blank\"><img loading=\"lazy\" decoding=\"async\" height=\"346\" width=\"450\" vspace=\"5\" border=\"0\" src=\"http:\/\/1boringoldman.com\/images\/promis-1.gif\" \/><\/a><\/div>\n<hr \/>\n<div align=\"justify\">I wrote the part of this post above the line this morning, and then drove into Atlanta for an old friend&#8217;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 <strong><font color=\"#200020\">Cross-Cutting Dimensional Assessments<\/font><\/strong> or the <strong><font color=\"#200020\">DSM-5<\/font><\/strong>. 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: <em>You&#8217;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&#8217;s treatment? and you think that this will help patients &quot;be reassured that the clinician is attending to the symptomatology that caused them to seek treatment&quot;? and you want to actually make it part of the DSM-5? Give me a break!<\/em> When I came back tonight, it was still open on my computer and I felt exactly the same way I felt this morning &#8211; <em>How silly!<\/em>&#8230;<\/div>\n","protected":false},"excerpt":{"rendered":"<p>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&#8230;] &#8211; a dream that persisted in spite of a string of remarkably lackluster and failed implementations [TMAP, [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-17120","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/17120","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=17120"}],"version-history":[{"count":29,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/17120\/revisions"}],"predecessor-version":[{"id":17151,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/17120\/revisions\/17151"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=17120"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=17120"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=17120"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}