{"id":17249,"date":"2011-12-13T21:48:58","date_gmt":"2011-12-14T02:48:58","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=17249"},"modified":"2011-12-13T22:33:19","modified_gmt":"2011-12-14T03:33:19","slug":"simply-absurd","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2011\/12\/13\/simply-absurd\/","title":{"rendered":"simply absurd&#8230;"},"content":{"rendered":"<div align=\"justify\">Earlier, I wrote about the PROMIS Depression Questionnaire [<u><strong><a href=\"http:\/\/1boringoldman.com\/index.php\/2011\/12\/10\/how-silly\" target=\"_blank\"><font color=\"#200020\">how silly!&hellip;<\/font><\/a><\/strong><\/u>] put together as an NIMH initiative. And it is silly. The eight questions approximate synonyms, conflating severity with frequency. But there&#8217;s another questionnaire being considered by the DSM-5: the PHQ-9 [Patient Health Questionnaire, 9 item], the one used in the study discussed in the last post. Here it is:<\/div>\n<div align=\"center\"><img decoding=\"async\" width=\"300\" vspace=\"7\" border=\"0\" src=\"http:\/\/1boringoldman.com\/images\/phq-9.gif\" \/><\/div>\n<div align=\"justify\">The PHQ-9 is a creation of the MacArthur Foundation [<a href=\"http:\/\/www.depression-primarycare.org\/about\/about\/\" target=\"_blank\"><u><strong><font color=\"#200020\">MacArthur Initiative on Depression and Primary Care<\/font><\/strong><\/u><\/a>] called RESPECT-Depression [<strong><font color=\"#200020\">Re-Engineering Systems for Primary Care Treatment of Depression Project<\/font><\/strong>]:<\/div>\n<ul><sup><\/p>\n<div align=\"justify\">The mission of the MacArthur Initiative on Depression and Primary Care is to enhance the ability of primary care clinicians to recognize and manage depression&#8230; The goals that serve the Initiative&#8217;s mission are:<\/div>\n<ol>\n<li>\n<div align=\"justify\">To develop practice systems that facilitate recognition and care of depression;<\/div>\n<\/li>\n<li>\n<div align=\"justify\">To develop educational programs and tools for primary care that enhance patient care;<\/div>\n<\/li>\n<li>\n<div align=\"justify\">To evaluate the impact of these programs, tools and models; and<\/div>\n<\/li>\n<li>\n<div align=\"justify\">To disseminate these ideas and materials to primary care clinicians, medical groups, specialty societies, health plans, and other organizations committed to high quality depression care.<\/div>\n<\/li>\n<\/ol>\n<p>      <\/sup><\/ul>\n<div align=\"justify\">The website covers the the program, the studies, it&#8217;s adoption by Health Plans, HMOs, etc. The gist of the argument is by now familiar &#8211; a Public Health argument about the under-treatment of depression.<\/div>\n<p>      <\/p>\n<div align=\"justify\">In the lead-in to the DSM-5 Revision process, there was a conference concerning adding a dimensional component to the DSM-5:<\/div>\n<blockquote>\n<div align=\"justify\"><a href=\"http:\/\/www.dsm5.org\/Research\/Pages\/DimensionalAspectsofPsychiatricDiagnosis%28July26-28,2006%29.aspx\" target=\"_blank\"><u><strong><font color=\"#200020\">Dimensional Aspects of Psychiatric Diagnosis [July 26-28, 2006]<\/font><\/strong><\/u><\/a><\/div>\n<div align=\"justify\"><sup>Prepared by Michael B. First, M.D., DSM Consultant to the American Psychiatric Institute for Research and Education [APIRE], a subsidiary of the American Psychiatric Association.<\/sup><\/div>\n<p align=\"justify\"><sup>A diagnosis-related research planning conference focusing on dimensional approaches in diagnostic classification was held at the Natcher Conference Center on the NIH campus in Bethesda, Maryland on July 27th and 28th, 2006. The conference was the seventh in a series of 12 conferences on &quot;The Future of Psychiatric Diagnosis: Refining the Research Agenda&quot; convened by the American Psychiatric Institute for Research and Education [APIRE] in collaboration with the WHO and NIH, with funding from NIH&#8230;<\/sup><\/p>\n<div align=\"justify\"><sup>John Helzer, MD [Burlington, VT] opened the conference with a description of its rationale and goals These were:<\/sup><\/div>\n<ol><sup>      <\/p>\n<li>\n<div align=\"justify\">to review the advantages and drawbacks of offering a quantitative &quot;dimensional&quot; component in <em>DSM-V<\/em> and ICD-11; <\/div>\n<\/li>\n<li>\n<div align=\"justify\">to discuss various alternative dimensional approaches; and <\/div>\n<\/li>\n<li>\n<div align=\"justify\">to discuss a research agenda relevant to designing and testing dimensional alternatives.<\/div>\n<\/li>\n<p>      <\/sup><\/ol>\n<div align=\"justify\"><sup>He stressed that the six diagnostic areas scheduled for formal presentation &#8211; i.e., substance use disorders, mood disorders, psychotic disorders, anxiety disorders, childhood disorders, and personality disorders &#8211; were illustrative examples and that it was not the intention of the conference to confine discussion to these areas. Dr. Helzer noted that although <em>DSM-III <\/em>was a revolutionary paradigmatic shift, the diagnostic progress it fostered revealed the inadequacies of a strictly categorical diagnostic model. He then offered four recommendations for <em>DSM-V<\/em>:<\/sup><\/div>\n<ol><sup>      <\/p>\n<li>\n<div align=\"justify\">that the <em>DSM-V<\/em> criteria should include options for dimensional approaches; <\/div>\n<\/li>\n<li>\n<div align=\"justify\">that the categorical approach of <em>DSM <\/em>should be retained given the ongoing need for diagnostic categories for clinical work and research; <\/div>\n<\/li>\n<li>\n<div align=\"justify\">that the content of <em>DSM-V<\/em> dimensional components be determined by categorical definitions given the need to be able to relate the dimensional scales back to the categorical definitions; and <\/div>\n<\/li>\n<li>\n<div align=\"justify\">that <em>DSM-V <\/em>should be structured to ensure maximum utility for future taxonomic needs&#8230;<\/div>\n<\/li>\n<p>      <\/sup><\/ol>\n<\/blockquote>\n<div align=\"justify\">And at this conference, the Mood Disorders Group ended with this:<\/div>\n<blockquote>\n<div align=\"justify\"><sup><strong><font color=\"#800000\">The mood disorders breakout group proposed adding dimensionality to major depressive disorder by exploring the implications of adopting the PHQ-9, a nine-item self-report scale with a 0-27 range of scores.<\/font><\/strong> Used as a severity measure, suggested cutpoints include 5-9 for mild, 10-14 for moderate, 15-19 for moderately severe, and 20 or greater for severe, with &quot;significantly improved&quot; defined as a 5-point drop after 6 weeks, &quot;responded to treatment&quot; as a 50% drop in score, and &quot;remission of depression&quot; as a score of less than 5. Such an approach has clinical utility in that it can identify probable cases, it identifies cases at risk who need referral, it confirmed current treatment in 60% of cases, it informed a change of treatment in 40% of cases, and in &gt;90% of visits, clinicians rated it as useful. It has research utility in that it sets benchmarks for improvement, recovery, and remission and permits clinical audits of practice. The scale still needs validation in different settings and with different types of patients [e.g., high risk patients with comorbid conditions].<\/sup><\/div>\n<\/blockquote>\n<div align=\"justify\">I have a number of reactions to this conference and where it proposes to take the field of psychiatry, some already stated, some probably coming attractions, but for the moment, I want to stick to the <font color=\"#200020\">PHQ-9<\/font>. It&#8217;s certainly more rational than the PROMIS Questionnaire. At least it queries the breadth of Depressive symptoms. It seems to confuse frequency with severity like the PROMIS Questionnaire, but in looking at the way it&#8217;s scored, I think they&#8217;re &quot;weeding out&quot; common unhappiness. As such things go, it is what it is &#8211; a waiting room screening instrument for Depression. What the MacArthur Foundation, the Health Care Plans, or Primary Care Physicians do with the PHQ-9 is none of my business. But the American Psychiatric Association is considering including it in the DSM-5 as a dimensional component of the diagnosis of Major Depressive Disorder, and I have plenty to say about that. They said:<\/div>\n<ul>\n<div align=\"justify\"><sup>Dr. Helzer noted that although <em>DSM-III <\/em>was a revolutionary  paradigmatic shift, the diagnostic progress it fostered revealed the  inadequacies of a strictly categorical diagnostic model.<\/sup><\/div>\n<\/ul>\n<div align=\"justify\">They say things like that as if they are facts. In the case in point, Depression, the DSM-III was not a <em>revolutionary paradigmatic shift<\/em>, it was a <em>cataclysmic error<\/em>, reducing multiple clinical syndromes to a fictitious unitary category &#8211; inadequate to be sure, but not because of missing dimensions, rather because poor clinical science. Beyond that, since when did a severity index become a part of diagnosis? But I&#8217;ll stay with the topic I defined, the PHQ-9 itself.   <\/div>\n<p> <\/p>\n<div align=\"justify\">In spite of their glowing remarks about the PHQ-9, it&#8217;s hard to imagine using it to follow a patient&#8217;s progress because of the way it&#8217;s constructed. It defines nine symptomatic areas and measures their severity by their frequency [in terms of number of days the symptom is present]. I know of nothing, including my own clinical experience, that suggests that depression improves by a symptom being present in more or less days. And if you look at any of the standard measures, that&#8217;s not at all how they work. The <a target=\"_blank\" href=\"http:\/\/healthnet.umassmed.edu\/mhealth\/HAMD.pdf\"><u><strong><font color=\"#200020\">Hamilton Rating Scale for Depression, Clinician Rated<\/font><\/strong><\/u><\/a> measures severity differently for each symptom, and the parameters are quality of the experience rather than simply frequency. It&#8217;s the same for the <a target=\"_blank\" href=\"https:\/\/www.outcometracker.org\/library\/MADRS.pdf\"><u><strong><font color=\"#200020\">Montgomery &Aring;sberg Depression Rating Scale<\/font><\/strong><\/u><\/a>. Even the simplistic <a target=\"_blank\" href=\"http:\/\/media.mycme.com\/documents\/13\/mdd-qids_3069.pdf\"><u><strong><font color=\"#200020\">QIDS-SR<\/font><\/strong><\/u><\/a>, a self rating depression scale used in STAR*D, measures severity with specific questions:<\/div>\n<ul><sup><\/p>\n<div align=\"justify\">10. Concentration\/Decision making:   <\/p>\n<ol>\n<div>0 There is no change in my usual capacity to concentrate or make decisions.<br \/>  1 I occasionally feel indecisive or find that my attention wanders.<br \/>  2 Most of the time, I struggle to focus my attention or to make decisions.<br \/>  3 I cannot concentrate well enough to read or cannot make even minor decisions.<\/div>\n<\/ol>\n<div>11. View of myself:<\/div>\n<ol>\n<div>0 I see myself as equally worthwhile and deserving as other people.<br \/>  1 I am more self-blaming than usual.<br \/>  2 I largely believe that I cause problems for others.<br \/>  3 I think almost constantly about major and minor defects in myself. <\/div>\n<\/ol><\/div>\n<p><\/sup><\/ul>\n<div align=\"justify\">So, for me, even considering the PHQ-9 for inclusion in the DSM-5 seems to further trivialize the entire DSM-5 enterprise. We already have a category [Major Depressive Disorder] that is not a diagnosis worthy&nbsp; of the state of our knowledge, one that needs to be deconstructed into the more clinically relevant syndromes we already accept. Now they propose adding a waiting-room screening tool that is not designed for detecting or monitoring change. This only adds to a suspicion that these changes are being tailored to the needs of the pharmaceutical or managed care industries rather that having anything to do with the clinical science of psychiatry. It&#8217;s one of the reasons there&#8217;s so much uproar about the DSM-5 &#8211; because of suggestions like this that are simply absurd&#8230;<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Earlier, I wrote about the PROMIS Depression Questionnaire [how silly!&hellip;] put together as an NIMH initiative. And it is silly. The eight questions approximate synonyms, conflating severity with frequency. But there&#8217;s another questionnaire being considered by the DSM-5: the PHQ-9 [Patient Health Questionnaire, 9 item], the one used in the study discussed in the last [&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_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-17249","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/17249","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=17249"}],"version-history":[{"count":25,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/17249\/revisions"}],"predecessor-version":[{"id":17274,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/17249\/revisions\/17274"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=17249"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=17249"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=17249"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}