Don’t ‘teach to the test’
I was disappointed to read Dr. Henry Nasrallah’s editorial calling for the use of clinician measurement tools in the management of psychiatric illness (“Long overdue: Measurement-based psychiatric practice,” From the Editor, Current Psychiatry, April 2009). I agree that general and vague comments such as “doing better” are of limited value. I would further argue that such documentation is the psychiatric equivalent of “WNL”—which stands for “we never looked”—in a medical review of systems. But I do not believe the answer is to further dumb down the practice of psychiatry by generating quantifiable, 1-dimensional scores that purport to measure how well our patient is doing.
In the past, when these psychometric tools were developed (approximately from 1960 to 1987), 2 primary concerns were voiced.
First, there was limited data to support their validity and reliability, although that concern is somewhat less now, at least with some of the tests Dr. Nasrallah recommended. These tests still lack criterion-related validity. For example, IQ as measured by an IQ test predicts performance on an IQ test, so it’s reliable. But to use that number to predict fitness for a job or even academic success ends up discriminating against some individuals or groups who are more than just a number.
Second, there was the concern that, similar to schoolteachers who end up teaching to a normative test, we could end up treating a patient’s test score rather than the discomfort with his or her life. I believe this also remains true. Unlike diabetes mellitus, which is defined by increased blood sugars, psychiatric diagnoses are purely syndromal and require “clinically significant distress or impairment” or they are not a disease according to DSM-IV-TR. It’s the distress and the impairment that we treat.
Today, I see 2 positive trends in our field: to find increasingly efficient methods to appropriately tailor and effectively deliver care and to be recovery-focused. It seems to me that routine and indiscriminate use of psychometrics obstructs both of these. Each test takes 30 to 40 minutes to administer and requires skilled and trained clinicians, if not psychiatrists themselves. That at least doubles the length of the visit with no evidence-based benefit. A recovery focus requires that we—as does the DSM—focus on our patients’ perceived impairments, not their test scores.
Lyle B. Forehand, Jr, MD
Dr. Nasrallah responds
I thank Dr. Forehand for his comments. I agree that psychiatric diagnoses at this time are purely syndromal and require “clinically significant distress or impairment.” What I am calling for is to quantify the various signs and symptoms of the distress and impairment before and after treatment with a standard scale widely used by all researchers and some clinicians.
The definition of remission, which is the phase that precedes recovery, actually is based on standard rating scales’ severity score for a given psychiatric illness. Therefore, clinicians must rate their patients on the scale corresponding to that illness to recognize when their patients have met the official criteria for remission.
Practitioners do not have to use a scale to rate the patient’s symptoms separate from the standard interviewing process. Rather, once clinicians become familiar with these scales, they could conduct their usual interview and then take a moment when writing their note in the chart to circle the score of each symptom they assessed during their clinical interaction, and cite the total score in the admission or progress note. A copy of the scale can be included as a supplement to the progress note and will ensure that all signs and symptoms related to an illness are assessed, rather than just some of them.
To summarize, until scientific research leads to actual lab tests for psychiatric disorders—and I believe that day will come—psychiatrists should quantify their patients’ clinical distress and impairment with the same objective measures used in evidence-based FDA trials, even if the scales’ reliability and validity are not perfect.
Henry A. Nasrallah, MD