Research paperAre self-report scales as effective as clinician rating scales in measuring treatment response in routine clinical practice?
Introduction
In psychiatry, quantified assessments of outcome are not the standard of care. Instead, in mental health clinical settings outcome evaluations are typically based on unstructured interactions that yield unquantified judgments of progress. This is at variance with other areas of medical care in which outcome is determined, in part, on the change of a numerical value. Body temperature, blood pressure, cholesterol values, blood sugar levels, cardiac ejection fraction, thyroid stimulating hormone levels, and white blood cell counts are examples of quantifiable variables that are used to evaluate treatment progress. Quantifiable outcome measures exist for most major psychiatric disorders, yet they are rarely used in routine clinical practice (Gilbody et al., 2002, Zimmerman and McGlinchey, 2008).
The quantitative measurement of treatment outcome has long been an integral component of research investigations of the efficacy and effectiveness of care. Recently, some investigators and treatment guidelines have suggested that measurement tools should be used to monitor the course of treatment in clinical practice (American Psychiatric Association, 2010, Harding et al., 2011, National Collaborating Centre for Mental Health, 2009, Trivedi et al., 2006). A better understanding of the effectiveness of psychiatric treatment in clinical practice depends, in part, on systematically measuring outcome. To accomplish this, reliable, valid, informative, and user-friendly scales are necessary. Clinicians are already overburdened with paperwork, and adding to this load by suggesting repeated detailed evaluations with such instruments as the Hamilton Rating Scale for Depression (HAMD) (Hamilton, 1960) or the Montgomery Asberg Depression Rating Scale (MADRS) (Montgomery and Asberg, 1979) is unlikely to meet with success. Clinician-rated scales are time consuming, require training to ensure the ratings are reliable and valid, and may be prone to clinician bias. Self-report questionnaires are inexpensive in terms of professional time needed for incorporation into the clinical encounter, they do not require special training for administration, and they correlate highly with clinician ratings. With modern technology, computer administered self-report assessments enable the conduct of large-scale outcome studies in clinical practice at low cost (Zimmerman and Martinez, 2012). Moreover, self-report scales are free of clinician bias, and are therefore free from the potential risk of clinician overestimation of patient improvement (which might occur when there is incentive to document treatment success).
A meta-analysis of treatment studies of depression found that effect sizes of treatment as assessed by self-administered scales were smaller than the effect sizes as assessed by clinician-rated measures (Cuijpers et al., 2010). Little research has compared the effect sizes of self-report and clinician rated scales in routine clinical practice. While many self-report scales have been developed to measure the severity of depression (Nezu et al., 2000) Zimmerman et al. (2008b), in discussing the use of self-report scales in routine clinical practice, recommended measures that assess the DSM-IV criteria for major depressive disorder (MDD) that are available for clinical use at no cost. Several such scales exist (Bech et al., 2001, Kroenke et al., 2001, Rush et al., 2003, Rush et al., 1996, Zimmerman et al., 2008a, Zimmerman et al., 2004). In consideration of increasing calls to demonstrate the effectiveness of treatment in routine practice, and the lower clinical burden imposed by self-report scales compared to clinician-rated scales, it is important to determine if the method of assessing outcome will significantly influence conclusions about the degree of treatment effectiveness.
Accordingly, in the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we compared three self-report scales assessing the DSM-IV symptom criteria for MDD and the 2 most widely used clinician administered scales in their sensitivity to change and evaluation of treatment response in depressed patients treated in routine practice.
Section snippets
Methods
One hundred fifty-three patients diagnosed with DSM-IV MDD who presented for treatment to the Rhode Island Hospital Department of Psychiatry outpatient practice (n = 78), or who were in ongoing treatment and had their medication changed due to lack of efficacy (n = 75), were evaluated at baseline and at 4-month follow-up. The mean interval between the baseline and follow-up evaluations was 16.4 weeks (SD = 4.2 weeks). Not all available patients participated in the study due to the lack of
Results
There was no difference in the amount of change in the patients who presented for treatment versus those in ongoing treatment who had their medication changed therefore the data from these 2 groups was combined. On each scale, the patients showed significant levels of improvement from baseline to follow-up (Table 1). A large effect size was found for each scale (Table 1), with little variability amongst the scales.
All correlations between the scales in change in scores from baseline to 4 months
Discussion
In the past few years there have been increasing calls for the utilization of such standardized measures to assess outcome in clinical practice (American Psychiatric Association, 2010, Harding et al., 2011, Morris and Trivedi, 2011), and it is likely that self-report scales are more likely to be used than clinician rated scales such as the HAMD and MADRS. The results of the present study found that when measuring outcome in clinical practice that the magnitude of change in depressive symptoms
Acknowledgments
None.
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2021, Journal of Affective DisordersCitation Excerpt :However, there is a debate about whether or not these different modes of administration can be used interchangeably (Uher et al., 2012). Several studies reported acceptable correlations and high levels of agreement between the total scores of these two rating types (e.g. Bech, 1992; Bernstein et al., 2007; Möller, 1991; Rush et al., 2006; Zimmerman et al., 2018), indicating that both types are highly comparable. Other studies found poorer correlations between self-reported and clinician administered outcomes (e.g. Carter et al., 2010; Cuijpers et al., 2010; Enns et al., 2000; Uher et al., 2012), indicating that these two assessment types may not be interchangeable.