A new study, published in the Journal of Affective Disorders, examines discrepancies between clinician- and patient-rated outcomes concerning inpatient depression treatment. Results show low levels of agreement between clinician-and-patient- reports measuring depressive symptoms, with more significant differences in cases where patients experienced deterioration in mental health.
These results raise questions about how well clinicians can assess improved mental health in clients undergoing therapeutic treatment. In addition, discrepancies in clinician and patient reports of mental health measures also challenge the validity of research studies utilizing clinician-rated outcomes as the primary measures of mental health.
“The most obvious explanation for our results would be that clinical judgment, because of a bias toward positive treatment outcomes, tends not to reliably detect negative outcomes from the patient’s perspective,” write the authors, led by Tim Kaiser, a researcher in the Department of Psychology at the University of Greifswald.
Mental health self-report measures have previously drawn attention to contextual and practice limitations. Standardizing mental health measures is associated with a range of issues, such as ignoring setting-specific needs, leading some researchers to propose a variety of self-report measures to meet the varying needs of clients and providers.
Additionally, past research has shown that scales assessing child and adolescent psychopathology may not have cross-cultural utility, suggesting that using self-report scales may provide ineffective measures across racially and ethnically marginalized groups.
Recent research highlighting the need for patient-centered care further contextualizes the complexity of discrepancies in self-report measures. For example, a recent study shows that increasing patient-centered care may prevent psychiatric rehospitalization by examining how service users relate to their communities and the resulting effects on mental health.
Incorporating patient perspectives in care is especially important when treating depression. Past research collecting service-users experiences with therapeutic care targeting depression shows mixed strengths and weaknesses across treatment settings, consistency, branding, and modality.
Although global rating scales are widely used to assess diagnostic criteria and treatment efficacy, clinician-reported measures often miss negative outcomes in psychotherapeutic treatment. Applying rating scales during clinical treatment of depression provides a unique barrier due to poor agreement among clinician- and patient reports for symptom remission and response.
Past studies on discrepancies between clinician and patient reports of depressive symptoms cause concern for potential oversight of patient input in treatment. The study authors explain:
“ . . . all of these studies focused solely on agreement in the case of improvement. They did not report how well patients who show no improvement or even deterioration are detected by clinician ratings.”
The researchers executed a quantitative analysis on a large sample of patients (n = 20,882) with a primary diagnosis of depression who received inpatient care. Patients received a range of treatment interventions, including Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy (ACT), group therapy, and antidepressant medication.
Clinician-reported ratings conducted after discharge were included in the analysis: the Clinician Global Impression Improvement scale (CGI-I) and Global Assessment of Functioning (GAF). In addition, the Patient Health Questionnaire-9 and the Beck Depression Inventory-II (BDI-II) were administered as a part of routine care after discharge.
After conducting a linear regression analyzing clinician-rated and patient-reported outcomes for depression, the authors found low levels of agreement between ratings for patients that experienced a slight improvement in symptoms. There were nearly nonexistent levels of agreement between ratings for patients that experienced deterioration after discharge. The results also show that clinician ratings on mental health were influenced by symptom severity at discharge rather than a change in symptomatology from the time of admission.
This study provides evidence that clinician-reported global clinical rating scores do not consider patient perspectives, resulting in significant discrepancies between clinician and patient perceptions of depressive symptoms during inpatient treatment.
Kaiser and colleagues recommend that patient-reported outcome measures be included in routine care as a tool to measure the quality of care. A second recommendation is highlighted around the improvement of training for clinicians in detecting symptom non-responsiveness and deterioration during inpatient treatment for depression.
Kaiser, T., Herzog, P., Voderholzer, U., and Brakemeier, E. (2022) Out of sight, out of mind? High discrepancy between observer- and patient-reported outcome after routine inpatient treatment for depression. Journal of Affective Disorders. 322-325. https://doi.org/10.1016/j.jad.2022.01.019 (Link)
Who would know better whether a depression treatment helped – the person being treated or the person who stigmatized the person as “depressed”? Of course, “patient-reported outcome measures [should] be included in routine care as a tool to measure the quality of care.”
An example of how a lack of listening to people who were given antidepressants resulted in the “mental health” industries being totally ignorant of a common symptom of antidepressant discontinuation syndrome, for decades.
And do tell, what is “professional” about knowing nothing about the common adverse and withdrawal effects of the drugs one coerces and forces people to take?
Why would they have to SAY that patient-reported measures should be “included?” Why wouldn’t they be the MOST IMPORTANT measure in every case?
Yes, big and systemic – ‘delusions of grandeur’ I’m a doctor, and smarter than everyone else – medical mistakes, Steve.
And what’s sad is that our medical community is only as credible as their sources of information. And the medical communities’ sources of information – other than the internet, which is being increasingly censored – are controlled by big Pharma.
And “fierce Pharma” has NOT proven itself to be a credible source of information. Instead, they’ve proven themselves to be a greed only inspired industry. Thus, the vast majority of the doctors’ sources of information are bogus.
And that’s “why patient-reported measures should be” respected as the “MOST IMPORTANT measure in every case?”
In working on our plan for the Advocates Taking Action Against Mental Illness in Kentucky, the emergent new terminology was to realize outcomes for in order to receive funding. To measure gains and/or show the progress of the developing organization, the phrasing for outcomes measurements for the organization would have to be realized in order to receive funding. And in taking the seminar with W. Edwards Deming, when I stood up to ask him about how to measure improvement in a mental hospital which is definitely different from realizing a representative form of democracy through a legitimate 501.C3, his reply was to either mark up or down once a day improvement with a + or minus -. (Then tally the markings over time). Obviously, at some point, the individual also is trying to understand am I getting better or worse.
How does one do this when life is a verb while becoming aware of one’s unique gifts?
The challenge to connect as an individual and within an organization across the state and provide input, represent and work towards a more insightful populace into our health required a certain level of commitment. That would occur within the organization and individuals though it seems after I would realize my time in the organization and a few turnovers, the organization would be undermined by the “outcomes” of a regional community mental health care system from a different part of the state and so called “professionals”.
“The most obvious explanation for our results would be that clinical judgment, because of a bias toward positive treatment outcomes, tends not to reliably detect negative outcomes from the patient’s perspective,”
This idea the giver of services looks at the service of giving mainly from their perspective rather than the receiver’s is such a huge problem and one of the biggest harm producing in psychotherapy.
The therapist really needs to be more of instrumental in the process of giving service than “gainer” of the experience.
If you ever listen to most therapist, their reference is often their POV, their feelings, their interjections more than the client’s.
The difference between a good therapist and a bad therapist is that the good therapist is concerned with the perspective of the client, and a bad therapist is concerned with their own perspective. The bad therapist wants to look/feel good about their work. The good therapist wants the client to regain control of their own perspective. The only valid measure of success in a therapist is the empowered client’s satisfaction with the process.
Mentally ill patients have anosognosia and are therefore unable to reliably describe their experience. Only psychiatrists and their clinical judgement are accurate measures of treatment outcome.
I think this is the bias that underlies psychiatry’s disdain for client self-report measures.
It means they’d have to deal empathetically with the patient’s actual needs, and be willing to admit it when they didn’t know what they were doing, which is most of the time. That would be intolerable, because they’d lose their superior status and have to be a vulnerable human being, just like the client is. Ironically, my experience tells me that the key to actually BEING helpful to a client is the willingness to be a vulnerable, genuine, humble, fallible human being who is willing to meet them where they are at and not think you know more than them about their own problems.
These people in the article have no idea how utterly ignorant they sound, to those of us trying to create & inhabit the post-psychiatry world. This article is yet more proof that the system has FAILED, just as it was intended. Depression is a state of dis-empowerment. Hospitialization itself is dis-empowering. Duh! My God, how stupid are you people? Will you EVER WAKE UP?….
I have an interaction there, from a physician to whom I said that I hat detoriated after my stay at her ward. I got so worse that I had to give up my studies.
She snapped at this, saying: “what do you mean by we made you ill (I have not said it like this, i had written that I got worse and could not study more since the stay at the ward)? You were ill before. You mean that you didn’t improve.”
She thought, she wasn’t invalidating, but herself felt invalidated when I said that she is having a bad reading ability.
The first question is what constitutes an outcome and how can it possibly be measured? For the client, too often swayed her investment and clinician’s wishful thinking, easily can convince herself that great things are happening. I certainly thought that. Unfortunately, the world I inhabited didn’t change around me as I collected all these so-called insights.
True enough! When you are engaged in a very unscientific enterprise, it is almost impossible to define an outcome. But I’d still maintain that under such subjective circumstances, the only one who can even formulate an “outcome” is the client. Of course, any clinician who tries to manipulate his/her client into deciding they had a “good outcome” just to make the therapist feel better deserves to spend eternity in purgatory.
I’ve yet to meet a therapist aware of his own dominance signaling. Therapy too easily becomes infantilizing promising actualization, dominance pretending empowerment, and artifice simulating authenticity. I threw myself into the process, so “wanting to change,” and exited scammed by stagecraft, incantation and salesmanship. I hope I helped my therapists’ feel like Saviors and Shamans, because I got nothing out of it.