Standardized Evaluation in Clinical Practice
Dr. First describes this book, part of volume 22 of the Review of Psychiatry series edited by John M. Oldham and Michelle B. Riba, as “a compendium of the available rating scales, tests, and measures that may be useful in caring for patients with mental illnesses.” It contains five chapters by experts in the field.
The first chapter, “Is There a Place for Research Diagnostic Methods in Clinical Settings?” by M.R. Basco, has it that clinical psychiatric diagnoses are often wrong when compared with “gold standard diagnoses.” The reader is encouraged to use trained nurses administering research diagnostic interviews, such as the Structured Clinical Interview for DSM-IV. A web address is provided.
The second chapter, “Integrating the Assessment Methods of Researchers Into Routine Clinical Practice” by M. Zimmerman, establishes that comorbid conditions frequently remain undetected and reviews a range of evaluation tools. A major element is the high cost of psychiatrist’s time. One proposal is that less expensive mental health professionals can score diagnostic instruments before the psychiatric interview.
The third chapter, “Use of Structured Diagnostic Interviews in Clinical Child Psychiatric Practice” by C.P. Lucas, finds that the diagnoses achieved in ordinary child clinical practice may be problematic. Lucas says that the accuracy of diagnoses based on structured interviews is comparable to that of clinicians’ diagnoses and that there is a “cost advantage” in this approach.
The fourth chapter, “Risk Factors for Suicidal Behavior” by M.A. Oquendo and colleagues, provides a useful discussion of a more tightly focused problem. They provide a stress-diathesis model and suggest that a diathesis may be indicated by impulsivity, pessimism, substance abuse, lack of social support, and a history of suicide attempts. They point out that in routine clinical practice, previous suicide behavior is properly documented in less than one-quarter of admissions. They consider half a dozen instruments and provide a copy of the Columbia Suicide History Form.
The final chapter, “Nationwide Implementation of Global Assessment of Function as an Indicator of Patient Severity and Services Outcomes” by W.W. Van Stone and colleagues, is an account of the means used to achieve compliance in U.S. Department of Veterans Affairs facilities with the use of the Global Assessment of Functioning Test. This required training sessions, the development of software, and an incentive system tied to the directors’ bonuses.
This book, written by experts, gives the general reader an understanding of the state of the art of standardized psychiatric evaluation. I was somewhat disappointed, not with this book, but with the progress in the field. Each chapter ends with reservations. One justification for the use of standardized instruments is cost. However, it is not clear that more time spent with a nonpsychiatrist worker and less time spent with a psychiatrist will be more cost-efficient (or accurate) than more time spent with a psychiatrist. Instead of going around that problem by employing professionals whose time costs less, there is much to recommend in changing the system of reimbursement for psychiatrists. The book points out that the time spent on standardized instruments may be considerable. Although it is accepted that psychiatrists have paid insufficient attention to the history of suicidal behavior, completion of the full range of instruments recommended in the chapter on this topic would be impractical. The chapter dealing with the national implementation of the Global Assessment of Functioning Scale (a relatively simple tool) warns that the use of standardized instruments is no quick fix. We should also take into account that molecular and genetic testing may soon have an impact on psychiatric practice. This book is a valuable resource and is recommended to those who want/need to know more about standardized evaluation in clinical psychiatry.
