Web audio at CurrentPsychiatry.com Dr. Gupta discusses how he uses behavioral health rating scales in his clinical practice Using rating scales in a clinical setting: A guide for psychiatrists Consider these brief, easy-to-use behavioral health rating scales to guide diagnosis, monitor care n the current health care environment, there is an increas- ing demand for objective assessment of disease states.1 IThis is particularly apparent in psychiatry, where docu- mentation of outcomes lags that of other areas of medicine. In 2012, the additional health care costs incurred by per- sons with mental health diagnoses were estimated to be $293 billion among commercially insured, Medicaid, and Medicare beneficiaries in the United States—a figure that is 273% higher than the cost for those without psychiatric diag- noses.2 Psychiatric and medical illnesses can be so tightly linked that accurate diagnosis and treatment of psychiatric disorders becomes essential to control medical illnesses. It is not surprising that there is increased scrutiny to the ways FRESNO BEE/CONTRIBUTOR in which psychiatric care can be objectively assessed and monitored, and payers such as Centers for Medicare and Julie M. Wood, PhD Medicaid Services (CMS) increasingly require objective doc- Consultant Medical Liaison, Neuroscience umentation of disease state improvement for payment.3 Lilly USA, LLC Indianapolis, Indiana Support for objective assessment of disease derives from the collaborative care model. This model is designed Sanjay Gupta, MD Clinical Professor to better integrate psychiatric and primary care by Departments of Psychiatry (among other practices) establishing the Patient-Centered SUNY Upstate Medical University Medical Home and emphasizing screening and monitor- Syracuse, New York SUNY Buffalo School of Medicine and Biomedical Sciences ing patient-reported outcomes over time to assess treat- Buffalo, New York 4 ment response. This approach, which is endorsed by the Member of CURRENT PSYCHIATRY Editorial Board American Psychiatric Association, is associated with sig- nificant improvements in outcomes compared with usual care.5 It tracks a patient’s progress using validated clinical rating scales and other screening tools (eg, Patient Health Disclosures The authors report no financial relationships with any company whose products are mentioned in Current Psychiatry this article or with manufacturers of competing products. Vol. 16, No. 2 21 Questionnaire [PHQ-9] for depression), an • Objectivity. The ability of a scale to approach that is analogous to how patients obtain the same results, regardless of who with type 2 diabetes mellitus are moni- administers, analyzes, or interprets it. 6 tored by hemoglobin A1c laboratory tests. • Reliability. The ability of a scale to An increasingly extensive body of research convey consistent and reproducible infor- supports the impact of this approach on mation across time, patients, and raters. treatment. A 2012 Cochrane Review asso- • Validity. The degree to which the scale Clinical ciated collaborative care with significant measures what it is supposed to measure rating scales improvements in depression and anxiety (eg, depressive symptoms). Sensitivity outcomes compared with usual treatment.7 and specificity are measures of validity Despite these findings, a recent and provide additional information about Kennedy Forum brief asserts that behav- the rating scale; namely, whether the scale ioral health is characterized by a “lack of can detect the presence of a disease (sen- systematic measurement to determine sitivity) and whether it detects only that whether patients are responding to treat- disease or condition and not another ment.”8 That same brief points to the many (specificity). Clinical Point easy-to-administer and validated rating • Establishment of norms. Whether a scale Not using scales scales and other screening tools that can provides reference values for different clini- reliably measure the frequency and sever- cal groups. or screening tools ity of psychiatric symptoms over time, and • Practicability. The resources required to denies clinicians vital likens the lack of their use as “equivalent administer the assessment instrument in information, such as to treating high blood pressure without terms of time, staff, and material. patient’s response using a blood pressure cuff to measure if a In addition to meeting these quality patient’s blood pressure is improving.”8 It criteria, selection of a scale can be based to treatment is estimated that only 18% of psychiatrists on whether it is self-rated or observer- and 11% of psychologists administer them rated. Advantages to self-rated scales, routinely.9,10 This lack of use denies clini- such as the PHQ-9, Mood Disorder cians important information that can help Questionnaire (MDQ), and Generalized detect deterioration or lack of improve- Anxiety Disorder 7-item (GAD-7) scale, ment in their patients. are their practicability—they are easy to Psychiatry is replete with rating scales administer and don’t require clinician or and screening tools, and the number of staff time—and their use in evaluating competing scales can make choosing a mea- and raising awareness of subjective states. sure difficult.1 Nonetheless, not all scales However, reliability may be a concern, are appropriate for clinical use; many are as some patients either may lack insight designed for research, for instance, and are or exaggerate or mask symptoms when lengthy and difficult to administer. completing such scales.13 Both observer This article reviews a number of rating and self-rated scales can be used together scales that are brief, useful, and easy to to minimize bias, identify symptoms that administer. A framework for the screen- might have been missed/not addressed ing tools addressed in this article is avail- in the clinical interview, and drive clini- able on the federally funded Center for cal decision-making. Both also can help Integrated Health Systems Web site (www. patients communicate with their provid- integration.samhsa.gov). This site pro- ers and make them feel more involved in motes the use of tools designed to assist in clinical decision-making.8 Discuss this article at screening and monitoring for depression, The following scales have met many www.facebook.com/ anxiety, bipolar disorder, substance use, of the quality criteria described here and CurrentPsychiatry and suicidality.11 are endorsed by the government payer system. They can easily be incorporated into clinical practice and will provide Quality criteria for rating scales useful clinical information that can assist The quality of a rating scale is determined in diagnosis and monitoring patient Current Psychiatry 22 February 2017 by the following attributes12: outcomes. Patient Health Questionnaire episodes earlier in life.21 Nonetheless, PHQ-9 is a 9-item self-report question- its specificity of >97% means that it will naire that can help to detect the presence effectively screen out just about all true of depression and supplement a thorough negatives.18 psychiatric and mental health interview. It scores the 9 DSM-IV criteria for depression on a scale of 0 (not at all) to 3 (nearly every Generalized Anxiety Disorder day). It is a public resource that is easy to 7-item scale find online, available without cost in sev- GAD-7 scale is a brief, self-administered eral languages, and takes just a few minutes questionnaire for screening and measur- to complete.14 ing severity of GAD.22 It asks patients to PHQ-9 has shown excellent test–retest rate 7 items that represent problems with reliability in screening for depression, and general anxiety and scores each item on normative data on the instrument’s use a scale of 0 (not at all) to 3 (nearly every are available in various clinical popula- day). Similar to the other measures, it is tions.15 Research has shown that as PHQ-9 easily accessible online. depression scores increase, functional Research evidence supports the reli- Clinical Point status decrease, while depressive symp- ability and validity of GAD-7 as a Reliability of these toms, sick days, and health care utiliza- measure of anxiety in the general popu- tion increase.15 In one study, a PHQ-9 score lation. Sensitivity and specificity are 89% scales may be a of ≥10 had 88% sensitivity and specificity and 82%, respectively. Normative data concern as some for detecting depression, with scores of 5, for age and sex specific subgroups sup- patients may lack 10, 15, and 20 indicating mild, moderate, port its use across age groups and in both insight or exaggerate moderately severe, and severe depression, males and females.23 The GAD-7 performs or mask symptoms respectively.16 In addition to its use as a well for detecting and monitoring not screening tool, PHQ-9 is a responsive and only GAD but also panic disorder, social reliable measure of depression treatment anxiety disorder, and posttraumatic stress outcomes.17 disorder.24 Mood Disorder Questionnaire CAGE questionnaire for detection MDQ is another brief, self-report question- of substance use naire that is available online. It is designed The CAGE questionnaire is a widely-used to identify and monitor patients who are screening tool that was originally devel- likely to meet diagnostic criteria for bipo- oped to detect alcohol abuse, but has lar disorder.18,19 been adapted to assess other substance The first question on the MDQ asks if the abuse.25,26 The omission of substance abuse patient has experienced any of 13 common from diagnostic