Dear Martin,
Yeah you are right there, the research area of Patient Reported Outcomes (PRO) in mental disorders and
conditions is not advanced as medicine and society might expect from a medical
specialty that does not rely on unequivocal biological indexes.
This delay may have been due to the difficulty to adequately define
and distinguish the domains of (i) the patients’ reports of symptoms and
associated impairments observed and described by the patient himself or herself
from (ii) the patients’ behaviors and observed associated impairments described
by the clinician/interviewer. PRO assessment in mental disorders and conditions
is to be disentangled from the assessment of the domain of the patients’
behaviors, performances and conduct observed by the clinician or somebody else:
this domain should focus only on “report that comes directly from the
patient”, in line with the assessment of PRO in medical disorders.
However, this neglected domain of mental health care is now being looked at urgently on both sides of the pond.
This specific domain of psychopathology, originally named by Jaspers
“phenomenology” and defined in terms of “Subjective Phenomena of Morbid Psychic
Life” - recently hypothesized extinct : Andreasen NC. DSM and the death of
phenomenology in America: An example of unintended consequences. Schizophr
Bull 2007;33(1):108-112. http://schizophreniabulletin.oxfordjournals.org/content/33/1/108.long
- is reformulated and advanced by contemporary psychiatric phenomenology as
(i) a component of the assessment of the symptoms (indicators) of the disorder
and of the diagnostic formulation (in combination with other components like
patient’s judgment and behaviour), and as (ii) the core of disorder-specific
“patient reported outcomes”, comparable to PROs of medical illnesses. This
reformulation enables the appropriate assessment of PROs in severe mental
disorders and schizophrenia in line with medical illnesses. For example, the
operational definition of the “passively received experiences” (the simplest,
most immediate PROs) of schizophrenia enables this domain to share the
characteristics of the “passively received experiences” of pain regarding
intensity, relief and frequency - Moscarelli M. Passive and Active
Schizophrenia: Toward a New Descriptive Micropsychopathology. Schizophr Bull
2009; 35(6):1183-96. http://schizophreniabulletin.oxfordjournals.org/content/35/6/1183.long
. - Pain has been recognized as a symptom that merits clinical attention in all
patients receiving care for any disorder by the NIH Clinical Center, Legal,
Ethics, and Safey Issues (http://www.cc.nih.gov/participate/patientinfo/legal.shtml):
“Every patient has the right to appropriate assessment and relief of
pain”. Similarly, the subjectively disturbing “passively received
experiences” of schizophrenia may share the right to be appropriately assessed
and targeted by treatment for relief. These are not my words, they are words of advice given to me by eminent conultants in mental health psychiatry.
As a NHS Commissioner, I strongly feel that the first step in getting these mental health PROMs is to map out standards for mental health services and insert them into our contracts with the mental health service providers,
just as they have done in Scotland:
Regards,
Ash
From: Martin Rathfelder <[log in to unmask]>
To: [log in to unmask]
Sent: Tuesday, 2 August 2011, 20:13
Subject: Re: "Reducing spending on low clinical value treatments"
If we only reward patient outcomes we won't be spending much on mental
health will we?