Web-Based Depression Assessment Elicits the Truth from Patients?

I found a couple of interesting articles about eliciting more reliable information from patients who are depressed. In the March 2012 issue of the Journal of Clinical Psychiatry, there was a survey about the high rate of untruthful information physicians get from depressed patients, as high as 70% [1]. Significant associations were female gender, younger age, and a lower degree of satisfaction in mutual communication. I’ve posted about this phenomenon before; see link Calling Me a Liar? « The Practical Psychosomaticist: James Amos, M.D.

I’ve recommended Dr. Mark Zimmerman’s use of standardized assessments of depression using his well-validated scale, the Clinically Useful Depression Outcome Scale (CUDOS) for quite a while now. Dr. Zimmerman and colleagues recently published a study in which the web-based version of the CUDOS performed as well as the paper-and-pencil version and seemed more acceptable to patients [2]. The 18 item CUDOS can be completed by patients in less than 3 minutes, can be rapidly scored, and assesses all the symptoms of major depressive disorder as well as global psychosocial functioning and quality of life. The web-based version or CUDOS-W might be a tool that would help capitalize on the “candor hypothesis”, which suggests that patients might be more truthful when responding to computer-administered tests.

Nothing replaces a strong, trusting therapeutic alliance between doctor and patient and to the degree that is lacking, it would be difficult to elicit reliable information about how a patient is doing regardless of how the data is gathered, whether by paper-and-pencil or web-based methods using depression rating scales. That said, in my opinion, the CUDOS-W is probably worth a look. According to the paper, there’s no charge to clinicians to use it and it’s available at web link Outcome Tracker and on my blogroll.

1. Norifusa Sawada, M., M. Hiroyuki Uchida, PhD,, et al. (2012). “How Successful Are Physicians in Eliciting the Truth From Their Patients? A Large-Scale Internet Survey From Patients’ Perspectives ” J Clin Psychiatry 73(3): 311-317.

Objective: How honestly patients report their symptoms and medication adherence to their physicians has not been adequately addressed in patients with depression. We therefore conducted a large-scale Internet survey in an effort to discover how successful physicians are in eliciting the truth from their patients and also to examine reasons for patients’ truth-concealing behaviors.

Method: 2,354 participants who had received treatment for depression within the past year and had been diagnosed with depression by Patient Health Questionaire were identified from 323,226 registrants at the Macromill database through screening procedures. Participants were asked to complete a questionnaire regarding their treatment for depression with a special focus on patient-physician relationship. This study was conducted from December 7 to 13, 2010, in Japan.

Results: 2,020 participants successfully completed the questionnaire. Overall, 70.2% of responders reported that they had withheld the truth from their physicians. A logistic regression model found significant associations of such a behavior with female sex (95% CI, 1.15–1.74; P = .001), younger age (95% CI, 0.49–0.97; P = .030), and a lower degree of satisfaction in mutual communication (95% CI, 3.17–6.58; P < .001). 69.2% and 52.6% of the participants refrained from telling about their “daily activities” and “symptoms,” respectively. Female participants were more likely to hide the facts concerning “adherence to prescribed medication” and “figures such as body temperature and weight.” 31.9% of participants had discontinued the treatment without consulting their physician, which was again more frequent in females, younger persons, and those who were not satisfied with communication with their physician.

Conclusions: While the findings obtained herein need to be replicated in other patient populations, a majority of patients with depression were reluctant to uncover the truth, which emphasizes the need for more fine-tuned suspicion among physicians about symptoms and medication adherence

2. Zimmerman, M. and J. H. Martinez (2011). “Web-based assessment of depression in patients treated in clinical practice: reliability, validity, and patient acceptance.” J Clin Psychiatry.

OBJECTIVE: Calls for the use of standardized assessments in clinical practice have been increasing. A Web-based administration of outcome assessments offers several potential advantages over paper-and-pencil assessments, such as patient convenience, reduced missing data, reduced costs, automatic scoring, and generation of large databases. The present study from the Rhode Island Methods to Improve Diagnostic Assessments and Services (MIDAS) project evaluated the acceptability, reliability, and validity of a Web-based administration of a depression scale in patients receiving ongoing care for depression. METHOD: From June 2009 to July 2010, fifty-three depressed outpatients completed a Web-based and a paper version of the Clinically Useful Depression Outcome Scale (CUDOS). The vast majority of patients met DSM-IV criteria for either major depressive disorder (n = 36) or bipolar disorder (n = 9). Patients were also asked to complete a brief 6-question survey of the acceptability of the 2 modes of scale administration. At the time of the visit, the patients’ psychiatrist completed the Montgomery-Asberg Depression Rating Scale (MADRS) and rated patients on the Clinical Global Impressions-Severity of Illness (CGI-S) scale and Global Assessment of Functioning (GAF). RESULTS: The correlation between the Web-administered and paper versions of the CUDOS was high (P < .001). The mean scores were similar on the paper and Internet administrations. The internal consistency of the paper and Internet administrations of the CUDOS was high (both values, Cronbach alpha = .93), and all item-scale correlations for the paper and Internet versions were significant (median for paper administration = 0.76; median for Internet administration = 0.74). The paper and Internet versions of the CUDOS were equally correlated with clinicians’ ratings on the MADRS, CGI-S, and GAF (all P values < .001). Patients reported high levels of satisfaction with Internet administration and preferred this method of monitoring outcome to paper administration in the office (all P values < .001). CONCLUSIONS: The results of this first study of the use of a Web-based system of monitoring outcome in routine clinical practice supported the reliability and validity of Internet administration of a depression scale, and patients clearly preferred Internet administration to completion of a paper-and-pencil questionnaire in the office.