Routine administration of validated outcome measures has not been shown to influence clinicians' behaviour. The recognition of emotional disorders seems to be increased only when there is some form of screening procedure, whereby an instrument is administered, scored by someone other than the clinician, and the results of those with high scores only fed back to the clinician.16
Increased recognition does not, however, necessarily translate into improved management of depression or improved outcome.
There are several explanations for the lack of effect in unselected patients. The first relates to the psychometric properties of questionnaires and clinicians' perception of their value. What is of most interest to clinicians in the context of routine care is predictive value—that is, the proportion of those predicted by the test as having the disease who turn out to have the disease—not sensitivity and specificity.21
Crucially, positive predictive value increases according to the prevalence of a disorder. Whereas unrecognised emotional disorders form a major portion of the clinical caseload in non-psychiatric services, their prevalence rarely exceeds 15%. Consequently only 50% of those patients with a positive screening result has a clinically important emotional disorder (“true positives”).10
Clinicians may intuitively recognise this and be unwilling to act on positive test results.22
This review shows that unselected questionnaire results add little to the clinical encounter. Calls for the routine application of such questionnaires in non-psychiatric settings3
seem therefore not to be supported.
A second explanation is that clinicians who have not been trained in psychiatry are not confident in dealing with emotional disorders. Supporting this conclusion is the observation that feedback is most effective when it is accompanied by an educational programme and provision of a dedicated outside referral agency that assumes responsibility for management.11
Our results also complement recent research, which shows that simple educational interventions such as the provision of guidelines on the detection and management of depression in primary care have little impact.23
However, more complex strategies for quality improvement, in which the feedback of individualised positive test results is accompanied by increased resources and local educational interventions delivered by opinion leaders, can result in improved outcome for depression.24
A third explanation relates to the methods employed in most of the included studies. In all but one, patients were randomised to have questionnaire results fed back to the clinician or not.11
It is possible that receiving feedback on some patients influences how other patients are managed. This cross contamination could dilute estimates of benefit. A more appropriate design would be a cluster randomisation study, whereby individual clinicians rather than individual patients are randomised.6
The largest and most striking result came from a study with several additional methodological problems, including inadequate randomisation, differences in the way in which cases were established between control and intervention arms, and difficulties generalising beyond the practice style of a single motivated doctor.8
Our results also show that more patients with emotional disorders would be recognised if every patient had a questionnaire administered, scored by someone other than the clinician, and only the positive test results fed back to the clinician, then. Clinicians therefore ignore raw scores on psychometric questionnaires when they have to add them up and interpret them themselves. This has implications for how screening tests should be implemented and evaluated in routine care settings. More user friendly formats for administration, such as computer based self completed questionnaires13
and the administration of these questionnaires by other staff are possibilities. However the resources used in administering, scoring, and feeding back results for all patients are substantial and may not be justified by the likely benefits.
What is already known on this topic
Much psychiatric morbidity goes undetected in general practice and general hospital settings
Self completed psychiatric questionnaires have acceptable validity and reliability and might be used as outcomes measures to guide clinical practice, yet research on the impact of results fed back to clinicians is contradictory
What this study adds
The routine administration of psychiatric questionnaires with feedback to clinicians does not improve the detection of emotional disorders or patient outcome, although those with high scores may benefit
The widely advocated use of simple questionnaires as outcomes measures in routine practice is not supported; more research is needed before this strategy is adopted