Patient-reported outcomes in psychiatry

Abstract

The recent trend for recognizing the need that patients actively participate in the assessment of the outcome of treatment is a welcome development, not only because it adds valuable data, but also because its recognition of the partnership role that the patients should have in research on outcome of mental illness.

Psychiatry is a discipline of medicine that deals with mental disorders. In their recognition, treatment, and prevention psychiatrists rely on their observations, and on communication with people who suffer from these disorders. Other disciplines of medicine have at their disposal a variety of laboratory investigations that help to reach the right diagnosis; psychiatry has few of these. It can use investigations that will make it possible to confirm the diagnosis of a comorbid physical illness or to discover a pathological process that presents itself with psychiatric symptoms; however, to make a diagnosis of most mental disorders psychiatrists have to rely on what the patients tell them.

It would therefore appear to be logical to expect that psychiatrists will rely on patients' reports when assessing the outcome of their interventions and the effects of their treatment; this, however, is only rarely the case. Psychiatrists usually rely on their assessment of the patients' condition, basing this on the presence and severity of psychiatric symptoms. They take the impairments in the performance of personal and social roles of their patients into account when assessing outcome, but see this as an additional set of information, understandable in relation to symptoms which they have recognized. They do not accept the notion that the patients' statements about how they feel and what they think about the effectiveness of the therapy that was offered to them is equivalent or more salient in the assessment of outcome than the psychological symptom profile that they have constructed.

Reliance on patients' reports in assessing the outcome of mental illness or its treatment undoubtedly leads to a more comprehensive and valid assessment of their condition. Yet, this way of proceeding raises several additional questions. The first of these concerns the limits of the physicians' professional expertise: society and its services until now considered that medically qualified physicians are the final arbiters of the state of health of individuals whom they examined. A change of this understanding of the role of doctors would have a number of consequences. Some of these could be legal, for example in relation to the assessment of testamentary competence or legal responsibility for unlawful acts; others would relate to health and disability insurance questions; others still to the capacity to perform in specific social roles.

A more substantial issue that is linked to the reliance on patients' statements in assessing the presence or absence of illness (and in measuring the quality of outcome of treatment) is the definition of mental health. For many the mental health of an individual is defined by the absence of mental illness and by the capacity of the individual to perform in personal and social roles. If this definition is accepted, it will be necessary to consider the patients' statements about the outcome of treatment as one of the determinants of their mental health. An alternative that is in many ways more attractive is to define mental health as an inner equilibrium that exists regardless of the presence or absence of illness or impairment. If this notion is accepted, mental health could coexist with mental illness and help the individual to overcome illness or to find ways to live with it. With such a view, statements of patients with mental illness about their condition would have an even greater credibility and importance because they would be separated from the background of mental health and thus more objective, related to illness and not to overall mental health and functioning.

The increasing acceptance of recovery from mental illness as a central goal of treatment is directly related to such a way of viewing illness and its consequences. Making the capacity of living with impairments and illness a goal of treatment equivalent to that of removing illness is of particular importance for psychiatry, because its currently available treatments are still imperfect, and most mental disorders have a tendency to assume a chronic course. It is therefore very good news that patients' statements are beginning to be given the weight that they deserve; taking them seriously into account will make psychiatric interventions more effective and patients' lives more tolerable.

Dialogues in Clinical Neuroscience and the coordinator of this issue deserve every praise for bringing together an illustrious group of scientists and practitioners to write about the challenges and benefits of considering patients' reports in the assessment of outcome of treatment and in clinical practice. It is to be hoped that this issue of the journal will make practitioners and researchers working in different parts of the world accept and use all the information that their patients can give them, and thus make their work and the life of their patients more productive and satisfying.