Ye, Who Are About to Screen: I Salute You
The APA DSM-5-TR Level 1 crosscutting measure gets it right
My wife works at an electronic health record company. She does not do this because it's just a job. She's dedicated to measurement. Today, that company, Osmind, and my professional society, the APA, have an announcement.
I'm in love with measurement also. One of the problems with measurement in psychiatry is that we have a lot of screening.. for very few things. Screening is a way to help look at broad populations, people not yet diagnosed with the disorder, and figure out who might have the problem.
The Patient Health Questionnaire-9 (PHQ-9) is a really common screening tool for depression, and it was invented by a drug company to make sure more people would get prescribed their drug.
This is the problem. Screening tools that build in bias over-diagnosis or under-diagnosis. If you have a screening tool for psychopathology, you'd want to screen for a broad array of problems people could have, not just one problem.
If you only screen people for depression, you make a lot of depression diagnoses, but you miss everything else.
The American Psychiatric Association had a mission to deal with this problem. They developed a measure, the APA DSM-5-TR Level 1 cross-cutting measure, that asks the following questions:
It's one or two questions each about a broad array of problems. This lets a health professional get a sense of where they're going to need to go diagnostically, past just “depression anxiety.”
This is crucial.
Has anyone seen the show “Baby Reindeer?” Anyone watching that show, which by the way I couldn't get through, because of trauma, will notice that there is stalking depicted. people want to talk about stalking and they use the words, “That's crazy!”
I am not here to opine on the use of the word “crazy” in general use, and I don't want anyone to feel belittled. I want to point out that if you only ask the question “Do you have a little interest or pleasure in doing things” to an individual portrayed in Baby Reindeer, you have a lot of important other domains of problems.
Depending on which character you asked, you get different questions using the above crosscutting measure which cuts across various domains of problems. In short, if you screen appropriately, you can get closer to a lot faster. The person getting stalked in the TV show is going to answer those questions differently than the person doing the stalking. What kind of “crazy” is a crucial question for physicians to answer, and the crosscutting measure is a great way to address this at scale. Except it wasn't being used at scale. A lot of work went into it, I am proud to say that today, thanks to my wife's work at Osmind, I have access to the APA crosscutting that I can just click and send people and a little bit more a little bit more frequently.
This is awesome. The ability to measure is the ability to know. Before we had a stethoscope, we couldn't know what was wrong with people’s hearts. We had our ears—we could've just put them on someone's chest, but it's awkward, so people did it less. The crosscutting is a stethoscope for psychiatry. It might not be an echocardiogram, and that's not the point. We need to start with something. And having it built into my EHR, it's awesome.
Yes, I have a conflict of interest here. My wife works at the company that made that happen. But I have another emotional conflict—this tool desperately needs to get into the hands of all of us in the field so that we can use it, easily.
It's a thing today. I'm excited about it.
Reminder— this Sunday, May 5th, I have a Frontier Psychiatrists Live Event…Rapid Acting Mental Health Treatment 2024 NYC. Ticket Link, is right there.