Through measurement positive care in psychiatry is conquered

It is now two decades since Speer [1] released his book on mental health outcome evaluation. Over the past years, Positive Psychiatry [2] and Measurement-Based Care [3] have been established as major issues within mental health outcome evaluation to increase the quality of life in our patients but also with the ambitious aim of preventing the development of mental disorders.

The mental health outcome evaluation suggested by Speer [1] was an attempt to transfer the ‘scientific purity’ from randomized, placebo-controlled, clinical trials to evaluation of the effectiveness of the care of our patients in the daily treatment settings. Both Positive Psychiatry and Measurement-Based Care (MBC) are rooted in this ‘scientific purity’ of clinical research. Speer [1] has referred to validated patient-reported questionnaires such as the Hopkins Symptom Checklist (SCL-90) and the General Well-Being Scale (GWB) as well as to validated clinician-reported rating scales such as the Hamilton Depression Scale (HAM-D) and Brief Psychiatric Rating Scale (BPRS). In Measurement-based care of mental disorders, all these outcome scales are considered as item banks from which brief subscales with acceptable ‘cash values’ pragmatically can be transferred to Positive Psychiatry and MBC [3].

In 2015, we started after the release of the clinical handbook by Jeste and Palmer [2], to organize yearly symposia on Positive Psychiatry in Denmark. At our latest symposium in September 2017, we focused on MBC. It is the presentations from this symposium, we have collected for publication in the Nordic Journal of Psychiatry. In agreement with the Chief Editor, Martin Balslev Jørgensen, we have reformulated these presentations as research articles or reviews.

We are very pleased that Professor Dilip Jeste and his group have contributed with an opening overview of measurement science in positive psychiatry.

To complete this whole issue of the journal we have invited Professor Giovanni Fava and his group to illustrate the Well-Being Therapy, which should be considered as an important psychological treatment within Positive Psychiatry.

Many of the presentations at the symposium focused on the clinimetric validity of the domains to be used for the outcomes in measurement-based trials within Positive Psychiatry. The domain of the improvement in the clinician reported symptoms covers depression (HAM-D₆), and anxiety (HAM-A₆). The patient’s report of their symptom burden is a generic SCL-10 subscale including both depression and anxiety symptoms.

The domain of restored health-related quality of life has been covered by the World Health Organization Well-Being Scale (WHO-5) [3,4]. The domain of personal recovery has been found very important to measure both in nonpsychotic and in psychotic disorders. Personal recovery is an attempt to stimulate patients in whom our treatment only offers partial remission to transcend their residual symptoms to experience at a more favorable level of existence by positive coping strategies.

The Transcranial Pulsed ElectroMagnetic Fields (T-PEMF) has recently been approved by the Danish authorities for the treatment of refractory depression. The results of a postmarketing study with T-PEMF to refractory depression should have been presented at our symposium. However, this study was delayed. On the other hand, T-PEMF has also been evaluated for treatment in Parkinson’s disease in a placebo-controlled trial. An Hawthorne effect turned up as a pre-placebo improvement, which recently also has been identified as a problem in MBC trials. We therefore found it important to include this T-PEMF study of patients with Parkinson’s disease.

It is a dilemma when testing the proof of MBC trials that placebo-controlled studies are difficult to applicate. In his monograph on the placebo effect in clinical practice, Brown [5] has listed such components of psychotherapy as sympathetic listening, having a regardful attitude and a general encouragement in the contact with the patients to be very similar to the components of the placebo effects identified in the placebo-controlled clinical trials of antidepressive medication. These components are also core issues in Positive Psychiatry [2], where they are referred to as positive psychosocial factors (PPSFs), for example, resilience, optimism and social engagement. These important positive outcomes can be measured by the WHO-5. The Hawthorne effect should be much more intensively evaluated in MBC trials and in Positive Psychiatry.

In his introduction to gestalt psychology, Köhler [6] considers clinical psychology as a very young science compared to the physical science. When physics only had access to more qualitative and less accurate observations, they were still able, like Hans Christian Ørsted in 1820, to discover the deflection of a magnet in the neighborhood of an electric current [6]. With the subsequent development of the electromagnetic fields, quantitative measurements became possible. We are now two centuries after Ørsted able to perform such quantitative measurements in psychiatry by the clinimetric procedures referred to in this issue of the journal as item response theory models. Thereby, clinical psychiatry has reached the level of physical science when measuring the “mental blood pressure” of our patients. Only through clinimetric measurements, positive care in psychiatry is conquered.

Disclosure statement

The author has no conflicts of interests.