The Business of Psychological Questionnaires

Questionnaires are certainly in vogue in mental health research.  Often they are referred to in technical-sounding jargon, for example it is common to call a questionnaire an "instrument"  or a "measurement tool."

There are good reasons to have well-standardized questionnaires.  In research, it is useful if people across the world are all using a similar type of questionnaire, so that comparisons can be made more easily and clearly.

In psychotherapy or other mental health practice, there is evidence that obtaining regular feedback from patients or clients can be valuable to improve the quality of the therapy, and to prevent mistakes.  One of the leaders in showing the importance of this is Michael Lambert, an esteemed psychologist and psychotherapy researcher from Brigham Young University.  In a nutshell, his research shows us that problems can occur in psychotherapy without the therapist realizing it:  the patient or client could be developing new symptoms, detaching or losing interest in the therapy, feeling upset or disappointed with the therapist, or even developing a life-threatening emergency, but the therapist may not know this, because it is not talked about or asked about in the session.  This could be because the patient is inhibited to share this information, but it could also be simply because the problem was never inquired about.  In therapy sessions, just like with any other interaction, one can follow a certain narrative pathway habitually, therefore missing things that could be quietly going wrong in the background.

So Lambert has developed a questionnaire called the OQ-45, which consists of 45 simple questions covering everything from mood, anxiety, relationship satisfaction, loneliness, drinking, family life, work life, cognition, and physical health.  The idea is for patients or clients to fill in this questionnaire frequently, maybe even before every therapy appointment, so that no potential evolving problem area would be "missed."   The questionnaire would only take a few minutes to fill out, and could be done in the waiting room before an appointment.    Samples of the OQ-45 can be found in an internet search.  


I believe that this type of questionnaire is useful.  Certainly we have to respect Lambert's many years of research, to acknowledge that feedback of this type can improve therapy.

But the therapeutic benefit of this is not due to some special property of the questionnaire itself!  And the therapeutic benefit does not require the sophisticated statistical analysis that is offered to purchasers of the questionnaire!  The benefit of this is simply to do a review of symptoms regularly with patients or clients.  

Questionnaires in psychology have become a business.  For hundreds of dollars, one can sign up to receive copies of a questionnaire, scoring manuals, or perhaps an on-line entry and scoring package, which may produce attractive graphs of results.

I believe that it is absurd--in most cases--to have to pay for something like this.  The therapeutic principle here is of simply keeping track of a wide range of symptoms or problems systematically.   The technology here is not a sophisticated x-ray machine or microscope -- rather, they are sets of simple questions such as "I'm a good person" or "My body hurts" (to be rated from 0-4).

I have jokingly thought of creating a questionnaire, to be marketed, with a full statistical analysis package and online access, called the "How Are You Doing" instrument (the HAY-D-1).  It would consist of a single question, "How are you doing?"  with the opportunity to choose from one of 5 responses.    Perhaps there could be a published article demonstrating its reliability, validity, and correlations with other established research instruments. 

Understandably, many researchers have worked long and hard to show useful results from their work.  And it could be very desirable for them to have a way to earn a financial reward from the fruits of their labor.  I suppose, in a free society, it is quite reasonable for people to attempt to sell such things, if people are willing to buy them.

But when there is this type of marketing and financial dealing going on, it can increase biases on the part of both the seller and the buyer.  The buyer, having paid good money for questionnaires or "instruments," is more likely to think highly of their acquisition, due to cognitive bias (think again of Daniel Kahneman's work showing such effects).  Perhaps therapists are more likely to rely on such purchased questionnaires rather than simply creating their own.

I think it could be useful, if questionnaires are to be used at all, to create custom symptom review questions.  There is also some evidence that questions about the therapeutic alliance could be pertinent to therapeutic progress; these are absent from many symptom review surveys, including the OQ-45.

A nice idea in CBT is to have the clients or patients be actively involved in assessing and planning their own progress, instead of having the therapist be the "assessor."  So, it could be a useful therapeutic exercise for clients or patients to design their own questionnaires, using their own language, and their own scale!  The therapist could encourage and suggest a wide range of categories of questions to be followed, covering areas of physical, social, occupational, cultural, and psychological health, as well as a category about the therapeutic alliance, but the questions themselves could be designed by the client or patient!    If statistical analysis was felt to be interesting or useful, we could easily design a simple app to create graphs, or use a spreadsheet -- we would not have to pay an extra fee for this!

So I support the idea of regularly conducting broad symptom reviews in psychotherapy, but I do not believe it is necessary to buy questionnaire packages.  It could be even better to design one's own package, or collaborate with a patient or client to design a custom, personalized survey.  

Quetiapine for non-psychotic depression and anxiety

I read a recent review last week which warned against the use of quetiapine for treating non-psychotic mood disorders.

Yet, I believe there are a number of reasons to consider quetiapine and similar medications for non-psychotic states:

1) there is a much lower risk of the medication causing mania or psychosis.  With antidepressants, there is always the risk of mania induction.  Quetiapine not only would not cause mania, it could protect against it.

2) the use of quetiapine could reduce the likelihood of other sedatives, such as benzodiazepines, being used as often.  Benzodiazepine dependence is very common.  Quetiapine is less "addictive."

3) the doses of quetiapine in non-psychotic states can often be very low (under 100 mg) causing a much lower risk of metabolic side-effects than full doses of 400-600 mg per day or more.

What about research evidence?

Mezhebovsky et al (2013) published results of a multi-centre study involving about 450 elderly patients, showing that quetiapine 50-300 mg (mean = 168 mg) daily for 11 weeks, led to significant improvements in generalized anxiety symptoms, compared to placebo.
( http://www.ncbi.nlm.nih.gov/pubmed/23070803  )
 As with most effective treatments, the medication group had about twice as much improvement as the placebo group.  It is true that sleep improvement could account for a significant proportion of the overall symptom score improvement, but there was also improvement in the other symptom domains.   There were no major metabolic side effect problems in the quetiapine group.  The most common side effect was somnolence (sleepiness).

A 2012 review by Sanford and Keating ( http://www.ncbi.nlm.nih.gov/pubmed/22519923 ) showed an abundance of evidence that quetiapine is beneficial for treating bipolar depression (typically at doses of 300 mg/day) and for preventing recurrences of any mood episode.  For those who benefit acutely from quetiapine, there is evidence that it is a more effective mood stabilizer--on its own--than lithium. 


In unipolar depression, quetiapine would be most commonly used when a standard treatment such as an antidepressant was not working well.  In a study by El-Khalili et al (2010), quetiapine up to 300 mg per day was added as an adjunct to previous therapy for non-remitting depression:
( http://www.ncbi.nlm.nih.gov/pubmed/20175941).  They showed a modest benefit of adding the quetiapine, particularly at a higher dose of 300 mg/d.    A nice component of this article is the inclusion of symptom subtypes.   Many critics would argue that quetiapine might simply be sedating, and improve sleep, leading to most of its benefit over placebo.  These results confirm that quetiapine improves sleep symptoms.  But there were also symptom improvements in other categories, such as pessimism, inner tension,  and concentration impairment.

In conclusion, I think that quetiapine deserves to be considered as a medication option for non-psychotic conditions.   In many cases, there are comorbidities or diagnostic uncertainties, in cases of depression.  Many studies exclude patients who have comorbidities, or who do not neatly fit into diagnostic categories.   Quetiapine is unlikely to worsen comorbid conditions, and may be beneficial for many.  This makes it a safe option to think about if there is uncertainty or complexity in the diagnosis.  Standard antidepressants in this situation may carry a higher risk of causing new problems, including agitation or a manic state.

 The risks of metabolic side effects, etc. need to be watched for carefully, with consideration of stopping or changing the plan if problems of this type arise.