Abstract
Background:
Considering the importance of clinical rating scales in psychiatric evaluation and their academic relevance, this study assessed the extent to which they were utilized in a tertiary care teaching hospital during patients’ hospital stays.
Methods:
We did a consecutive sampling of patients’ records and retrieved data from medical records of the patients admitted with the diagnoses of schizophrenia, bipolar affective disorder (BPAD), and depressive disorder in the psychiatry wards. Data regarding the use of clinical rating scales (Brief Psychiatric Rating Scale (BPRS), Young Mania Rating Scale (YMRS), or Hamilton Depression Rating Scale (HDRS)) each week was collected and analyzed accordingly.
Results:
Out of 50 case records retrieved, the majority (60%) were male. The sample mean age was 37.76 ± 12.78 years. Forty percent of the sample records had schizophrenia, 38% had BPAD-mania, and 22% had depressive disorders. The sample had an average inpatient hospital stay of 17.68 ± 8.25 days. At baseline, only 54% were administered respective clinical rating scales. At the end of the first week, 42% were assessed using clinical rating scales. At the end of the second and third weeks, only 35.9.1% and 13.3% of patients were monitored by rating scales, and the utilization rate declined further, with a downward slump in subsequent weeks.
Conclusions:
Utilization of clinical rating scales was found to be low in our tertiary care teaching hospital. Postgraduate trainees need more exposure and formal training in applying psychiatric rating scales for better patient care.
Periodic monitoring of psychiatric patients using a clinical rating scale was found to be low even in tertiary care teaching hospitals. It is very important to audit ourselves, address the lacunae, and rectify them to improve our clinical practice to the recommended standards. In this time of change in healthcare practices, with the emphasis on quality-of-care indicators, psychiatrists should be encouraged to utilize rating scales. It is time for educational institutions to provide training in simple, efficient, and cost-effective outcome instruments.Key Messages:
Individuals across the globe experience mental health issues, making it crucial to accurately assess their symptoms for appropriate diagnosis, treatment, and ongoing support. Rating scales are tools that apply predefined criteria to assess an individual’s complaints and functioning. 1 The capacity to employ rating scales to identify prodromal or subsyndromal conditions during psychiatric evaluations would represent a significant advance in developing and evaluating preventive strategies for psychiatric disorders. 2 Rating scales serve as a valuable tool for mental health practitioners to evaluate symptoms, diagnose mental health conditions, gauge severity, guide treatment choices, and forecast prognosis and outcomes. 3
The rating scales emphasize certain standardized frameworks ensuring consistency across physicians and hospital settings.4,5 The main purpose of rating scales is to supplement our routine clinical interview and mental status examination and aid in screening, diagnosis, and assessment to make informed decisions. 6 Monitoring of clinical conditions using rating scales in hospital settings provides real-time indications and rating scales help predict the course and treatment strategies for the disorder.7,8 Judicious usage of validated rating scales often reduces subjective bias and provides quantitative measurement of clinical symptoms. 9 Hence, it indirectly helps therapists adhere to nonjudgemental approaches during the assessment of patients. It also guides the treating team in making treatment adjustments to quicken recovery10,11 and plays a vital role in research operational protocol.12,13
On the background of all these utilities of rating scales, there was a need to look into the extent of its actual utilization in routine clinical practice. Only a few studies from Western countries have reported the extent of usage of psychiatric rating scales in routine clinical practice.14–16 However, those studies were predominantly postal or mail-based survey questionnaires, and any audit or medical chart reviews did not objectively support results. Given hardly any available Indian studies in this domain and considering the importance of rating scales in psychiatric clinical evaluation and academic curriculum, we did this study to evaluate the extent of usage of rating scales in our inpatient settings.
Hypothesis
We hypothesized that clinical rating scales are routinely administered in teaching hospitals for all patients admitted with major psychiatric illnesses, such as schizophrenia, bipolar affective disorders (BPADs), and depressive disorders.
Aim
The aim of this study was to determine the extent of usage of psychiatric clinical rating scales in patients admitted with major psychiatric disorders, such as schizophrenia, BPADs, and depressive disorders.
Objectives
The objective of this study was to analyze the proportion of patients admitted with the diagnoses of schizophrenia, manic episodes, and depressive episodes who were administered the Brief Psychiatric Rating Scale (BPRS), Young Mania Rating Scale (YMRS), and Hamilton Depression Rating Scale (HDRS), respectively, at the baseline and every week till discharge.
Methods
The study was carried out in a tertiary care medical college hospital, which has an undergraduate course for 35 years and a postgraduate course in psychiatry for nearly 25 years. At the time of the study, there were six psychiatry consultants, two clinical psychologists, and twelve postgraduate students in psychiatry. The Institute’s Human Ethics Committee approved the study.
The study investigators retrieved the medical records of all the patients admitted to the psychiatry ward between 1 January and 30 April 2020. We started data collection in August 2020 and ended in September 2020. We reviewed the medical records and used a semi-structured proforma to collect data regarding the diagnosis of the patient, duration of stay in the hospital, whether any rating scales were administered on the day of admission or not, whether the scales were repeated at least once every week until the discharge of the patient, and if no scales were administered is there any reason mentioned for not administering the rating scale. Only the medical records of patients admitted to the psychiatry ward with International Classification of Diseases (ICD) Classification of Mental and Behavioural Disorders, 17 diagnoses of schizophrenia and BPAD, both manic and depressive episodes, and depressive disorders were included in the study. Medical records of patients with a duration of hospital stay of less than seven days and medical records of patients discharged against medical advice were excluded from the study, as the rating scales would have been administered less frequently if the inpatient stay period was very short. Finally, we included the medical records of 50 patients (Figure 1) that fulfilled our study criteria and were analyzed. The data was analyzed using the SPSS, 18 version 30.0.0 for Windows.
BPAD: Bipolar affective disorder; RDD: Recurrent depressive disorder.
The categorical data were described in frequency and percentage, whereas continuous variables such as age and duration of hospital stay were represented as mean and standard deviation (SD). We used the chi-squared and Fisher’s exact test to compare categorical variables and the Student’s t-test for continuous variables to compare the sample with the clinical rating scale assessment status. Bivariate analysis was done to analyze the possible association with any confounding factors such as age, gender, diagnosis of the sample, and duration of hospital stay. We used STROBE, 19 reporting guidelines for our cross-sectional observational study, and a checklist uploaded as ‘Supplementary online material’.
BPRS,20–22 YMRS,23,24 and HDRS 25 are commonly used validated clinical rating scales to evaluate the severity of symptoms and prognosis in patients with the diagnosis of schizophrenia, manic episodes, and depressive episodes, respectively.
Brief Psychiatric Rating Scale (BPRS)20–22
The 18-item version covers a broad range of areas, including thought disturbance, emotional withdrawal, retardation, anxiety, depression, hostility, and suspiciousness. The scale has a reliability coefficient of 0.56–0.87. It usually takes 15–30 minutes to administer the scale. It is applicable for all ages and retains the same form across all versions of this scale. The observer-rated English version scale was used in our hospital setting.
Young Mania Rating Scale (YMRS)23,24
This scale consists of 11 items. Every item receives a severity score, and four items are assessed on a scale from 0 to 8 (irritability, speech, thought content, and disruptive/aggressive behavior). The other seven items are assessed on a scale from 0 to 4, resulting in a cumulative score that ranges from 0 to 60. This scale demonstrates a strong inter-rater reliability of 0.93 and internal reliability of 0.8 to 0.91. Most of the Indian studies utilized this scale to monitor manic symptoms, and the English version of the scale was used in our inpatient hospital settings.
Hamilton Depression Rating Scale (HDRS) 25
The 17-item scale demonstrates strong inter-rater reliability (0.80–0.98), test–retest reliability (0.81), and validity (0.65–0.90) when compared to overall assessments of depression severity. It is the most commonly utilized clinician-rated depression assessment scale that requires 20–30 minutes for administration and is validated in the Indian population across different cultural settings. 24
Results
Baseline Characteristics of the Sample
Among the 50 medical records retrieved, the majority (60%) belong to males. The average age of the sample was 37.76 ± (SD = 12.78) years. Women had an average age of 39.55 years (SD = 13.13), while men had an average age of 36.30 years (SD = 12.54). Forty percent of the sample case records were found to have a diagnosis of schizophrenia, and 38% of case records were diagnosed as having manic episodes. The remaining 22% of patients’ records were found to be diagnosed with depressive disorders. The sample had an average inpatient hospital stay of 17.68 ± 8.25 days (Table 1).
Baseline Demographic Details of the Sample.
Baseline Assessment of Sample Using Clinical Rating Scales
Out of the 50 subjects in the study, only 27 patients (54%) had assessments with respective validated clinical rating scales at the time of admission. In the remaining 23 patients (46%), there was no baseline assessment using respective psychiatric rating scales.
Weekly Monitoring of Patients Using Clinical Rating Scales
At the end of the first week, only 42% of them were assessed using clinical rating scales, and the proportion of patients monitored using psychiatric rating scales further declined with a downward slump in subsequent weeks. At the end of the second and third weeks, nearly 64.1% and 86.7% of patients were not monitored by psychiatric rating scales, respectively. In the following weeks, this proportion of patients without rating scale monitoring increased further, as shown in Table 2 and Figure 2. Among subjects with assessments done at baseline and every week, we could not find any statistically significant association between positive assessment status and the sample’s age, gender, diagnosis, and duration of hospital stay (Table 1).
Rate of Monitoring of Patients Using Psychiatric Rating Scales During Hospital Stay.
aAs the patients get discharged, the number of sample declines during the subsequent weeks.
Clinical Rating Scale Assessment Status During Hospital Stay Across Every Week.
Discussion
In our study, we found that only 54% of patients were administered a rating scale at their initial evaluation. The number of patients assessed at least once a week with rating scales declined progressively during their hospital stay. This demonstrates the scanty usage of clinical rating scales, even in teaching hospitals. This was also evident in other previous Western studies that quantified psychiatrists’ use of rating scales.14–16 In a study done in Canada, 14 which looked into the usage of rating scales among consulting psychiatrists, 27% of psychiatrists had never utilized clinical rating scales in their experience. Only 50% of them had used rating scales to monitor patient progress and severity during pharmacotherapy and psychotherapy. Sixty-one percent of those who utilized rating scales commonly used HDRS at various intervals during the treatment regimen. Interestingly, 69% of them never used BPRS in their clinical practice. Also, in another study, 15 done in the United Kingdom to study the usage of outcome measures in their clinical practice, there were similar trends of below-average usage of clinical rating scales. Around 55.3% of them never used any rating scales in depressive disorders, and surprisingly, 72.9% had never used any rating scales in Schizophrenia patients. Only 10.5% and 6.5% routinely used validated clinical rating scales for affective and schizophrenia disorders, respectively.
Considering the modern trend toward evidence-based medicine, the usage of rating scales to quantify the outcome measures was a healthy practice.12,26 Practitioners have been encouraged to include them in their routine practice. 27 Many Western studies underline the importance of the administration of clinical rating scales in validating treatment strategies and responses.7,8 Periodic rating scale administration in hospital settings helps clinicians make decisions and achieve diagnostic accuracy, thereby adjusting treatment plans accordingly.6,28 Hence, scanty utilization of rating scales among practitioners would indirectly hamper the prospects of patients’ medical care.
Measurement-based assessment and outcomes are being increasingly recommended in mental health. 13 Frequent monitoring of patients’ symptoms using clinical rating scales enhances the patient’s satisfaction level and increases the therapist’s engagement with the patient. Routine usage of psychiatric rating scales in hospital settings also helps the therapist to explain the baseline severity level, provide a quantitative assessment of improvement during the hospital stay, and provide clear, understandable communication to patients’ family members and caretakers.28,29
Routine utilization of clinical rating scales reduces the subjective bias of therapists and develops mutual respect and empathy for patient conditions. 6 The cordial relationship between therapist and patient remains the cornerstone in the successful treatment of psychiatric patients. The usage of psychiatric clinical rating scales helps in improving the health outcome indicators and restoring the equilibrium of the doctor–patient relationship.29,30 The rating scales are only adjuncts to clinical interviews and do not replace the value of clinical interviews. However, learning to administer the scales during the training period of postgraduates helps the trainees to assess different domains of illness and not just focus on only the domains that they have learned till then.
Usually, teaching hospitals emphasize effective evidence-based medicine and standardized research operation protocol. Routine usage of clinical rating scales in tertiary care teaching hospital settings enables effective data collection and also helps in better evaluation and understanding of mental health conditions. 12 Despite being a teaching institution, our study’s findings reveal no universal usage of rating scales in psychiatric ward inpatient settings. However, this was notable even in other Western studies that failed to produce the difference between academic teaching centers and nonteaching hospital settings in terms of the administration of rating scales. 16
The main reason for the poor use of the clinical rating scale might be time constraints and inadequate documentation. However, to minimize the influence of these factors, our study included records of only inpatients and excluded records of patients with less than seven days stay and patients discharged against medical advice. Also, to rule out other confounding factors, we analyzed for a possible association between age, diagnosis, gender, and the duration of hospital stay with positive clinical rating scale assessment status at baseline and also every week and found out there was no statistical significance of the association.
Previous studies15,29 looked into the reasons for poor usage of rating scales in both outpatient and inpatient settings. They found various reasons, such as time-consuming nature, lack of value, and lack of enthusiasm. A surprising reason found by Oluboka et al. 14 was the reported lack of exposure to formal training in the administration of clinical rating scales; they indicated that 56% of the psychiatrists in their study reported not receiving any formal training in the administration of rating scales. 14
To summarize, psychiatric rating scales can effectively augment professional skills and supplement clinical experience with evidence-based medicine and research by enhancing diagnostic accuracy and comprehensiveness. Nevertheless, improper use or excessive dependence on rating scales may obscure the actual effects and result in possible misinterpretations. Hence, one should advocate with caution in emphasizing the periodic usage of clinical rating scales for psychiatric patients.
The limitations and challenges of our study include a small sample size and a target sample that included only inpatient records. Our study results fail to give information and details regarding the qualifications and experience of mental health professionals. Factors such as mental health professional level of expertise, his/her mental health service experience, and exposure to formal training in clinical rating scales may be influencing the administration of clinical rating scales for patients. This is a single-center study, and the results cannot be generalized to other teaching hospitals. The average duration of patients’ stay in our sample records was only around 17 days. Hence, these results cannot be generalized and may not apply to long-term inpatient care mental health establishments and nonteaching psychiatric hospitals. As we were only focusing on whether rating scales were utilized in evaluating the patients, we missed other important clinical correlates, such as changes in rating scale scores with every evaluation and the effect of treatment on rating scale scores.
Conclusion
Psychiatric rating scales serve as essential instruments for trained psychiatrists, clinical psychologists, and various mental health practitioners. From this study, we conclude that although recommended by guidelines, periodic monitoring of psychiatric patients using a clinical rating scale is often followed only sometimes, even in tertiary care teaching hospitals. However, the periodic utilization of clinical rating scales in routine practice with more formal training and exposure can reap benefits for patients in the context of treatment evaluation and therapeutic management. Also interestingly, considering the current developments of the Mental Health Care Act 2017, 31 and provisions of advance directives and nominated representatives, better effective health communication and healthy doctor–patient relationships will be the pillars of strength for successful therapeutic interventions. In the context of improved patient satisfaction and positive health experience, regular, improved, periodic monitoring of psychiatric patients using clinical rating scales will be the right step in the right direction toward patients’ welfare and optimal comprehensive care.
Supplementary Material
The supplementary material for this article is available online.
Footnotes
Acknowledgements
We want to thank all the supporting staffs who assisted during medical records retrieval and review process.
Data Availability Statement
The data supporting the findings of this study are available with corresponding author and can be produced on request.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Ethical Approval
We obtained approval from our Institutional Human Ethics Committee, PSGIMSR, Coimbatore (Ref No 014/276/IHEC).
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Informed Consent
Our study involves only cross—sectional retrospective review of medical case records and involves no human study participants. Hence informed consent was not applicable.
References
Supplementary Material
Please find the following supplemental material available below.
For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.
For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.
