Informative value of referral letters from general practice for child and adolescent mental healthcare

Although referral letters (RLs) form a nodal point in a patient's care journey, little is known about their informative value in child and adolescent mental healthcare. To determine the informative value of RLs to child and adolescent psychiatry, we conducted a chart review in medical records of minors registered at specialized mental healthcare between January 2015 and December 2017 (The Netherlands). Symptoms indicated in RLs originating from general practice (N = 723) were coded and cross-tabulated with the best estimate clinical classifications made in psychiatry. Results revealed that over half of the minors in the sample were classified in concordance with at least one reason for referral. We found fair to excellent discriminative ability for indications made in RLs concerning the most common psychiatric classifications (95% CI AUC: 60.9-70.6 for anxiety disorders to 90.5-100.0 for eating disorders). Logistic regression analyses suggested no statistically significant effects of gender, age, severity or mental healthcare history, with the exception of age and attention deficit hyperactivity disorders (ADHD), as RLs better predicted ADHD with increasing age (OR = 1.14, 95% CI 1.03-1.27). Contextual problems, such as difficulties studying, problems with parents or being bullied were indicated frequently and associated with classifications in various disorder groups. To conclude, general practitioners' RLs showed informative value, contrary to common beliefs. Replication studies are needed to reliably incorporate RLs into the diagnostic work-up.

Experts’ Failure to Consider the Negative Predictive Power of Symptom Validity Tests

Feigning (i.e., grossly exaggerating or fabricating) symptoms distorts diagnostic evaluations. Therefore, dedicated tools known as symptom validity tests (SVTs) have been developed to help clinicians differentiate feigned from genuine symptom presentations. While a deviant SVT score is an indicator of a feigned symptom presentation, a non-deviant score provides support for the hypothesis that the symptom presentation is valid. Ideally, non-deviant SVT scores should temper suspicion of feigning even in cases where the patient fits the DSM’s stereotypical yet faulty profile of the “antisocial” feigner. Across three studies, we tested whether non-deviant SVT scores, indeed, have this corrective effect. We gave psychology students (Study 1, N = 55) and clinical experts (Study 2, N = 42; Study 3, N = 93) a case alluding to the DSM profile of feigning. In successive steps, they received information about the case, among which non-deviant SVT outcomes. After each step, participants rated how strongly they suspected feigning and how confident they were about their judgment. Both students and experts showed suspicion rates around the midpoint of the scale (i.e., 50) and did not respond to non-deviant SVT outcomes with lowered suspicion rates. In Study 4, we educated participants (i.e., psychology students, N = 92) about the shortcomings of the DSM’s antisocial typology of feigning and the importance of the negative predictive power of SVTs, after which they processed the case information. Judgments remained roughly similar to those in Studies 1–3. Taken together, our findings suggest that students and experts alike have difficulties understanding that non-deviant scores on SVTs reduce the probability of feigning as a correct differential diagnosis.

Decision making biases in the allied health professions: A systematic scoping review

Objectives

Cognitive and other biases can influence the quality of healthcare decision making. While substantial research has explored how biases can lead to diagnostic or other errors in medicine, fewer studies have examined how they impact the decision making of other healthcare professionals. This scoping review aimed to identify and synthesise a broad range of research investigating whether decisions made by allied health professionals are influenced by cognitive, affective or other biases.

Materials and methods

A systematic literature search was conducted in five electronic databases. Title, abstract and full text screening was undertaken in duplicate, using prespecified eligibility criteria designed to identify studies attempting to demonstrate the presence of bias when allied healthcare professionals make decisions. A narrative synthesis was undertaken, focussing on the type of allied health profession, type of decision, and type of bias reported within the included studies.

Results

The search strategy identified 149 studies. Of these, 119 studies came from the field of psychology, with substantially fewer from social work, physical and occupational therapy, speech pathology, audiology and genetic counselling. Diagnostic and assessment decisions were the most common decision types, with fewer studies assessing treatment, prognostic or other clinical decisions. Studies investigated the presence of over 30 cognitive, affective and other decision making biases, including stereotyping biases, anchoring, and confirmation bias. Overall, 77% of the studies reported at least one outcome that represented the presence of a bias.

Conclusion

This scoping review provides an overview of studies investigating whether decisions made by allied health professionals are influenced by cognitive, affective or other biases. Biases have the potential to seriously impact the quality, consistency and accuracy of decision making in allied health practice. The findings highlight a need for further research particularly in professional disciplines outside of psychology, using methods that reflect real life healthcare decision making.