Questionnaires Give Us Data; They Do Not Tell Your Story

Another questionnaire

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My patient came in to tell me how her antidepressant was working. Her mood seemed brighter, but she told me things were no better. “Maybe I need a different medicine,” she said. I reviewed specific symptoms of depression and she maintained that there was no improvement.

At this juncture, I pivoted to my formula for what to do when I am unsure about how someone is doing. I read back to her exactly what she told me on her first visit. “I just am not myself. Everything feels like a struggle. I cry at TV shows and snap at my kids. Nothing makes me happy.” After hearing this, she said, “Oh, that’s not me at all. Those things are gone.”

Scenarios like this played out often in my office. A person’s own words capture their life in their language and are as recognizable to them as their reflection in a mirror.

Nonetheless, more and more clinicians depend on questionnaires as they are pressed for time and must cover a great deal of ground. In addition, the internet hosts many sites with questionnaires that report a diagnosis or problem with the click of a mouse.

There are certainly places for questionnaires in mental health practice, but where and when needs some fleshing out. I will focus on self-rated questionnaires (filled out only by patients; clinicians do not participate) as they are commonly used now in both medicine and mental health. I am not looking at the questions about medical history, medicines, and allergies that all clinicians use for background purposes. What I have in mind are questionnaires used specifically to diagnose a mental health problem.

Questionnaires are tools—and like any tool, they have their uses and limitations. The most important limitation is they do not tell the story of what has happened to you. How a problem snuck up on you, what may have sparked its development, what symptoms bothered you the most, how it interfered with your life, and so on. These questions are not overly personal or subjective. They are at the core of what has happened, what is wrong, and how your life might be improved.

Another important issue with questionnaires is that when self-rated, they become overly sensitive. That is, people are more likely to answer “yes" to many questions. As there are no follow-up questions, it may seem like someone has more problems than they really do. We have seen this with bipolar disorder.

There are things questionnaires do very well.

1. Screening: A few well-worded questions can flag people who may have a specific problem. This is particularly helpful in primary care and in vulnerable populations, such as cancer and heart disease, where a patient’s state of mind could be overlooked due to other urgent concerns.
2. Following changes during treatment: A snapshot of where things are sets up a helpful way of identifying change. This is vital in research and can be adapted for clinical situations.
3. Symptoms that manifest in many different ways: Some symptoms show themselves in so many ways it is easy to miss in a broad interview. ADHD and psychosis are key examples of this. Asking 20 or 30 questions will likely pick up a problem.

As I mentioned above, questionnaires do not focus on your experience. This does not imply some lofty sense of personal meaning, just how something manifests in your body, mind, and life.

When I go to a specialist, I may get several sheets with the usual background questions about medicines, allergies, etc. However, each medical specialist asks their own questions.

My cardiologist, for example, asks me about things that concern him. Do I have chest pain? Shortness of breath? Palpitations? He wants to hear what I say and how I say it in order to ask follow-up questions. If I give positive answers, he must dig deeper for details. Do I really have chest pain or a muscle strain? Palpitations or too much coffee?

This is most relevant in mental health work. Our questions are about deep subjective experience. All positive answers (“Yes, I sleep terribly”) or pertinent negatives (“No, I am no longer suicidal”) need follow-up. Each answer raises a follow-up question to clarify, explore an implication, or expand on an important subject.

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For the person above who is sleeping terribly, does she stay in bed? Drink coffee at night? Work very late? Nap during the day? As you can see there is much to learn before we simply say that she has insomnia.

As for the non-suicidal person, when did this change? Does she mean she no longer has a plan or has no thoughts at all about suicide? There is clearly much to clarify here.

When I was teaching psychiatric trainees, I would often surprise them by saying that I was most interested in the second thing they did. Not the first medicine they gave someone, but the one used if the first did not work. Similarly, not the first question asked but the follow-up question. This showed an understanding of the problems at hand, rather than a memorized plan.

Although always important in healthcare, a good relationship is most essential in mental health care, even at the first meeting. A distracted, discourteous clinician does not help you marshal complete answers, while a warm, interested one helps you to participate as openly and thoroughly as you can. In mental health care, the relationship is the conduit for the flow of information between patient and clinician.

If the relationship is the conduit, language is what flows through it. But language naturally contains much ambiguity, especially regarding personal experience. This is where the know-how of the clinician comes in.

I’ll take this opportunity to undo a common, but misleading saying in psychiatry. This is not the “art of psychiatry.” It is not based on creativity and self-expression. Rather, it is the “skill of psychiatry.” Good training and practice produce skill—whether in a therapist, surgeon, cook, or carpenter.

While we do not have blood tests and X-rays, collecting detailed information is, fortunately, enough to help with many clinical situations. This is primarily done with an interview or conversation.

But other sources are very valuable. These include questionnaires, records of past care, and people close to the patient. All of these should be used if necessary. These different sources make for a cohesive and revealing narrative about a life and what has happened to it.

Aside from good treatment, the best thing any clinician can do for a patient is to get a clear and thorough story and write it down. This will benefit them in their current situation and for years to come. Understanding how to get the facts for the story is the first step. Questionnaires have a place here, but it is secondary to a face-to-face discussion where a person can answer questions about their life with their own words.