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The Reliability of Psychiatric Assessment: An Analysis

Graylingwell Hospital

J. Morrissey, M.D., D.P.M., Consultant, J. Towers, M.D., D.P.M., Consultant and J. Scrivener, M.B.E., D.P.H., D.P.M., Senior Hospital Medical Officer

Graylingwell Hospital, Chichester

ABSTRACT

1. Six groups of patients, each of 15 new referrals to the Chichester Mental Health Service, were independently examined by pairs of psychiatrists at approximately three-day intervals. The groups were homogeneous with respect to age, sex and social class.
   
2. Agreement on duration of present illness was attained in about 60 per cent.of patients, being lowest for the patients diagnosed as neurotic.
   
3. Agreement on family history was obtained in about 85 per cent. of patients, being lowest with those over 55 years of age.
   
4. Agreement on previous psychiatric illness was reached in about 70 per cent. of patients with higher agreement among those diagnosed as having an organic illness.
   
5. On comparing the assessments made on symptomatology, agreement values of between 85 per cent. (for depression) and 0 per cent. (for aggression, thought-disorder) were found. The final rank order correlated at a significant level with that for the incidence of the various symptoms.
   
6. Agreement on diagnosis, using an agreed list of 11 possible diagnoses, was attained at a specific level in about 65 per cent. of the patients and at a broader or generic level in a further 15 per cent. Agreement on diagnosis was strongly associated with agreement on previous history and with the number of previous illnesses. On the other hand there was no demonstrable association with agreement on symptoms or with the other variables mentioned. Highly significant discrepancies emerged between the agreement levels achieved in different diagnostic categories, being highest with organic patients and lowest with neurotics.
   
7. Agreement on therapy (based on a choice of 10 treatments) was found in 65 per cent. of the cases, with approximate agreement in a further 5 per cent. The level was considerably higher in the functional psychoses than in the remaining patients and in the former group it was also shown that agreement on therapy reflected diagnostic agreement, though this association could not be substantiated for the total sample. It was also shown that diagnosis has significant inferences for therapy. E.C.T. and psychotherapy were recommended with a far higher level of concordance (each about 75 per cent.) than was pharmacological therapy (40 per cent.).
   
8. No important differences could be demonstrated between the ability of the five psychiatrists taking part in reaching agreement with their colleagues on any of the variables enumerated above.
   
9. Comparison of our findings with those of other workers confirms that concordance of diagnostic opinion varies according to the diagnostic group and also suggests that higher levels are attained with more severely disturbed patients.