September 15, 2011

Are We ‘Winging It’ in Mental Health? Using Checklists to Improve Care for Consumers

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Kelli Harding, MD

Columbia University Medical Center, New York, NY


Imagine on your next flight, while settling into your seat, overhearing that your pilot has decided to forgo the aviation industry standard pre-flight checklist and will rely instead only on his expert knowledge from years of flying. While, odds are, you’d still make your destination, you may wonder why he would risk it with all those lives at stake? After all, he is human.

For mental health clinicians, it is uncommon to utilize checklists with consumers, despite numerous validated measures available for a variety of conditions. As a field, we rely on the concept of a checklist, the Diagnostic and Statistical Manual of Mental Disorders (DSM), to communicate among clinicians and guide diagnosis and treatment. Yet, the DSM-IV-TR has nearly 400 diagnoses, with thousands of specific criteria, and to commit them fully to memory for instant recall in any given clinical interview without an occasional lapse is superhuman. Even with the most frequently used criteria, such as the 9 for a major depressive episode, it can be easy to forget to ask about guilt or concentration every time when interacting with the complex person in front of you. Checklists are not perfect, but neither are we.

Incorporating ‘tools’ such as checklists or standardized measures into practice, also known as measurement-based care (MBC), is a way to ensure that the simple stuff has not been overlooked so the clinician can focus attention on the patient. It doesn’t replace an expert clinician’s opinion. It only augments it. For the airline pilot, experience and knowledge are critical to a safe journey, especially when the unexpected arises, yet it would seem senseless and risky to his passengers to abandon performing a routine checklist except in exceptional circumstances. Similarly, patients rely on doctors’ experience and knowledge, and the use of checklists and measures can ensure that simple, avoidable human errors are prevented.

While system issues influence the adoption of measures into routine mental health care,1 clinicians’ attitudes also play a role. Since I became interested in how MBC could improve standards for the field during my clinical research fellowship at Columbia, I’ve learned to brace myself for the strong reactions I get from colleagues on this topic. Aside from the fears of “cookbook medicine,” many clinicians find something offensive about the idea that an expert with years or decades of specialized training and practice needs to utilize a checklist or measure. The mental health field is not alone in this attitude; doctors across all specialties over time have been reluctant to embrace routine measures. After all, it wasn’t physicians who made monitoring vital signs, such as blood pressure, standard—it was nurses.2

The next time a patient asks you about using a checklist or standard measure in his or her care, resist the temptation to say, “Only researchers use measures.” Try it out. It may offer you a different perspective on the individual in front of you. Measurements and self-report checklists are an opportunity to partner with patients and engage them in their own health. Clinicians navigate the care of many patients daily, and, as with pilots, checklists provide backup to ensure that patients land safely in recovery.

Financial disclosure:Dr Harding had no relevant personal financial relationships to report.

Acknowledgment: The author would like to acknowledge Dr Harold Alan Pincus for offering thoughtful comments on the draft of the blog.


1. Harding KJ, Rush AJ, Arbuckle M, et al. Measurement-based care in psychiatric practice: a policy framework for implementation. J Clin Psychiatry. 2011;72(8):1136–1143. Abstract

2. Gawande A. The Checklist Manifesto. London, UK: Profile Books; 2009. Accessed September 14, 2011.​

Category: Mental Illness
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22 thoughts on “Are We ‘Winging It’ in Mental Health? Using Checklists to Improve Care for Consumers

  1. When I started working in clinical trials I became a convert to the value of the checklists for psychiatry. Especially in the evaluation of suicidal patients, using a clinical checklist shows that the right questions were asked. Combining this with the doctor’s skills and experience can only benefit patient care.
  2. I too like the check lists but when that is all there is wich is happening now with computer records, the patient’s record reads like the DSM. (But I love the computer records on the computer or printed out as they are legible.) There also has to be specific personal narrative data also. The group sessions are cut and paste and uninformative too often and if printed out makes a bulky record and if the patient is new to me gets awfully difficult to find pages that have some narrative detail to documment past unique “content” or history for the patient and to compare what the patient is saying to me now with what she was troubled by in the recent past.
  3. i fully support the use of checklists. the obstacle is in the management and administrative levels. they need to be convinced about its value and efficacy and then fully embrace it.
  4. I don’t think diagnostic criteria or symptom monitoring scales are quite analgous to the safety checklists used in aviation and found equally valuable in so many other areas including medicine. Those are process oriented checklists at a level above the more context specific content oriented diagnostic criteria list and are used to standardize your work flow process across diagnoses and encounters to eliminate critical errors of omission. The concept properly understood is quite adptable to outpatient medicine including psychiatry. I don’t think such a checklist would include “ask about guilt” as that is not a critical part of the workflow for every encounter, but “suicide risk assesment” might be as would be “confirm current med list”, ” review side effects”, “assess compliance”. After onset of mid- life distractibility and discovery of their value in aviation, i wouldn’t practice without them. They are not however a substitute for the diagnostic and therapeutic arts, but a fallback to prevent the all too numerous medical misadventures that result from neglect of the simple mundane procedures of daily practice in the face of distractions.
  5. Have used BDI for 40 years with an understanding that it is only one of the importand parts of the dr.patient encounter. The lists have become even more useful since the onslaught of Managed Care and the time crunch. Several pts have been saved since their responses to questions to “suicidal” were revealing and,although required in a decent interview ,sometimes overlooked.I regularly screen pts for anxiety,depression,bipolar and ADHD,including substance abuse ,psychotic disorders.
  6. The decision to use or not use symptom rating scales such as the BDI or to double check DSM diagnotic criteria is a decision made at an altogether different level than that to use checklists as conceived in aviation. Â Whether it does more good than harm to use scales depends on context such as type of patient, time, doctor-patient relationship, and psychotherapeutic orientation. Â

    The analogous application of the aviation checklist would be, if one indeed decides that a symptom checklist like the BDI or HAM-A is appropriate as a routine for one’s practice, to have one of the checklist items that one checks off in every encounter be “appropriate symptom scale completed” . Â It wouldn’t be “complete BDI” unless you have decided that all patients get a BDI on all visits regardless of diagnosis.

    My most recent checklist for example includes “suicide assessment” but not a particular method. Â It might eventually, but the central point is to make sure that the basic work flow with every patient that should never be forgotten is not forgotten. . . Like reviewing side effects, new meds added by other doctors, etc. Â To confuse the checklist with the procedure introduces added complexity which is likely to produce more lapses rather than fewer. Â The checklist for surgery isn’t how to do the procedure, it is to make sure it is the right procedure on the right patient–confirming that this is indeed the right leg amputation.

  7. These tools serve at many levels. Used systematically, 1. they allow the clinician to screen and capture information that they may then decide to expand on, 2. They give patients another chance to organize their own thoughts before the interview or visit, 3. They record a state of being or symptom picture at a point in time for reference, 4. They allow triage of effort and support data-rich referral, 5. They allow research on individual and group levels including assessment of specific interventions over time, 6. They allow more empathic listening time as some data is already collected and documented, 7. They increase the liklihood the clinician will not be sidetracked by a particular illness presentation, and will capture more of the range of problems, 8. They demonstrate the clinician’s intention to be thorough and comprehensive, and 9., they allow comparison against a norm group.
    To do all these things, the tool used should be broad in scope, nit focused on just one domain of illness. The tool should also be standardized, meaning that it will have been developed and tested, and demonstrated to do the job needed. It then will increase the quality of the patient experience as well as the potential for efficacy.
  8. As a clinician in an E.R. setting I get concerned when non mental health professionals rely solely on a check list for diagnostic and treatment purposes. I have had multiple people say “my doctor gave me a brief questionnaire and says I’m bipolar” and put me on _______ medicine. I think these are often provided by drug companies and should be used with caution.
  9. I understand the necessity of checklists in ensuring that we look at the client from different perspectives to get a whole picture. Having said that, as clinicians we rely as much on intuition or other methods of defining our clients. I will always reach for my DSM when coming up with a working diagnosis for a new client but even a checklist would not prevent me from having to revise it as I get to know the client better. We have some important tools in checklists regarding depression and suicide that I find handy but I do not want to rely on them for every aspect of treatment. Providing therapy to a person is a process that frequently changes with the client’s needs. I don’t know of any checklist that can be used universally for every client to get them from beginning to end of treatment.
  10. As a patient and a patient advocate I would suggest that there are two important “lists” that psychiatrists need to “check” regularly. The first is: current treatment protocols, and the second is: recent advances in our understanding of mental illness and its treatment. I see far too much protocol discordant treatment (a term borrowed from Roger McIntyre) and far too little use of best practices. These are probably not the lists that the author had in mind but in my experience they are of the utmost importance.
  11. Clinicians are not winning it. The point is that checklists are useless and don’t provide anything valuable to expert clinicians. Checklists only enforce laziness and the unwillingness to listen and understand the patient. They are a mechanical tool and promote laziness and superficiality in thinking. They may be useful when one is dealig with physical symptoms but psychiatry is not medicine no matter what the establishment wants us to believe.
    Lastly, checklists are also a tool of control of the physician-patient relationsheip by third parties.
  12. Checklists and validated scales are to the psychiatrist as SMA-18 & lipid panels are to the internist. When the average psychiatrist uses scales then the realization that the patient is not at remission will fully be known. When I speak with psychiatrists the success rates are remarkable. When I speakmto their patients I see a different reality.
  13. What a boring and annoying encounter for the patient to be asked the same tedious questions over and over. We are not flying a plane. We are interacting with human beings. Checklists have value, but limited to initiial evaluation and when the patient has had a significant clinical change.
  14. Check lists are wonderful to satisfy the surveyors and absolutely useless if you want to monitor/find out what is going on with the patient.
    They are also wonderful if a person is too lazy to describe a patient in detail.
  15. For medico-legal and ethical reasons, clozapine initiation checklists are extremely important. With the multitude of adverse events associated with the use of clozapine one cannot always rely on one’s memory. The prescriber may quite easily forget to perform an essential bit of enquiry or test that may potentially be hazardous for the mental health care user. A checklist serves to prevent any such disaster; similar to what an aeroplane pilot would do, keeping his crew, passengers and himself safe.
  16. I think most would agree that checklists serve a minor purpose. Too often there are simplistic “checklists” created by drug companies that don’t explore the real issues at hand. While there are some good assessment tools, the best course of treatment is provided by the educated, experienced, and well researched clinician.
  17. When you have fifteen minutes for a medication check, the value of a completed form like the PHQ-9 is exceptional. If i believe that I can do as well without the checklists then I am in denial of the omissions I have made in the past and will make in the future. Excellent Article!
  18. So who says you only get 15 minutes for a “med check?” Try being assertive and demand 30 minutes (it’s called a 90805). Who determines the quality of care, the doctor or the administrator?

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