In Medicine, All the World May Be a Stage

Actors are starting to have some impact on the “medical stage,” at least to a modest degree. For instance, some medical schools are using actors to train medical students for some intervention—say, how to get a patient to stop smoking. Also, some medical specialty boards are exploring the possibility of using actors instead of real patients during the oral part of certification examinations.

And now a company called Fox Learning Systems is developing a software program to improve interrater reliability in multicenter depression studies, and the program uses actors.

In any clinical trial, the validity of its conclusions is influenced by the reliability of the outcomes measured. Thus, in trials using more than one rater, it is critical that all raters employ the rating scales in a reliable way.

Of course, videotapes of actual patients can be mailed to each rater, who then returns both the videotapes and the rating scores to a central coordinator. However, this is a labor-intensive and often expensive process. Further, when patients decide that they no longer wish to have their videotaped interviews used for training purposes, it can be hard to make sure that all videotapes are returned to ensure privacy.

Thus, Fox Learning Systems, located in Bridgeville, Pa., and founded by Debra Fox, a former television news reporter and anchor, is developing a software program to train raters in the use of psychiatry scales and to test for interrater reliability. Although the initial focus is on the development of such a program for use in depression medication trials, the company also foresees that it could be used for other kinds of clinical trials as well—say, anxiety or psychosis.

The Fox program appears to have several advantages over the traditional way of training and testing raters. Video images can be transmitted anywhere electronically without the unwieldy process of sending and receiving videotapes. Rating scores can be saved online in a centralized database. And actors can be used instead of actual patients so that patient privacy is no longer an issue.

But can actors truly imitate depressed patients? This has to be the case for the program to work, so some of the developers of the program conducted a study to find out. They included Jules Rosen, M.D., who is a professor of psychiatry at the University of Pittsburgh and has a commercial interest in the venture, as well as Benoit Mulsant, M.D., who is a professor of psychiatry at the University of Pittsburgh and a consultant to the project. The study was funded by the National Institute of Mental Health.

In this study, a male actor and a female actor were recruited to create realistic portrayals of people without depression, with mild or moderate depression, or with severe depression. The actors were trained by viewing videotaped interviews of patients at these different stages. Four raters experienced with the Hamilton Depression Rating Scale and with previously established reliability for this scale were then shown videotapes of subjects without depression, with mild to moderate depression, or with severe depression and were asked to state whether the subjects were actors or real patients. They answered correctly only 44 percent of the time—in other words, they could not distinguish actors and patients better than chance.

The raters were also asked to rate the subjects they viewed with the Hamilton Depression Rating Scale. Scores generated for the actors while portraying no depression, mild to moderate depression, or severe depression were highly correlated with the scores generated for the real patients when not depressed, mild to moderately depressed, or severely depressed.

“These results demonstrate the feasibility of using trained actors to portray depressive psychopathology to establish interrater reliability,” Rosen, Mulsant, and the other people involved in developing the software program reported in the October American Journal of Psychiatry.

Fox Learning Systems plans to sell the program, Mulsant told Psychiatric News. The program will probably be ready by next spring, Rosen said. Projected markets are academic medical centers and clinical research organizations. “We are hoping this product will improve the quality of trials while reducing the cost,” Rosen added.

The study, “Actors' Portrayals of Depression to Test Inter-rater Reliability in Clinical Trials,” is posted online at<http://ajp.psychiatryonline.org/cgi/content/full/161/10/1909>.▪