Thomas A. Ban
Neuropsychopharmacology in Historical Perspective.

Education in the field in the Post-Psychopharmacology Era

Collated 18

Per Bech:  Measurement-based care in mental disorders (New York: Springer; 2016)

Foreword and Review


Foreword by Thomas A. Ban


        The Third edition of the Diagnostic and Statistical Manual (DSM) of the American Psychiatric Association was introduced in 1980. It was the first consensus-based classification with a multiaxial evaluation and operationalized diagnostic criteria. The information generated by DSM-III met the needs of both traditions of medicine: the tradition of Galen, focused on disease, recorded on Axis I and III (psychiatric syndromes and non-psychiatric medical illness), and the tradition of Hippocrates, focused on patients, recorded on Axis IV and V (severity of psychosocial stressors and level of adaptive functioning). Furthermore, by defining mental disorders   in terms of “algorithmic symptom criterion,” DSM-III, as Per Bech recognized, rendered psychiatric diagnoses based on psychopathology and psychiatric nosology accessible to “psychometrics.”

        The origin of “psychometrics,” the discipline dedicated to measuring mental phenomena and performances, was in the work of Wilhelm Wundt in the third quarter of the 19th century. The new discipline had a major impact on the development of psychiatry by stimulating Emil Kraepelin  to develop a “symptom check list” for ”monitoring” patients. The data collected with the employment of this “nominal scale” were instrumental to the formulation of his diagnostic concepts of “dementia praecox” and “manic-depressive psychosis.” It was also research he began in Wundt’s laboratories that led Kraepelin to introduce “pharmacopsychology” for studying the action of drugs on mental functions with the employment of psychometric performance tests.

        Subsequent to Kraepelin’s early contributions, “psychometric” research in psychiatry was virtually dormant for decades, to re-emerge during the first half of the 20th century (in the 1950s) with the introduction of the first set of effective pharmacological treatments for mental disorders. In the years that followed it received wings with the replacement of “testimonials” by information generated in clinical investigations in the evaluation of a rapidly growing number of psychotropic drugs. By the end of the 1960s, “psychometrics” dominated clinical drug development for mental disorders.

        A 1969 graduate of the medical school of Copenhagen University, Per Bech became involved in psychopharmacology and psychometrics during his training in psychiatry at Aarhus University in Aarhus, Denmark. Following the footsteps of Kraepelin, who studied dose-effect relationships with alcohol by measuring reaction time in Wundt’s laboratories, Bech studied dose-effect relationships with tetrahydrocannabinol with the employment of various psychological measurements. Then, in the 1970s while working in Ole Rafaelsen’s Psychochemical Institute in Copenhagen, Bech became involved in the evaluation of validity of rating scales for measuring changes in the course of treatment of depression and mania, as well as in developing new scales. His dissertation on the “clinical and psychometric validity of rating scales in depression and mania” earned him the degree of Doctor of Medical Science in 1981. In the same year, following the publication of his first book, Rating Scales for Affective Disorders Their Validity and Consistency, he received the prestigious Ana-Monika Prize for his contributions in the field of depression.

        During the 1980s pharmacotherapy with psychotropic drugs became the primary form of treatment for mental disorders and with the introduction of DSM-III (1980) psychiatric patients were classified by diagnoses, accessible to “psychometrics” and treated with drugs developed by a methodology based on “psychometrics.” An active participant of this development, Bech broadened the scope of his research to study scales employed in a wide variety of mental disorders and in 1986, he presented his findings in a “Mini-compendium of rating scales for states of anxiety depression mania schizophrenia with corresponding DSM-III syndromes” written in collaboration with M. Kastrup and O.J. Rafaelsen. By the 1990s, Bech’s research embraced mental health and not only its pathology; he was developing instruments suitable for measuring also the effects of treatment on enjoyment of life and adaptation to society, as reflected in his book, Rating Scales for Psychopathology, Health Status and Quality of Life, published in 1993.

        Actively involved in clinical investigations with psychotropic drugs and psychometrics throughout the years, in 2008 Bech was appointed professor of applied or clinical psychometrics at Copenhagen University. Three years later in 2011, he published Clinical Psychometrics, in which he defined the field, outlined its development, summarized its progress between 1993 and 2011 and conceptualized his own  contributions to it over four decades. The two major models for testing  the  measurement aspect of rating scales, Hotelling’s Principal Component Analysis, for identifying the structure of items included in a scale,  and Rasch’s  and Mokken’s Item Response Theory models for examining the “scalability” of rating scales are given special attention. Yet,  at the heart of the monograph is Bech’s “pharmacopsychometric triangle” of which one of the angles “covers” measurements relevant to therapeutic (desired) effects, another angle covers measurements relevant to side or adverse (unwanted) effects and the third, measurements relevant to patients’ quality of life. The “psychometric triangle” is a conceptual construct for translating the therapeutic ratio of psychotropic drugs into measurable benefits of treatment in patients’ well-being, based on patients’ “subjective” experience.

        While in Clinical Psychometrics Bech provides a conceptual framework for “measurement – based care of mental disorders,” in this monograph he translates theory into practice by selecting easy to use, short and valid rating scales and questionnaires which could be used in both, i.e., in clinical research throughout the clinical development of psychotropic drugs and in the daily practice in evaluating patients. By integrating the use of the scales he selected which clinical routine would open up the possibility of an accountable clinical practice in psychiatry. It would also generate information that would allow for rational decisions whether treatment with a particular new drug should be adopted.   

This ultra-short monograph of Per Bech is for everyone to read who is involved in prescribing psychotropic drugs. Its publication signals the need for including “clinical psychometrics” in the medical curriculum and not only in psychiatry residency training programs.


July 8, 2019


Reviewed by Per Bech


Information on Contents

        The book has 10 chapters: negative mental health, personality dimensions, self-reported symptom scales, clinician-administrated symptom rating scales, positive mental health, the pharmacopsychometric triangle for measurement-based care, diagnostic rating scales, social functioning disability scales, a practical outcome evaluation plan and conclusion; it also includes examples and an index.


Author’s Statement

        The book is based on the principle of measurement-based care in focusing on measurement instruments (rating scales or questionnaires) conventionally used in clinical research as randomized, placebo-controlled trials of psychopharmacological medication which are shortened to be easy-to-use in the daily routine of care in mental disorders. With reference to the pharmacopsychometric triangle these instruments should be able to differentiate between the desired clinical effect and the undesired side-effects with patient-reported quality of life scales to ultimately conclude if the treatment has helped for the mental disorder being treated. The self-reported symptom scales are derived using the Symptom Checklist (SCL-90) as an item bank and the clinician-administrated, short, valid scales derived from the Hamilton Anxiety Scale, the Hamilton Depression Scale and the Brief Psychiatric Rating Scale as an item bank. The brief side-effect scales are derived from the Danish Udvalg for Kliniske Undersogelser (UKU) side effect scale and the short quality of life scale from the Psychological General Well-being scale.

        The clinical significance of these outcome scales is estimated by effect size statistics for response issues and number needed to treat (NNT) for remission issues.


March 30, 2017

            January 30, 2020