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
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
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>.▪
Am J Psychiatry20041611909