Distress Risk Assessment Method (DRAM)

DRAM (Main et al. 1992) was developed specifically as a screening tool for the identification of distress in LBP patients. It comprises a somatic awareness scale (The MSPQ and the Modified Zung Depression Inventory). DRAM offers a simple classification of patients into those showing no psychological distress, those at risk of developing major psychological overlay, and those clearly distressed. Four patient types were identified on the basis of scores on the two short questionnaires.


N: Modified Zung score 17.

R: Modified Zung score 17-33 and MSPQ score LE 12.

DD: Modified Zung score GE 34.

DS: Modified Zung score 17-33 and MSPQ score GE 13.

In the original validation study, the authors found increased risk of poor outcome across the distress categories for no improvement of pain (N vs. Type R: odds ratio (OR) 2.0; N vs. DD/DS: OR 3.5), higher levels of disability (N vs. R: OR 1.9; N vs. DD/DS: OR 5.2), and for not working (N vs. R: OR 1.5; N vs. DD/DS: OR 2.5). In a study of outcome of osteopathic treatment, Burton et al. (2004b) found that a higher level of somatic symptoms (MSPQ) inter alia was associated with poorer outcome. Trief et al. (2000), in a prospective study of psychological predictors of lumbar surgery found the DRAM classification to be a strong predictor of outcome.

However, a caveat is in order, in patients with significantly troublesome pain problems, a patient-centred approach to evaluation is always appropriate and it is certainly not appropriate to view distress as a contraindication to treatment with good surgical indications (Hobby et al. 2001).

Recommendations for use

  • ? Recommended in secondary and tertiary care clinics as a screening tool to aid clinical appraisal of the patient.
  • ? Particularly recommended in problem back clinics and pain clinics.
  • ? Should be viewed as a first-stage screener, not as a complete psychological assessment or as a test of malingering.
  • ? Distress and its management should always be considered as part of decisions about surgery.
  • ? Distress patients not requiring surgery require pain management.

Adapted from Main et al. (1992, p. 52).

Although based on a restricted domain (somatic and depressive symptoms only), this short screening test has been validated specifically for patients consulting with LBP and does seem to have predictive validity for a range of outcomes

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