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Benefits of measurement-based care in psychiatry
Dr Erik Vanderlip (Oregon Health & Science University, USA) was involved in forming the Workgroup on Implementation of Measurement-Based Care in 2021. At this APA Online 2022 session, he presented insights and advice for psychiatrists on implementing measurement-based care (MBC), addressing some of the challenges and future directions.
What is MBC?
There is a significant gap between results obtained in randomized controlled trials and those seen in routine mental healthcare. Dr Vanderlip suggested one of the reasons is that trial protocols often include systematic measurement of symptom severity and algorithm-based treatment adjustments depending on patient response. There are many validated symptom rating scales that reliably measure change in severity of symptoms over time, and yet studies have shown that only 18% of psychiatrists in the USA routinely administer such rating scales to their patients.1 Based on clinical judgment alone, mental healthcare providers recognized 21% of patients who were deteriorating,2 with lower detection rates for those not improving as expected.3
Only 18% of psychiatrists in the USA routine administer symptom rating scales to their patients
MBC is an evidence-based strategy that aims to improve outcomes in routine clinical practice. It enables clinicians to use symptom rating scales to monitor outcome measures, and prompts them to adjust treatment plans when patients are not responding adequately.4 Assessments can include symptom improvement, goal attainment, or a combination of both.
Key components of MBC include:
- routine and systematic symptom measurement using evidence-based instruments
- timely sharing of results with patients
- incorporation of outcome measurement into real-time medical decision making
Benefits of MBC
There is a growing evidence base that measurement-based care can improve outcomes for patients
There is a growing evidence base that MBC can improve outcomes for patients. In their literature review of 51 articles Fortney et al.4 concluded that in virtually all randomized controlled trials, with frequent and timely feedback of patient-reported symptoms to the healthcare provider, there were significantly improved outcomes. Dr Vanderlip explained that, from his clinical experience, MBC also helps patient engagement, with reduction in stigma and validation of symptoms, and aids team-based care, as members have shared defined goals to work towards together.
With the increasing demand on mental health services, MBC can be used to best steward limited resources, providing objective measures to triage available healthcare to those in most need. MBC components can be incorporated directly into technology platforms and electronic medical records.
Meta-analyses5,6 have shown that effect sizes are greatest for outpatient settings, patient self-rating, frequent monitoring and feedback, feedback of changes in symptom severity over time, and structured feedback to both clinician and patient during the encounter.
Overcoming barriers to implementation
Measurement-based care is not a replacement for clinical judgment, but a tool to support and enhance it
There are perceived barriers to implementation of MBC at the patient, clinician, and system levels, and Dr Vanderlip discussed ways these challenges can be overcome. From the patient’s perspective, digital technologies are available to help them complete MBC questionnaires in advance, and it is important that their clinician acknowledges and incorporates the MBC results into the consultation. For clinicians, MBC should not be seen as a replacement for clinical judgment, but as a tool to support and enhance it, and early adopters can lead by example. At a healthcare system level, staff training is important, and a structured framework for stakeholders to find agreed measures to use is critical. Factors to be considered when deciding the most appropriate measure(s) include cost, ease of administration, clinical validity, and reliability.
Emerging tools
Emerging measurement-based care tools allow more personalized and efficient assessment
Legacy instruments (e.g., Patient Health Questionnaire-9) are well-established and easy to use and access, but can be associated with response bias and inefficiency. Emerging MBC tools include Computerized Adaptive Testing,7 based on item response theory, that allows more personalized and efficient assessment on a common scale. Measures will need to be adapted to incorporate emerging treatments and increased understanding of underlying disease pathology.
Our correspondent’s highlights from the symposium are meant as a fair representation of the scientific content presented. The views and opinions expressed on this page do not necessarily reflect those of Lundbeck.
References
- Zimmerman M, McGlinchey JB. Why don’t psychiatrists use scales to measure outcome when treating depressed patients? J Clin Psychiatry 2008; 69(12):1916–9.
- Hatfield D, McCullough L, Frantz SHB, et al. Do we know when our clients get worse? an investigation of therapists' ability to detect negative client change. Clin Psychol Psychother 2010;17(1):25-32.
- Hannan C, Lambert MJ, Harmon C, et al. A lab test and algorithms for identifying clients at risk for treatment failure. J Clin Psychol 2005; 61(2):155–63.
- Fortney JC, Unützer J, Wrenn G, et al. A Tipping Point for Measurement-Based Care. Psychiatr Serv 2017;68(2):179-88.
- Knaup C, Koesters M, Schoefer D, et al. Effect of feedback of treatment outcome in specialist mental healthcare: meta-analysis. Br J Psychiatry 2009;195(1):15-22.
- Krägeloh CU, Czuba KJ, Billington DR, et al. Using feedback from patient-reported outcome measures in mental health services: a scoping study and typology. Psychiatr Serv 2015;66(3):224-41.
- Gibbons RD, Weiss DJ, Frank E, et al. Computerized Adaptive Diagnosis and Testing of Mental Health Disorders. Annu Rev Clin Psychol 2016;12:83-104.