Measurement-Based Outcome for Depression

by Lisa Brauer, PhD

As treatment goals for depression shift from simple symptom resolution to remission and recovery, management strategies and functional outcome measures also must shift. An important element of developing a treatment plan geared toward functional recovery is to recognize that depression is a chronic illness that needs to be viewed as such. Principles of chronic disease management used for other chronic illnesses, including diabetes and hypertension, need to be applied to depression as well.

One important aspect of chronic disease management, apart from early and appropriate initial therapy, is the ongoing assessment of patients for drug response, side effects, quality of life, and functional measures. Ongoing assessment provides feedback to the clinician that can then be used to adjust components of treatment if warranted, and to identify partial or nonresponders relatively early in the course of treatment. Importantly, the use of quantitative assessment tools provides for objective and measurement-based information on which to base evaluations of treatment response.

In a review and commentary published by Zimmerman and colleagues(1) in the June 2008 issue of Primary Psychiatry, the authors point out that this type of ongoing, quantitative assessment of patients is the standard of care in most disciplines. As an example, they provide the scenario of a patient that reports, among other things, feeling feverish. The standard of care in part dictates that the clinician measure the patient's temperature as an objective measure of whether or not there is fever. The temperature taken at this visit can be used as a comparison for the temperature taken at a subsequent visit to assess whether change (i.e., response to treatment) has occurred. In a patient with diabetes, blood glucose is routinely measured; in a patient with hypertension, blood pressure is monitored at clinic visits over time. In these instances and many others, it seems intuitive that objective, quantifiable measurement is required in order to properly manage the patient.

Yet, this approach has not been widely accepted in the field of psychiatry. Zimmerman and colleagues explain, "Psychiatry is the only medical discipline in which quantified measurements of outcome are not the standard of care. In mental health clinical settings, outcomes evaluations are typically based on unstructured interactions that yield unquantified judgments of progress. This is at variance with other areas of medical care in which outcome is partially determined by a change of a numerical value. […] In treating psychiatric disorders, standardized, quantifiable outcome measures exist for psychiatric disorders, yet they are rarely used in routine clinical practice."

In reviewing the literature on depression, Zimmerman and colleagues begin by emphasizing the value of this strategy in routine clinical practice. The use of quantitative, standardized assessment tools on a regular basis may help to detect residual depressive symptoms in patients who otherwise appear to have been responsive to treatment. The existence of residual symptoms can compromise outcome and places patients at higher risk for relapse, so early detection and intervention can be important for these patients.(2,3) In addition, early identification of partial or nonresponders may stimulate discussion related to adherence, side effects, quality of life issues, or other factors that may recommend consideration of an alternative or adjunctive therapy. In addition, studies of more than 1,500 patients that have randomized physicians to feedback or no feedback conditions have demonstrated that patient outcomes for partial responders are better when their physicians receive feedback than when they do not.(4,5) In some cases, patients who were not doing well but who were assigned to physician feedback conditions actually had more therapy sessions.

In addition to the medical literature arguing for the clinical benefit of this approach, there is building consensus among experts that psychiatrists should adopt this practice. According to Rakesh Jain, MD, MPH, Director of Adult and Child Psycho-Pharmacology Research at R/D Clinical Research, Inc. in Lake Jackson, Texas, "Psychiatry is rich in tools but poor in teaching doctors how to implement them or to interpret them, or even to know that they should use them on a routine basis. Psychiatrists are not buying into the idea that measurement-based practice is a good idea. This misconception must change if we are going to improve quality of care."

The most current data on the use of measurement-based practice in psychiatry echo Dr. Jain's concerns. Two studies, of more than 300 psychiatrists each, in the United States(6) and the United Kingdom(7) have shown that on average less than 12% of clinicians surveyed routinely used rating scales when monitoring patients with depression. As many as 50% of physicians in both studies said they never used such scales. When psychiatrists in the U.S. study were questioned about their reluctance to use quantitative scales in routine management of depression, just over 25% of those surveyed said that they did not believe the scales would be helpful clinically; about 34% said the scales take too much time, and a similar percentage cited lack of training in how to use the scales.

A number of scales have been developed for use in psychiatric practice, the most recent of which have taken into account physician concerns over the potential time burden of their use. Both patient self-report and clinician rating scales have been developed for patients with depression, and of course, each approach has its benefits and drawbacks. Dr. Zimmerman reports that over the past 10 years, he and his colleagues have developed a short 15-item patient self-report scale called the Clinically Useful Depression Outcome Scale (CUDOS), which includes items reflective of all the major DSM-IV criteria for major depression and dysthymic disorder, quality of life, and functional impairment. In his review, he reports validation data showing that scores on the CUDOS correlate well with those on the Beck Depression Inventory, Clinical Global Impression, Hamilton Depression Rating Scale, and Montgomery-Åsberg Depression Rating Scale. The CUDOS, like the other scales, is sensitive to changes in depression severity and detects patients in remission. Surveys of patients indicate that they did not believe completing the CUDOS is overly burdensome, and there was general willingness to complete it at repeated office visits.

In light of data showing that measurement-based care is beneficial, expert consensus that the field should adopt this approach, and the availability of measurement tools, it is unfortunate that this approach has not yet become the standard of care in psychiatry. According to Zimmerman and colleagues, "[…] this is an inadequate and indefensible state of current practice. Would a physician treat diabetes without measuring glucose levels? Would he or she treat hypertension without measuring blood pressure or a febrile illness without measuring body temperature? Of course not; the same should be true of the treatment of depression."

For more information on this and other pressing issues in psychiatry, visit our website at www.neuroscienceCME.com/CC367, and join us on February 23 for a neuroscienceCME webcast titled "Depression Management in Healthcare Systems: A Team Approach to Care" followed by a live Q&A session with experts diagnosing and managing depression in psychiatry and primary care.

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References

1. Zimmerman M, McGlinchey J.B., Chelminski I. An inadequate community standard of care: lack of measurement of outcome when treating depression in clinical practice. Prim Psychiatry 2008;15:67-75.
2. Paykel ES, Ramana R, Cooper Z, Hayhurst H, Kerr J, Barocka A. Residual symptoms after partial remission. An important outcome in depression. Psychol Med 1995;25:1171-1180.
3. Pintor L, Gasto C, Navarro V, Torres X, Fananas L. Relapse of major depression after complete and partial remission during a 2-year follow-up. J Affect Disord 2003;73:237-244.
4. Lambert MJ, Whipple JL, Smart DW, Vermeersch DA, Nielsen SL, Hawkins EJ. The effects of providing therapists with feedback on patient progress during psychotherapy: are outcomes enhanced? Psychother Res 2001;11:49-68.
5. Lambert MJ, Whipple JL, Vermeersch DA, et al. Enhancing psychotherapy outcomes via providing feedback on client progress: a replication. Clin Psychol Psychother 2002;9:91-103.
6. Zimmerman M, McGlinchey JB. Why don't psychiatrists use scales to measure outcome when treating depressed patients? J Clin Psychiatry (in press).
7. Gilbody S, House A, Sheldon T. Psychiatrists in the UK do not use outcomes measures. National survey. Br J Psychiatry 2002;180:101-103.