The burden of mental disorders is well known. Mental disorders are common, resulting in significant disability as well as contributing to — and complicating — chronic health conditions. Most mental disorders are untreated, and the COVID-19 pandemic has only further highlighted significant disparities in access to treatment. Effective pharmacologic and psychological treatments are available, yet outcomes in routine practice are often weaker than what is found in randomized controlled trials.
Measurement-based care (MBC) can improve the outcomes of routine mental health practice. MBC involves routinely and systematically evaluating mental health symptoms, ideally before or during a clinical encounter, to both inform and direct mental health treatment. For example, in 2015, a randomized controlled study of MBC in the treatment of depression found a much higher remission rate among the MBC group compared to the usual treatment (73.8% vs. 28.8%).
What accounts for the impact of MBC on outcomes? MBC can help providers track the response of their patients to treatments, alert providers to when patients need to adjust treatment, and aid clinical decision-making. For example, MBC can facilitate changes in dosage and medications, improve case conceptualization, identify the need to change treatment modality and targets, or inform when patients need an increase or decrease in service frequency and intensity. MBC can also facilitate communication between patients and providers, improving the therapeutic relationship as well as shared decision-making.
Patients like MBC. They accept MBC as part of the treatment process and report that it improves their care. When implemented correctly, providers also like MBC, recognizing its many benefits and utility in treating their patients. Although providers often express fears about the burden of MBC, successful implementation of MBC usually results in little to no burdens for providers; indeed, MBC is associated with positive experiences for patients and clinicians alike.
I have firsthand knowledge of the utility of MBC. In 2006, I was brought into a large behavioral health organization to answer a seemingly simple question: Do our patients get better? Like many organizations, this organization relied on standard customer satisfaction surveys and other regulatory or quality metrics to gauge performance; however, these approaches almost invariably focused on the process of care (e.g., number of patients on multiple antipsychotics), but not the outcome of care. To meet their needs, I created a system that measured how patients changed in their symptoms, functional impairment, and quality of life over the course of treatment.
For the first time, this organization got what they needed: data that definitely showed patient progress. Once they got this data, both clinicians and administrators wanted more. Yet my bespoke, homegrown outcome systems, which initially relied on time-intensive, costly, and inflexible paper-based approaches, couldn’t keep up. They wanted a quick and easy way to not only collect the data without disrupting the clinical flow, but also accessible and useful presentations of patient progress so they could evaluate how their current treatment methods were working for both individual patients and across programs.
They ultimately found their answer with Owl, a measurement-based care platform that collects and measures patient outcomes in a much more quick and efficient way than my initial homegrown system. Finally, the clinicians at this organization had tangible evidence that their patients were improving, or more importantly, alerts when they were not improving and a different course of action was needed. Clinicians and administrators were thirsty for this data. After all, MBC helps clinicians do a better job understanding and treating their patients, ultimately improving patient outcomes and opening up access to care. And isn’t this the ultimate goal in behavioral health?
Despite the clear benefits of MBC, routine use of MBC remains rare. The available evidence suggests that less than 20% of psychiatrists, psychologists, and master’s level providers use any meaningful level of MBC. Why do so few providers use MBC?
Concerns with the practicality of implementing MBC is one of the primary barriers to the utilization of MBC. Practical concerns can include the time required to complete measures, the administrative burden of administering measures, and disruptions to patient flow and processes. Another barrier is the reliance of providers on clinical judgment. Even when providers recognize that MBC is likely to improve their treatments, providers may fall back on their clinical judgment when the infrastructure for MBC is not available. Unfortunately, clinical judgment is not always accurate: One study found that nearly 80% of providers did not accurately note deterioration in their patients.
Although adoption of MBC has been slow, technological solutions hold promise for accelerating the integration of MBC into routine mental healthcare. Many – if not all – of the perceived and actual barriers associated with MBC can be addressed through technology infrastructure that supports fully automated MBC systems. Automated MBC systems can be integrated into existing clinical workflows, including the electronic health record, providing a seamless experience for both the patient and the provider.
As stated previously, accelerating the adoption of MBC will not only improve care but increase access to care. Given that MBC is associated with a faster response to treatment (e.g., 4.5 weeks in MBC group vs. 8.1 weeks in usual care), the increased efficiencies gained in using MBC allows for greater throughput of patients and increased access. By monitoring remissions rates, MBC can also help to identify when patients no longer need a specific level of care, facilitating quicker transitions to lower levels of care and termination, thereby increasing access for new patients to enter the system.
The available evidence is clear: MBC holds promise in improving mental healthcare. To actualize the potential of MBC, however, providers and the organizations that support them must make MBC a routine expectation in the provision of mental health treatment.
About Jason J. Washburn, Ph.D., ABPP
Jason J. Washburn, Ph.D., ABPP is an associate professor in the Department of Psychiatry and Behavioral Sciences at the Northwestern University Feinberg School of Medicine, where he is also the Director of Graduate Studies for the MA and Ph.D. programs in Clinical Psychology. For over a decade, he served as the Director of the Center for Evidence-Based Practice for AMITA Health Alexian Brothers Behavioral Health Hospital, where he oversaw clinical outcomes and research associated with the Center for Self-Injury Recovery.