The critical role of measurement-based care in mental health treatmentKlint Fung
Despite its potential benefits, only a small fraction of clinicians currently use measurement-based care practices. This article explores the importance of measurement-based care and highlights why assessments are important within this approach and what features are critical to support measurement-based care.
What is measurement-based care?
You may have heard of phrases like evidence-based practice 1, patient-centered care 2, and precision medicine 3, which are recent pushes to improve the quality of care in mental healthcare. The gist of these approaches is for clinicians to make decisions based on the best available research. Through close collaboration with the patient, clinicians should provide treatment that is not only the most effective for most patients but is also the most applicable to the specific patient they are treating. To do so, clinicians are encouraged to routinely collect information about the patient throughout treatment and collaboratively make treatment decisions based on this information with the patient 4. This practice is recommended in the fields of clinical psychology 5, school psychology 6, and psychiatry 7 and is known by a variety of names, including measurement-based care, routine outcome monitoring, feedback-informed treatment, and practice-based evidence.
- Routinely collecting treatment-related information, such as the patient-reported and clinician-rated symptoms, functioning, and opinions about the treatment process, rated by clinicians, support workers, family members, and/or patients.
- The clinician and patient reviewing and discussing the information together, for example, via a feedback session.
- Based on the information, continuing or adjusting the treatment plan (therapy, medication, accommodations, or other services).
Why should clinicians engage in measurement-based care?
There are several reasons to advocate for the practice of measurement-based care.
Routinely collecting treatment-related information allows different parties to evaluate its general effectiveness and cost-efficiency 5, 7, 9, 10. For patients receiving services, they may want to know if the treatment is working and if it is worth their time and money, which is, in fact, within their rights. Some patients may not consider this, especially if they have received the same treatment for some time. Others may feel uncomfortable explicitly telling their doctor or psychologist that the treatment is not working as well as was hoped and may feel more comfortable sharing through a less direct means like a routine questionnaire.
Clinicians need to know how their patient responds to treatment. A clinician may think their patient is doing well, but patients deteriorating or not improving happens more often than clinicians think 11, 12. It is best practice to rely on reliable and valid assessments rather than general impressions. For example, the Canadian Psychological Association cites outcome and progress monitoring as an ethical obligation for psychologists 8. Additionally, decision-makers in professional organizations, government, funding agencies, or insurance providers may want to know the quality and impact of different treatments, and the outcomes of investments.
Measurement-based care increases treatment effectiveness, at least in principle. As mentioned, routinely collecting treatment-related information would allow the clinician and patient to adjust their approach if treatment is not on track. Evidence generally supports this point: although some studies showed no difference, others showed that measurement-based care improved patients’ symptoms and likelihood to stay in treatment to a small to moderate degree, especially for cases where treatment is not progressing as expected 9, 10, 11.
Measurement-based care makes patients more engaged in the treatment process 9, 10. Patients reported that they understood their conditions more, they could better express themselves to the clinician, that the clinician was taking their opinion and treatment more seriously, and they had general satisfaction with treatment when receiving measurement-based care as opposed to treatment as usual.
Why aren’t more clinicians engaging in measurement-based care?
Like patients, clinicians also generally have a favorable view of measurement-based care. Given the potential benefits listed, and buy-in from patients, clinicians, and governing organizations, it may come as a surprise that less than a fifth of clinicians, including psychiatrists, psychologists, and other mental healthcare professionals, engage in measurement-based care practices 11, 12.
There are several reasons why this is the case. Measurement-based care is not ingrained in clinicians’ training and culture 4, 7, 9, 10, although there are signs that it is becoming more prominent 5, 8. Clinicians also expressed concern about the ease of routinely administering tests, which, in turn, is related to the time it takes, their perceived knowledge of the tests, and their tech-savviness because tests are commonly administered on digital devices and through the internet culture 4, 7, 9–12. In addition, clinicians doubted the applicability of existing tests. For example, they may feel that existing tests may not adequately measure the complex conditions of their patients (for example, some patients have very specific obsessions and delusions) 4, 7, 9, 10. Other considerations included patient privacy security and the lack of incentives from management, professional organizations, and third-party funders 4, 7, 9, 10.
What features are critical to support measurement-based care?
Introducing measurement-based care into your practice may seem daunting, but it allows clinicians and their clients to check in with each other regularly, reflect on objective symptom change data, and uncover insights or patterns that can inform treatment decisions.
Here at MHS, we want to make it easier for you to incorporate measurement-based care within your practice. Our team is comprised of experts in the field of psychology and mental health, psychometrics, training and education, information technology, user experience, and other areas who collaborate closely to provide solutions related to psychological and behavioral assessments. We understand the barriers surrounding low participation in measurement-based care and some of the main obstacles clinicians and organizations face in incorporating this approach into their practices. In response, we strive to:
- Develop tests that have strong evidence of reliability and validity (that is, they are precise in their ability to measure exactly what is supposed to be measured).
- Develop tests that are applicable to individuals with different psychological conditions, ages, genders, socioeconomic statuses, racial/ethnic groups, and other demographics through the development of the test content as well as ensuring accessible features and availability in multiple languages, where possible.
- Develop tests that can be administered within the time constraints of routine clinical practice.
- Develop technology that makes tests easy for patients to complete and for clinicians to administer, score, and interpret.
- Develop technology that safely stores patient information and can be easily integrated into patient records.
- Facilitate the feedback process between clinicians and patients.
- Develop tests that provide insights that inform actionable treatment decisions.
- Provide training, support, and recommendations for clinicians and patients on which tests to use and how to use them.
1 American Psychological Association. (2021, April). Policy statement on evidence-based practice in psychology. https://www.apa.org/practice/guidelines/evidence-based-statement
2 Epstein, R. M., & Street, R. L. (2011). The Values and Value of Patient-Centered Care. Annals of Family Medicine, 9(2), 100–103.
3 U.S. Food And Drug Administration. (2018). Precision Medicine. https://www.fda.gov/medical-devices/in-vitro-diagnostics/precision-medicine
4 Boswell, J., Hepner, K. A., Lysell, K., Rothrock, N. E., Bott, N. T., Childs, A. W., Douglas, S. P., Owings-Fonner, N., Wright, C., Stephens, K. A., Bard, D., Aajmain, S., & Bobbitt, B. L. (2023). The need for a measurement-based care professional practice guideline. Psychotherapy, 60(1), 1–16.
5 American Psychological Association. (2022, August). Measurement-based care. https://www.apaservices.org/practice/measurement-based-care
6 Connors, E. H., Lyon, A. R., Garcia, K., Sichel, C. E., Hoover, S., Weist, M. D., & Tebes, J. K. (2022). Implementation strategies to promote measurement-based care in schools: evidence from mental health experts across the USA. Implementation Science Communications, 3(1).
7 Aboraya, A. (2018, November 11). Measurement-based Care in Psychiatry—Past, Present, and Future. PubMed Central (PMC). https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6380611/
8 Tasca, G. A., Angus, L., Bonli, R., Drapeau, M., Fitzpatrick, M., Hunsley, J., & Knoll, M. (2019). Outcome and progress monitoring in psychotherapy: Report of a Canadian Psychological Association Task Force. Canadian Psychology / Psychologie canadienne, 60(3), 165–177.
9 Lewis, C. C., Boyd, M. R., Puspitasari, A. J., Navarro, E. I., Howard, J., Kassab, H., Hoffman, M., Scott, K., Lyon, A. R., Douglas, S. P., Simon, G. E., & Kroenke, K. (2019). Implementing Measurement-Based Care in Behavioral Health. JAMA Psychiatry, 76(3), 324.
10 Harding, K. G., Rush, A. J., Arbuckle, M. R., Trivedi, M. H., & Pincus, H. A. (2011). Measurement-Based Care in Psychiatric Practice. The Journal of Clinical Psychiatry, 72(08), 1136–1143.
11 Zimmerman M, McGlinchey JB: Why don’t psychiatrists use scales to measure outcome when treating depressed patients? Journal of Clinical Psychiatry 69:1916–1919, 2008
12 Hatfield D, McCullough L, Frantz SH, et al: Do we know when our clients get worse? An investigation of therapists’ ability to detect negative client change. Clinical Psychology and Psychotherapy 17: 25–32, 2010