Refining Measurement-Based Care to Improve Behavioral Health Outcomes
November 4, 2024 · Guest Contributor
Measurement-based care isn’t working well in behavioral health care. We can fix it by improving the measures we use.
By Carl Feinstein, MD, Chief Medical Officer, Trayt Health
A major limitation in the diagnosis and treatment of behavioral health disorders is the absence of objective biomarkers to measure treatment status. Physical medicine is quite different: Clinicians measure the effectiveness of diabetes treatment by testing a person’s blood glucose levels; hypertension can be monitored through blood pressure readings; and a temperature reading from a thermometer can show progress treating a fever.
However, there is no physical measure, blood lab test or x-ray that can definitively point to treatment response for a mental health condition such as anxiety, depression or schizophrenia. Instead, clinicians have developed consensus, multi-symptom diagnostic criteria (e.g., DSM, WHO ICD-11) to make a reliable diagnosis.
Over time, diagnostic criteria have been modified and quantified as measurement scales by adjusting the wording of the criteria, to make it less technical and more easily understood by a wider range of people, and assigning a numerical rating for severity. Once the rating scales are thoroughly studied and tested, they earn the status of evidence-based rating scales (EBRS).
Limitations of Evidence-Based Rating Scales
While EBRS are the foundation of measurement-based care and recognized as the gold standard for treatment outcomes and effectiveness, they are not widely used in practice.1 In a recent study, only 46% of behavioral health clinicians reported using any kind of EBRS with at least half their patients.2
Why are so few clinicians using EBRS for measurement-based care? One likely explanation is that these scales—regardless of how empirically sound they may be—are not patient-friendly. This leads to low patient engagement and non-adherence in completing the rating scales, even when they are requested by clinicians.
In addition, some clinicians feel that EBRS are not fine-tuned enough to show what is really going on in their patient’s lives and do not provide useful information for engaging with patients. While EBRS have been successful in controlled clinical trials, this has not consistently translated into real-world effectiveness.
A Practical Approach to Measurement-Based Care
Measurement-based care is about communication. Having patients provide feedback to clinicians for use in ongoing treatment planning leads to better outcomes. We need more patient-centered tools to enable that communication.
In practice, this means shorter, more granular and less technical questions that capture the real-life psychosocial and interpersonal challenges that people care about. Asking these types of questions will encourage patients to communicate openly about how their treatment is progressing, and will provide valuable information for clinicians, facilitating an improved patient-clinician relationship.
In addition to tracking the severity of symptoms, here are some other types of data we should collect in this process.
- Between-visit symptom and experience data. These can help clinicians understand a patient’s day-to-day life experiences with work, school or family relationships. In this digital age, organizations can leverage technology to collect real-time insights from the patient—and with the patient’s permission—from other people in the patient’s ecosystem.
- Social determinants of health data. Factors such as housing insecurity, neighborhood food deserts, lack of reliable transportation and community safety all significantly impact mental health and treatment success. When clinicians have access to these data, they can incorporate SDOH into diagnoses and treatment plans, connecting individuals to appropriate social services and removing barriers.
- Social determinants of mental health data. These are non-medical drivers of behavioral health—such as adverse childhood experiences, family dynamics and cultural attitudes toward therapy—that combine to create a person’s unique lived experience.
EBRS remain important for quality assurance and for use in clinical trials. They may also be valuable for the minority of patients who are willing to use them to report on the progress of their ongoing treatment. However, successful implementation of a measurement-based care treatment process must be able to engage most patients.
While there is certainly research to be done in evaluating any new methodology, we must include patient engagement and accessibility as a top priority in tracking treatment outcomes for measurement-based care.
This blog is brought to you by Trayt Health and the views expressed are solely those of the sponsor.
1 Monitoring Treatment Progress and Providing Feedback is Viewed Favorably but Rarely Used in Practice; Amanda Jensen-Doss, Emily M. Becker Haimes, Ashley M. Smith, Aaron R. Lyon, Cara C. Lewis, Cameo F. Stanick, Kristin M. Hawley; Accessed October 2024.
2 A Survey of Behavioral Health Care Providers on Use and Barriers to Use of Measurement-Based Care; Breanna C. Keepers, Caleb W. Easterly, Nora Dennis, Marisa Elena Domino, Ish P. Bhalla; Accessed October 2024.
