Using scales to monitor symptoms and treat depression (measurement based care)
- Mark Zimmerman, MD
Mark Zimmerman, MD
- Associate Professor of Psychiatry
- Brown University School of Medicine
It is necessary to evaluate outcome in order to determine the effectiveness of treatment. Clinicians treating hypertension do this by consistently measuring blood pressure, and treatment of diabetes always involves measuring serum glucose or hemoglobin A1C.
Psychiatrists treating depression can monitor progress by serially measuring severity of symptoms with a standardized scale. However, most psychiatrists do not. A study in 2000 sent a survey to 500 psychiatrists, and found that among the 340 who responded, 58 percent never used a scale to measure clinical change of depression and anxiety . Another survey of 306 psychiatrists in 2006 to 2007 found that 29 percent never used scales and 32 percent did so rarely. Among the psychiatrists who did not routinely monitor symptoms with a standardized scale, the primary reasons were lack of training and time. In addition, the psychiatrists did not believe that scales would be clinically helpful.
Mental health clinicians typically assess progress of their depressed patients through unstructured interactions that yield unquantified judgments. Some clinicians ask only broad, global questions such as “How are you feeling?” or “How are you doing?” Many patients reply with global responses such as “Okay” or “Fine.” However, these responses often do not accurately reflect the patient’s clinical status. As a result, it is increasingly recognized that incorporating standardized scales into clinical practice to measure depression may help clinicians evaluate the patient’s current status more accurately.
This topic reviews the use of depression rating scales in routine clinical practice. Initial treatment of depression and management of treatment resistant patients are discussed elsewhere. (See "Unipolar major depression in adults: Choosing initial treatment" and "Unipolar treatment resistant depression in adults: Epidemiology, risk factors, assessment, and prognosis", section on 'Assessment and identification' and "Unipolar depression in adults: Treatment of resistant depression".)
EVIDENCE OF EFFICACY
The evidence indicates that systematically monitoring depressive symptoms with a standardized scale can improve treatment outcomes. In some studies, monitoring was part of a program that included education or reinforcement of evidence based treatment:
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- EVIDENCE OF EFFICACY
- REASONS TO MEASURE OUTCOME
- Identify nonresponders
- Detect residual symptoms
- Reduce dropout from treatment
- Help patients recognize improvement
- Detect seasonal variation
- DESIRABLE FEATURES OF A DEPRESSION OUTCOME SCALE
- Patient perspective
- Clinician perspective
- Desirable features
- POTENTIAL OBSTACLES IN MEASURING OUTCOME
- Patient acceptability
- Clinician acceptability
- SELF-REPORT MEASUREMENT
- COMMONLY USED SELF-REPORT DEPRESSION SCALES
- Self-report scales in the public domain
- - Patient Health Questionnaire - Nine Item
- - Clinically Useful Depression Outcome Scale
- - Quick Inventory of Depressive Symptomatology - Self Report 16 Item
- WHEN AND WHERE TO MEASURE
- COMPUTERIZED AND PAPER FORMATS
- ADVERSE SIDE EFFECTS SCALE
- SUMMARY AND RECOMMENDATIONS