Outcome Assessment in Depression

Depression is one of the most significant direct and indirect threats to health and wellness. The negative impact of depression on work, productivity, interpersonal relationships, leisure activities, and a sense of well-being and enjoyment of life cannot be emphasized enough.

With the expansion of treatment choices in both psychotherapy and pharmacotherapy, it is becoming increasingly important to monitor patients’ progress using both measurement tools and clinical judgment. Measuring improvement and deterioration is paramount in evaluating the need for changing, adding, or maintaining therapeutic interventions. Measuring progress is becoming a clinical practice reality and is no longer limited to research methodology. However, the past decades have witnessed a sole emphasis on one dimension of outcome measurement—symptom severity.

Time-limited pharmaceutical studies propagated the notion that improvement is somehow equivalent to response, which is defined as a 50% reduction in symptom severity. Not only was symptom remission neglected, but more important, the mere definition of a psychiatric disorder—impairment of social, occupational, and other important areas of functioning—was abandoned. Moreover, quality-of-life assessment was seldom mentioned (it has only gained more attention recently).

Comprehensive outcome assessment and measurement emphasize the importance of incorporating the 3 dimensions—symptom severity, functioning, and quality of life—into both clinical and research outcome assessments. This article emphasizes this multidimensional approach and reviews practical instruments that can be incorporated into daily practice.

Defining recovery

To define recovery, a medical analogy is used: imagine a patient who broke her arm in an unfortunate fall. The recovery process is expected to go through 3 stages:

• Symptom reduction: with decreases in pain and limitation of movement through surgical and medical treatments.
• Restoration of functioning: with the ability to gradually go back to work, take care of family needs, and participate in leisure activities through physical therapy and patient education.
• Quality-of-life improvement: with the ability to enjoy work, relationships, fun activities, and having an overall sense of well-being.

The same stages hold true for recovery from depression and other psychiatric illnesses. Granted, there is an expected overlap between the 3 stages, eg, some residual or chronic symptoms might be lagging and might continue to interfere with functioning or quality of life despite the individual’s continuous attempts to function and enjoy life.

Depressive disorders can be chronic and/or relapsing, which strengthens the argument for periodic assessment of intervention outcomes. However, a sole emphasis on symptom reduction seriously limits optimal outcome. The front-line clinician has an obligation to regularly monitor, measure, and optimize interventions.

Measuring outcomes

The implementation of a practical procedure for outcome assessment needs to include measurement tools for symptom severity, functioning, and quality of life. Self-report measures are favored over clinician-rated measures because they save the clinician the effort of scoring and interpreting the results. Clinician-based measures may be added when doubts arise about the reliability of the patient’s self-report (minimization or magnification of symptoms). Although this can be easily applied to symptom severity and functioning measures, quality of life is always in the eye of the beholder and can only be self-reported.

It is rewarding to implement self-report measures (that patients can complete in the waiting room) that are compatible with modern definitions of depression, and to administer them at baseline and at regular intervals (eg, every 3 months).

However, the quest to identify a practical and user-friendly set of measures has proved to be challenging for clinicians.