
- Vol 31 No 10
- Volume 31
- Issue 10
The Importance of Measuring Outcomes in Clinical Practice
Standardized, quantifiable outcome measures exist for most major psychiatric disorders, yet they are rarely used in routine clinical practice. This article identifies the rationale for using psychiatric scales.
BRIEF COMMUNICATION
Imagine going to your primary care physician with a fever and symptoms of an upper respiratory tract infection. The doctor puts his or her palm to your forehead and agrees that you feel warm. A course of treatment is recommended, you return in a couple of days, and he or she again feels your forehead and notes that you are cooler. Would you be happy with this approach to care? Would you continue to see a doctor who evaluated your body temperature in this way? We would not accept this level of care from an internist, a family practitioner, or a pediatrician-and yet this is the community standard of care provided by most behavioral health clinicians when treating psychiatric disorders.
To determine the impact of treatment, it is necessary to evaluate outcome. In mental health clinical settings, this typically is based on unstructured interactions that yield unquantified judgments of progress. This is at variance with other areas of medical care in which outcome is determined, in part, on the change of a numerical value. Body temperature, blood pressure, cholesterol values, blood sugar levels, cardiac ejection fraction, and white blood cell counts are examples of quantifiable variables that are used to evaluate treatment progress. In the mental health field, standardized, quantifiable outcome measures exist for most major psychiatric disorders, yet they are rarely used in routine clinical practice. To determine the impact of treatment it is not simply a matter of evaluating outcome, but rather a matter of measuring outcome.
The results of two surveys of psychiatrists, however, suggest that standardized scales are not being used to evaluate outcome in clinical practice.
Psychiatrists who reported never, rarely, or only sometimes using scales to monitor outcome were asked the reasons for not routinely using scales in their clinical practice. More than one-quarter of them indicated that they did not believe using scales would be clinically helpful, that they take too much time to use, or that they were not trained in their use (Table).
The results of these two surveys found that psychiatrists typically do not use standardized scales of established reliability and validity when treating depression. One issue identified as an obstacle in their use is the perceived burden of scale completion. If the payers of the delivery of mental health treatment increasingly encourage, or require, the measurement of outcome, then the user-friendliness of measurement tools, as well as their reliability and validity, will be critical to their widespread adoption. Clinicians are already overburdened with paperwork, and adding to this load by requiring repeated detailed evaluations with such instruments as the Hamilton Rating Scale for Depression3 is unlikely to meet with success.
Self-report questionnaires are a cost-effective option because they are inexpensive in terms of professional time needed for administration, and they correlate highly with clinician ratings. To be sure, there are also limitations with self-report questionnaires such as response set biases, and their use may be limited by the readability of the scale and literacy of the respondent. However, self-report scales are free of clinician bias and are therefore free of clinician overestimation of patient improvement (which might occur when there are incentives to document treatment success).
This article was originally posted on 9/4/2014 and has since been updated.
Disclosures:
Dr Zimmerman is Director of Outpatient Psychiatry and the Partial Hospital Program, Rhode Island Hospital, and Professor of Psychiatry and Human Behavior at Brown University in Providence, Rhode Island. The author reports no conflicts of interest concerning the subject matter of this article.
References:
1. Gilbody SM, House AO, Sheldon TA.
2. Zimmerman M, McGlinchey JB.
3. Hamilton M. A rating scale for depression. J Neurol Neurosurg Psychiatry. 1960;23:56-62.
Articles in this issue
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Introduction: The Challenges of Treating Older Adultsalmost 11 years ago
Hoarding in Late Life: Implications for Cliniciansalmost 11 years ago
Diagnosis and Treatment of Late-Life Depressionalmost 11 years ago
Treating Complex Trauma Survivorsalmost 11 years ago
Severely Depressed Most Responsive to Combined Cognitive and Drug Rxalmost 11 years ago
Strategies for Treatment-Resistant OCDalmost 11 years ago
The Most Exciting Time in the History of Psychiatryalmost 11 years ago
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