What is Measurement-Based Care?
Measurement-based care is extensively used in medical conditions and involves matching treatment interventions with the outcomes for those treatments. For example, a provider would periodically measure fasting blood glucose or glycosylated hemoglobin in an individual with diabetes to make adjustments to the treatment plan, including medication and lifestyle changes. With healthcare insurance companies, including Medicare, tying reimbursements to healthcare outcomes, measurement-based care is becoming the norm. Measurement-based care fosters self-management by making the individual aware if they are on the right treatment plan or if they need to modify it in collaboration with their provider. Measurement-based care in depression is an algorithmic application of published, accepted, clinical guidelines and consists of four steps (Morris et al., 2012):
Step 1: Screening
Your provider may use one of the several available tools to screen for the presence and the severity of depressive symptoms. The Patient Health Questionnaire-9 (PHQ-9) is commonly used in primary care settings and is both a screening and a diagnostic tool for depression. Other tools such as Generalized Anxiety Disorder-7 (GAD-7) may also be used to screen for co-occurring anxiety. Screening is a brief process and a positive screen leads to a more comprehensive evaluation of symptoms and functional impairment associated with the symptoms.
Step 2: Treatment selection
Following your diagnosis with depression, your provider will discuss a range of available options, including medications. If an antidepressant is chosen, your provider and you will jointly decide on the antidepressant that would work best for your after considering the following:
- Your current symptoms.
- Your past history with antidepressants.
- The anticipated effectiveness of the antidepressant in your case.
- Tolerability – the degree to which you can tolerate adverse effects of the antidepressant.
- Safety – the risk in terms of clinical adverse events that you are exposed to due to the antidepressant as assessed by physical examination or laboratory testing.
Step 3: Monitoring outcomes and adjusting medication
This is the heart of measurement-based care and involves measuring the following four parameters:
- Depressive symptoms severity using tools such as the PHQ-9.
- Adherence to antidepressant treatment.
- Safety: Safety is assessed based on monitoring for the emergence of any events listed as black-box warnings or other warnings and precautions, or commonly reported adverse events as listed in the FDA-approved prescribing information for the particular medication.
Measurement-based care helps a provider determine if an individual with depression has received an adequate antidepressant trial or not. If an individual has had 26-49% reduction in their depressive symptoms on a depression rating scale such as the PHQ-9, then their response to the antidepressant is considered a partial response. The next logical step guided by measurement-based care is to assess for tolerability and safety and if there are no issues with these, then the next step would be to increase the dose of the antidepressant roughly every 2 weeks until a minimum therapeutic dose has been reached or until one achieves remission (Morris et al., 2012). Other strategies such as augmentation with other non-antidepressant medications or therapy may be also tried in partial response. Similarly, non-response (less than or equal to 25% reduction in symptoms) would trigger a change in medication after an adequate trial with an antidepressant.
Step 4: Long-term monitoring and maintenance
Here the goal of treatment is remission and return to previous functioning levels. Two questions that are addressed in this step are:
- What to do if the antidepressant stops working?
- When should the antidepressant be stopped after a period of sustained remission?
While advocating for yourself, insist that your provider follows a paradigm of measurement-based care for treating your depression. A study showed that compared to individuals receiving standard care, those receiving measurement-based care are more likely to achieve greater response and remission rates (Guo et al., 2015). This study also found that individuals receiving standard care were on lower dosage of antidepressants compared to individuals receiving measurement-based care. Thus, measurement-based care ensures that you are receiving an antidepressant at an adequate dose and are not stuck at a low sub-therapeutic dose. It also ensures that you are tolerating the antidepressant well without any safety issues, that you are adhering with the treatment regimen, and that the treatment regimen is changed if the response is inadequate. The period between 1 and 3 months after starting an antidepressant may be most critical for fine-tuning the antidepressants, which may yield faster and better outcome (Guo et al., 2015).
Adapted from The Complete Guide to Self-Management of Depression: Practical and Proven Methods. This comprehensive and easy-to-read book offers the reader a menu of options to self-manage depression that go above and beyond the traditional approaches to treat depression and includes complementary and alternative medicine approaches, exercise, mindfulness, role of social support, and bright light therapy. Besides therapy techniques, the book also provides an evidence-based overview of the role medications in treating depression - when to take them, how long to take them, when and how to stop them, and what to do when medications stop working.
HARPREET S. DUGGAL, MD, FAPA
Guo, T., Xiang, Y. T., Xiao, L., Hu, C. Q., Chiu, H. F. K., Ungvari, G. S., Correll, C. U., Lai, K. Y. C., Feng, L., Geng, Y., Feng, Y., & Wang, G. (2015). Measurement-based care versus standard care for major depression: a randomized controlled trial with blind raters. American Journal of Psychiatry, 172(10), 1004-1013.
Morris, D. W., Toups, M., & Trivedi, M. H. (2012). Measurement-based care in the treatment of clinical depression. FOCUS, X(4), 428-433.