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
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 what antidepressant 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:
a. Depressive symptoms severity using tools such as the PHQ-9.
b. Tolerability: A commonly used tool is the self-reported Frequency, Intensity, and Burden of Side Effects Rating (FIBSER) (Wisniewski et al., 2006).
c. Adherence to antidepressant treatment: A simple 4-item questionnaire, Morisky Medication Adherence Scale (MMAS-4), can be used to assess adherence (Morisky et al., 1986). The items include:
- Do you ever forget to take your medicine?
- Are you careless at times about taking your medicine?
- Sometimes if you feel worse when you take the medicine, do you stop taking it?
- When you feel better do you sometimes stop taking your medicine?
d. 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, 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 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 follow 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 evidence-based book The Complete Guide to Self-Management of Depression: Practical and Proven Methods.
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.
Morisky, D. E., Green, L. W., & Levine, D. M. (1986). Concurrent and predictive validity of a self-reported measure of medication adherence. Medical Care, 24(1), 67-74.
Morris, D. W., Toups, M., & Trivedi, M. H. (2012). Measurement-based care in the treatment of clinical depression. FOCUS, X(4), 428-433.
Wisniewski, S. R., Rush, A. J., Balasubramani, G. K., Trivedi, M. H., Nierenberg, A. A., & STAR-D Investigators. (2006). Self-rated global measure of the frequency, intensity, and burden of side effects. Journal of Psychiatric Practice, 12(2), 71-79.