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. 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. While measurement-based care has been proven to improve outcomes for medical conditions, mental health, unfortunately, has lagged behind in adopting it as a regular practice.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 the most commonly used tool in primary care settings to screen depression. It is a self-reporting scale that has nine items which parallel the DSM-IV criteria for major depressive disorder with a total score ranging from 0-27 (Kroenke al., 2001). A cut-off score of 10 or higher on PHQ-9 correctly identifies major depressive disorder in 88% of individuals and rules it out in 85% of individuals being screened for this condition (Levis et al., 2019).
Step 2: Treatment selection: Following your diagnosis with depression, your provider will discuss a range of available options, including medications and/or psychotherapy. If an antidepressant is chosen, your provider and you will jointly decide on what antidepressant would work best for you after considering the following:
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. If there are no issues with these, then the dose of the antidepressant should be increased 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 complementing with psychotherapy may be also tried in partial response. Similarly, a 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:
Response: Response is defined as a significant level of improvement in depression following a treatment. This improvement is big enough to separate an individual who is a responder from a non-responder. The concept of response is applied to first 4-8 weeks of starting a new treatment for depression. Typically, in studies of depression, response denotes a 50% reduction in depression scores in one of the rating scales for depression. For example, if your initial score on PHQ-9 was 22 and it dropped to 11 after six weeks of starting an intervention, then you will be considered as having a positive response to treatment.
Remission: Remission is defined as clinical improvement, which is greater than response with few signs of depression still remaining and a lower likelihood of subsequent exacerbations. Remission can be partial if an individual still has more than minimal symptoms of depression, but not enough to meet the clinical criteria for depression. On the other hand, in full remission, an individual has no more than minimal symptoms of depression. For example, if your score on the PHQ-9 drops to less than 5 and is sustained at that level for at least a few weeks, then your depression is in full remission.
Relapse: Relapse is defined as re-emergence of depressive symptoms after response to treatment, but before reaching recovery. For example, if your PHQ-9 score initially decreased from 16 to 4 after starting a treatment, but again rose to 10 and stayed the same for at least two weeks, then your depression has relapsed.
Recovery: Recovery means achieving full remission for at least six months. In terms of self-assessment, it would be having a score below 5 on the PHQ-9 for at least 6 months. But recovery is more than just a number. It signifies an individual’s return to their previous healthy level of functioning accompanied with a general sense of well-being. People in recovery may not be entirely free from depressive symptoms. They may still have good and bad days, but their sense of optimism and hope helps them have a sustained recovery, especially if they are using the tools to self-manage depression.
Recurrence: Recurrence is return of depressive symptoms, which meet criteria for a new episode of depression after at least six months of recovery. A score higher of 10 or higher on the PHQ-9 signals a recurrence.
The 5Rs have long been used in clinical research in depression, but seldom used as a self-management tool by people with depression. Knowing these definitions empowers you to track the course of your depression by using the self-assessment tools such as the PHQ-9 as described above. It also prepares you to have a meaningful dialogue with your healthcare provider, which ensures that you get optimal and effective treatment. The gold standard for treating depression doesn’t stop at response, but is full remission leading to recovery. Failure to achieve full remission is associated with higher risk of relapse of depressive symptoms, increased functional impairment, and a greater burden of other medical and psychiatric conditions (McIntyre & O’Donovan, 2004). Make full remission leading to recovery your goal in your journey of overcoming depression.
To learn more about evidence-based self-management techniques that are proven to work for depression, check out Dr. Duggal's Author Page.
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.
Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine, 16, 606-613.
Levis, B., Benedetti, A, & Thombs, B. D. (2019). Accuracy of patient health questionnaire-9 (PHQ-9) for screening to detect major depression: Individual participant data meta-analysis. British Medical Journal, 365:l1476. doi: 10.1136/bmj.l1476.
Löwe, B, Unüzer, J., Callahan, C. M., Perkins, A. J., & Kroenke, K. (2004). Monitoring depression treatment outcomes with the patient health questionnaire-9. Medical Care, 42(12), 1194-1201.
Morris, D. W., Toups, M., & Trivedi, M. H. (2012). Measurement-based care in the treatment of clinical depression. FOCUS, X(4), 428-433.
McIntyre, R. S., & O’Donovan, C. (2004). The human cost of not achieving full remission in depression. Canadian Journal of Psychiatry, 49(3 Suppl 1), 10S-16S.
Riso, L. P., Thase, M. E., Howland, R. H., Friedman, E. S., Simons, A. D., & Tu, X. M. (1997). A prospective test of criteria for response, remission, relapse, recovery, and recurrence in depressed patients treated with cognitive behavior therapy. Journal of Affective Disorders, 43, 131-142.
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 the most commonly used tool in primary care settings to screen depression. It is a self-reporting scale that has nine items which parallel the DSM-IV criteria for major depressive disorder with a total score ranging from 0-27 (Kroenke al., 2001). A cut-off score of 10 or higher on PHQ-9 correctly identifies major depressive disorder in 88% of individuals and rules it out in 85% of individuals being screened for this condition (Levis et al., 2019).
Step 2: Treatment selection: Following your diagnosis with depression, your provider will discuss a range of available options, including medications and/or psychotherapy. If an antidepressant is chosen, your provider and you will jointly decide on what antidepressant would work best for you 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.
- Affordability.
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. If there are no issues with these, then the dose of the antidepressant should be increased 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 complementing with psychotherapy may be also tried in partial response. Similarly, a 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?
Monitor Your Depression Using the “5 Rs”
Once diagnosed with depression, you can track the course of your depression using the “5 Rs,” which are defined as below (Frank et al., 1991; Riso et al., 1997). Here again, PHQ-9 has been proven to be a reliable measure for gauging response to depression treatment (Löwe et al., 2004).Response: Response is defined as a significant level of improvement in depression following a treatment. This improvement is big enough to separate an individual who is a responder from a non-responder. The concept of response is applied to first 4-8 weeks of starting a new treatment for depression. Typically, in studies of depression, response denotes a 50% reduction in depression scores in one of the rating scales for depression. For example, if your initial score on PHQ-9 was 22 and it dropped to 11 after six weeks of starting an intervention, then you will be considered as having a positive response to treatment.
Remission: Remission is defined as clinical improvement, which is greater than response with few signs of depression still remaining and a lower likelihood of subsequent exacerbations. Remission can be partial if an individual still has more than minimal symptoms of depression, but not enough to meet the clinical criteria for depression. On the other hand, in full remission, an individual has no more than minimal symptoms of depression. For example, if your score on the PHQ-9 drops to less than 5 and is sustained at that level for at least a few weeks, then your depression is in full remission.
Relapse: Relapse is defined as re-emergence of depressive symptoms after response to treatment, but before reaching recovery. For example, if your PHQ-9 score initially decreased from 16 to 4 after starting a treatment, but again rose to 10 and stayed the same for at least two weeks, then your depression has relapsed.
Recovery: Recovery means achieving full remission for at least six months. In terms of self-assessment, it would be having a score below 5 on the PHQ-9 for at least 6 months. But recovery is more than just a number. It signifies an individual’s return to their previous healthy level of functioning accompanied with a general sense of well-being. People in recovery may not be entirely free from depressive symptoms. They may still have good and bad days, but their sense of optimism and hope helps them have a sustained recovery, especially if they are using the tools to self-manage depression.
Recurrence: Recurrence is return of depressive symptoms, which meet criteria for a new episode of depression after at least six months of recovery. A score higher of 10 or higher on the PHQ-9 signals a recurrence.
The 5Rs have long been used in clinical research in depression, but seldom used as a self-management tool by people with depression. Knowing these definitions empowers you to track the course of your depression by using the self-assessment tools such as the PHQ-9 as described above. It also prepares you to have a meaningful dialogue with your healthcare provider, which ensures that you get optimal and effective treatment. The gold standard for treating depression doesn’t stop at response, but is full remission leading to recovery. Failure to achieve full remission is associated with higher risk of relapse of depressive symptoms, increased functional impairment, and a greater burden of other medical and psychiatric conditions (McIntyre & O’Donovan, 2004). Make full remission leading to recovery your goal in your journey of overcoming depression.
To learn more about evidence-based self-management techniques that are proven to work for depression, check out Dr. Duggal's Author Page.
HARPREET S. DUGGAL, MD, FAPA
REFERENCES
Frank, E., Prien, R. F., Jarrett, R. B., Keller, M. B., Kupfer, D. J., Lavori, P. W., Rush, A. J., & Weissman, M. M. (1991). Conceptualization and rationale for consensus definitions for terms in major depressive disorder: remission, recovery, relapse, and recurrence. Archives of General Psychiatry, 48, 851-855.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.
Kroenke, K., Spitzer, R. L., & Williams, J. B. (2001). The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine, 16, 606-613.
Levis, B., Benedetti, A, & Thombs, B. D. (2019). Accuracy of patient health questionnaire-9 (PHQ-9) for screening to detect major depression: Individual participant data meta-analysis. British Medical Journal, 365:l1476. doi: 10.1136/bmj.l1476.
Löwe, B, Unüzer, J., Callahan, C. M., Perkins, A. J., & Kroenke, K. (2004). Monitoring depression treatment outcomes with the patient health questionnaire-9. Medical Care, 42(12), 1194-1201.
Morris, D. W., Toups, M., & Trivedi, M. H. (2012). Measurement-based care in the treatment of clinical depression. FOCUS, X(4), 428-433.
McIntyre, R. S., & O’Donovan, C. (2004). The human cost of not achieving full remission in depression. Canadian Journal of Psychiatry, 49(3 Suppl 1), 10S-16S.
Riso, L. P., Thase, M. E., Howland, R. H., Friedman, E. S., Simons, A. D., & Tu, X. M. (1997). A prospective test of criteria for response, remission, relapse, recovery, and recurrence in depressed patients treated with cognitive behavior therapy. Journal of Affective Disorders, 43, 131-142.
Dr Duggal, first of all I have been enjoying the posts, first time reading the blog as the subject is dear to what we are building. I think there are opportunities to really use measurements and quantify / model approaches to anxiety, stress and depression and would like to dig in more.
ReplyDelete