The Role of Patient Reported Outcome Measures in Mental Health

Dave Johnson, LCSW
Michael Conner, PsyD 

The healthcare industry promotes the use of Patient Reported Outcome Measures (PROMs) to engage patients in giving information to their health care providers about patients’ responses to care given for their health conditions, medical and mental health symptoms, pain, substance use, level of functioning, etc.  PROMs allow health care providers to have feedback concerning patients’ well-being, physical and emotional functional status, health behaviors, and experience with care.  

Domains

1. symptoms

2. pain

3. physical activity

4. social and functional skills

5. social activity

6. medication use & side-effects

7. experience of care

 PROMs use standardized questionnaires and scales completed by patients to obtain a quantitative measure regarding one or more of the domains of care and status. 

Mental health treatment literature uses terminology such as Measurement Based Care (MBC), Feedback Informed Treatment (FIT), Outcomes Informed Care (OIC), and Client-directed Outcome Informed Therapy (CDOIT).  All of these terms are encompassed under the broad heading of Routine Outcome Monitoring (ROM). Rarely, in mental health, do therapists and counselors reflect on the similarity to PROMs.

The use of commonly accepted and understood measures and terminology can effectively and efficiently support screening, diagnosis, intervention choice, progress, treatment adherence, alliance and outcomes in both medical and mental health care.  In order to accomplish these effectiveness and efficiencies, professionals must reconcile the similarities and differences between the medical professions’ use of Patient Reported Outcome Measures (PROM) and the mental health professions’ use of ROMs.  There are challenges. 

It is significant that industry publications, presentations and experts acknowledge that most mental health professionals believe themselves to be in the top ten percent in achieving positive outcomes. A second challenge is that most mental health professionals believe they can accurately identify their patients’ response to treatment as improving or not improving without need for standardized measures. Third, psychotherapeutic clinicians often see patient reported outcomes systems as an imposition or distraction from the treatment process or simply as irrelevant to their work with patients. 

Taken together, these unsubstantiated beliefs explain why few mental heath professionals use any standardized measure to inform their practice or monitor how their patients responses to treatment.  Surveys have identified that only a small fraction of clinicians (approximately 12% of psychologists/18% of psychiatrists) use any standard assessment or outcomes measures in their practices.

Myths in MH Treatment

1. Patients don’t want to be screened or see measures of their progress (They do.)

2. Providers are equally effective (They aren’t)

3. Providers know when patients are “On Track” (They don’t.)

4. Academic degrees, experience and training predict outcomes (They don’t.)

5. Most patients do not recover quickly (Many do recover quickly.)

6. Patients with severe symptoms recover slowly (People with severe conditions may also recover quickly.)

7. Therapist self-ratings are generally accurate (They aren’t.)

Those mental health clinicians who do use standardized measures may have adopted one of the commercially promoted ROM systems identified with the terms above: e.g. ACORN, CIOM, FIT, PCOMS, and OQ systems. These systems may focus on one or more of the domains of general well-being, degree of distress, symptom severity, therapeutic alliance, and/or satisfaction with treatment.

There are challenges to the use of the existing commercially promoted ROM systems; their measures have been designed primarily for psychotherapy treatment. A significant portion of mental health treatment is with medication only, or medication with minimal counseling. Such treatment is generally provided by psychiatrists, often by primary care physicians; in such treatment modalities clinicians are interested in measures of change for specific conditions such as depression, anxiety, ADHD, etc. The focus is on the response of patients to psychotherapeutic treatment irrespective of modality, be it psychotherapy, psychopharmacology or both in varying proportions.

 Additionally, the existing commercially promoted systems may not facilitate communication among care-giving professionals or between professionals and patients/clients. Nor is there a clear alignment with medicine’s Patient Reported Outcome Measures, thus there may not be a clear path to design value-based payment systems relative to patient reported outcomes. For example, CMS' MACRA program requires that standard condition-specific measures such as the PHQ 9 be administered and reported.

Patient does well, declines and then improves to a new level.

 Several of the existing commercially promoted ROM systems have established decision supports to alert clinicians (and behavioral health professionals) when a person is not responding to treatment/services or is at risk of dropping out. However, these alerts apply only to a small subset of patients at risk for a poor outcome (~8%); they do not help shape the treatment of the other 92% of patients. This is because standard measures are generic assessments of overall severity of distress and do not speak to the specific symptoms, problems, or goals that bring people to counseling, psychotherapy or psychopharmacology. For many patients improvement may not be incremental and may involve setbacks before new gains can be made..

 Importantly, the impact of Routine Outcome Measures (ROM) in psychotherapy treatment has been shown to be only modestly beneficial, and that benefit applies to only a small subset of patients at risk for a poor outcome. Recent studies found that the outcomes of clinicians participating in ROM do not improve over time, and, in fact, appear to get slightly worse! (Miller, et al, 2015; Wampold, 2015)

ROMs used to ascertain dose-response drafts suggest that, depending on the patient population and how you analyze the data suggests that patients may respond more in the first 6 sessions, benefit less after that but may also continue to benefit with extended treatment. Not all patients respond the same ways.

 Why PROMs

• Flexible

• Not restrictive to proprietary scales

• Accommodates fixed or variable interval measures

• Common language facilitates discussion between therapists and patient; patient and physician; therapist and physician

• Not restricted by treatment modality, i.e., useful if treatment is medication only or psychotherapy only, or some combination of treatment modalities

• Accomplishes similar goals of ROMs related to informing overall clinical outcomes

• Can be applied in socially and culturally appropriate ways to a broad range of behavioral and mental health presenting problems.

 When there are disappointing results it is important to consider other options. One possible option is to adopt the Patient Reported Outcome (PRO) methodology. Here, we are distinguishing between PRO and ROM, in which the ROM follows a prescribed protocol such as administering a scale at every session, before or after the session. ROM also prescribes which scales are to be used, generally the same scale regardless of presenting problem. On the other hand, the PROs methodology brings flexibility to the mental health treatment process while achieving the benefits of ROMs. A clinician may select one or more instruments to obtain patient reported symptoms and outcomes. Additionally, the clinician may choose the frequency and timing for requests that a client respond to a standardized scale. Analytical systems can then provide scoring and graphs to reflect the individual’s response over time. When scales such as the PHQ-9, GAD-7, ACE, PCL-17, TAPS-2, WHODAS, etc. are used, meaningful communications are also facilitated with primary care providers (PCP). Statistical techniques that include an effect size, reliable change index, and clinical cut scores facilitate an understanding of the individual’s responses to the selected PROMs over time. Metrics can be established that address average change over time, the percentage of patients’ improvement, and the percentage of individuals meeting specified benchmarks of change.

By adopting the PRO methodology mental health professionals can come in line with the rest of the health care community in obtaining feedback from patients regarding their symptoms, functioning, well-being, health behaviors and experience of care.  It offers both flexibility and the meaningfulness of standardized scales, and facilitates communication with other health care professions consistent with their use of PROMs. Mental health professionals will be wise to develop habits of standardized assessment and follow up to improve client satisfaction, clinical outcomes and communication with other health care professionals.

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 End Notes

 Author, Turning Point Clinically Informed Outcomes.  http://www.turningpointfoundation.org/ways-to-care/resources/

 Author, (2013) Patient Reported Outcomes (PROs) in Performance Measurement. National Quality Forum. http://www.qualityforum.org/publications/2012/12/patient-reported_outcomes_final_report.aspx

 Brown, G.S., Simon, A., Cameron, J., & Minami, T. (2015). A collaborative outcome resource network (ACORN): Tools for increasing the value of psychotherapy. Psychotherapy, 52:4, 412-421.

 Duncan, B.L., & Reese, R.J., (2015). The partners for Change Outcome Management System (PCOMS): Revisiting the client’s frame of reference. Psychotherapy, 52:4, 391-401.

 Guo, T, et al (2015) Measurement-based care versus standard care for major depression: A randomized control trial with blind raters. American Journal of Psychiatry, 172:10, 1004-1013.

 Kopta, M., Owen, J., & Budge, S. (2015). Measuring psychotherapy outcomes with the behavioral health measure-20: Efficient and comprehensive. Psychotherapy, 52:4, 442-448.

 Lambert, M.J. (2015). Progress feedback and the OQ-System: The past and the future. Psychotherapy, 52, 381-390.

 Lewis, C.L., Boyd, M., Puspitasari, A., Navarro, E., Howard J., Kassab, H., Hoffman, M., Scott, K., Lyon, A., Douglas, S., Simon, G., Kroenke, K. (2018) Implementing Measurement-Based Care in Behavioral Health: A Review, doi:10.1001/jamapsychiatry.2018.3329

 Lewis, C. C, Scott, K., Marti, C.N., Marriott, B.R., Kroenke, K., Putz, J.W., Mendel, P., & Rutkowski (2015). Implementing measurement-based care (iMBC) for depression in community mental health: A dynamic cluster randomized trial study protocol. Implementation Science, 10:127.

 Miller, S.D., Hubble, M.A., Chow, D., & Seidel, J. (2015) Beyond measures and monitoring: Realizing the potential of feedback-informed treatment. Psychotherapy, 52:4, 449-457.

Robinsonia, L., Delgadilo, J. & Kellett, S. (2019) .The dose-response effect in routinely delivered psychological therapies: A systematic review. Psychotherapy Research, (December 29)

 Wampold, B.E. (2015). Routine outcome monitoring: Coming of age—With the usual developmental challenges. Psychotherapy, 52:4, 458-462.

 Youn, S.J., Kraus, D.R., & Castonguay, L.G. (2012). The treatment outcome package: Facilitating practice and clinically relevant research. Psychotherapy, 49:2, 115-122.