Measurement‐based care: opportunities to improve global mental health care

Measurement‐based care (MBC) is a flexible, patient‐centered, clinical process that has the potential to improve the quality of global mental health care. It uses standardized and/or individualized patient‐reported outcome measures (PROMs) administered routinely and repeatedly during mental health treatment to track progress and guide treatment planning.

We previously proposed an operationalization of MBC called “Collect, Share, Act”, derived from the model developed by the US Department of Veterans Affairs, Office of Mental Health ¹ . In Collect, collaboratively‐chosen PROMs are administered routinely throughout care. In Share, clinicians engage patients in timely discussions of PROM data to ensure a shared understanding. In Act, patients and providers collaboratively use PROM data, along with other sources of information including clinical judgment, to assess progress and make clinical decisions about the course of treatment. Transparency, collaboration and empowerment are integral to the model ¹ . MBC can be added to any mental health practice to improve outcomes ² .

Strong research evidence supporting MBC has proliferated in high‐income countries (HIC) ² , and MBC has also been studied in middle‐income countries (MIC) ³ . There is ample evidence that MBC improves outcomes and reduces treatment dropout when integrated with psychotherapy conducted by specialized mental health providers in HIC².

Although the ideal frequency for PROM administration is currently unknown, evidence suggests that more is better. MBC processes must occur frequently enough to detect patient deterioration or lack of response to treatment, so that personalized adjustments can be made ⁴ . Therefore, providers often integrate MBC at every visit.

Symptom‐based PROMs are commonly used ⁵ , but are not required. Practitioners may individually tailor measures assessing a range of outcomes (e.g., quality of life, individualized goals, functioning) to better align with patients’ treatment goals ⁴ . Additionally, two highly‐researched MBC outcome measures monitor therapeutic alliance, because of its well‐established positive impact on mental health treatment outcomes ² . It has been hypothesized that, in addition to facilitating personalized treatment adjustments, MBC improves outcomes by strengthening patient‐provider communication, engagement and alliance, but there is little direct evidence to support this ⁶ .

It is unclear if and to what extent MBC is used in low‐income countries (LICs), as we could not locate examples in the literature. However, a major barrier to identifying global MBC research and practice is semantics. It is possible that MBC is being used in some LICs, but practices are either unpublished, or we are unable to locate published examples because of the varied and sometimes idiosyncratic terms used in the literature – including “performance feedback” ² , “routine outcomes monitoring” or even just “outcome measures” ³ – although confusingly these terms are also sometimes used to describe non‐MBC processes. Authors also commonly omit descriptions of assessment processes altogether, aside from stating that self‐assessments were utilized.

Without a clear and consistent terminology, we cannot accurately assess the current state of global MBC practice. Nonetheless, it seems reasonable to assume that MBC is not practiced routinely around the world. Because it improves outcomes and can be added to any mental health treatment ² , integrating it more widely and into more models of care has the potential to improve global mental health outcomes.

The absence of mental health specialty care systems in LICs ⁷ may be a barrier to MBC adoption, as current models of MBC are integrated into psychotherapy and other forms of specialist mental health services. Therefore, increasing integration of MBC into mental health care in LICs likely hinges on the development of creative and innovative adaptations of MBC to enhance models of care currently practiced in those countries, such as task‐sharing models that employ trained non‐specialist health professionals or non‐licensed para‐professionals to conduct mental health interventions ⁷ . MBC might make task‐sharing models more effective. Recent implementation research details effective MBC supervision and consultation methods with licensed providers that could be extended and adapted to task‐sharing models ⁸ .

Another evidence gap is in non‐clinical interventions such as care navigation, therapeutic mentoring, brief early intervention, and peer support. How might we re‐envision the basic model of MBC to enhance such interventions? Adaptations to the MBC clinical model that consider the cultures in which they are adopted should also be carefully considered. A full range of research will be necessary to support these ideas, from model development to feasibility, effectiveness and implementation studies.

LIC systems of mental health care may also be deterred from adopting MBC due to concerns around technology infrastructure and funding. MBC is often facilitated by electronic health records. There is a recent proliferation of measurement feedback systems, which are technologies designed to collect and display PROMs ⁶ . While technology may facilitate implementation, and clinical decision support added to MBC may enhance MBC effectiveness ² , globally there is an incorrect assumption that MBC requires technology. Indeed, many clinicians practice high‐quality MBC collecting PROMs with paper forms on clipboards. Technological solutions for MBC that can be developed and scaled up in LIC could be impactful, but should not be considered a prerequisite for adoption.

Underscoring these suggestions is our call for consistent definitions, careful operationalizations, and complete descriptions of MBC practice and adaptations in evaluations and publications ⁶ . To be effective, PROM data must be used collaboratively with patients to develop goals, monitor progress, and adjust treatment ⁹ . Innovative models must carefully operationalize the clinical intervention and not assume that providers know how to incorporate PROM data into clinical interventions.

Further, we cannot know to what extent MBC is being implemented when practices are poorly described. The literature is replete with references to using PROMs, but with vague descriptions such as “tracks outcomes with PROMs” or “PROMs were integrated into clinical care” or “feedback was provided”, without elaboration on PROM frequency, use and purpose. We must understand how PROMs were used, not just that they were collected. Reaching consensus around terms and operationalizing clinical interventions in research and other scholarly work is critical for identification of best practices and ultimately for advancing the field.

PROM development is another area ripe for investigation globally. Many PROMs were developed as research outcome measures, but are now used clinically because few specific MBC measures exist. Research on what makes a good PROM and how to tailor PROMs, including how to use non‐symptom PROMs – such as those measuring recovery, well‐being, functional status, quality of life – as well as better understanding of the use of individualized PROMs, would help providers adopt MBC with more patients and treatments, and may add value ⁵ , ⁶ . Co‐development of new PROMs with patients would help us measure what patients truly find important ⁵ . Finally, to expand MBC geographically, we must develop more PROMs in a range of languages, with content incorporating non‐Western cultural perspectives ³ .

MBC improves mental health outcomes ² and can make mental health treatment more collaborative ¹ . The increased adoption of MBC and development of novel adaptations suitable for a range of mental health interventions may improve global mental health care effectiveness and patient‐centeredness. We call on the global mental health community to explore MBC in a wider range of interventions and settings, while using consistent terminology and operationalizations to optimize our ability to communicate with and learn from each other.