Major Depressive Disorder Podcast

Applying Measurement-Based Care in Major Depressive Disorder

Madhukar Trivedi, MD; Bradley Gaynes, MD, MPH

Disclosures

July 13, 2022

This transcript has been edited for clarity.

Madhukar Trivedi, MD: Hello. I am Madhukar Trivedi and welcome to Medscape InDiscussion on major depressive disorder. Today we are going to talk about evidence-based care and how best to deliver it with measurement-based care guidelines, collaborative care, etc. I want to first introduce our guest, Dr Brad Gaynes, who is professor of psychiatry at University of North Carolina, Chapel Hill. He is a well-known clinical translation and implementation scientist. He has done large-scale clinical trials as well as implementation work with measurement-based care. This is wonderful — welcome, Brad.

Bradley Gaynes, MD: Thank you.

Trivedi: I will jump right into the topic. Dr Gaynes, I'd like you to give a sense of how someone begins to treat depression in their private practice, in psychiatry settings, or in medical centers. Currently, as you know, even in the most well-organized places, a lot of clinical care happens with interview-based decision-making. Can you give us a sense of how one would move from there to best deliver the care we have using measurements?

Gaynes: The question of how to start applying measurement-based care and how to initiate it, Madhukar, is a really good one. One of the things I've observed and one of the most important things to get over is the idea that applying measurement-based care means you're just looking at numbers, and you're not actually interacting with or working with or collaborating with patients to help them better treat their depression. That's a key piece because one of the great benefits and one of the things that measurement-based care taught me is that it provides a systematic approach. But then you bring more to it. The first step is to appreciate that when we're applying measurement-based care, using the measures is an important part, but not the whole part, of what clinicians bring to their interactions with patients. Once we are comfortable knowing that measurements are just a part of what we do, it's easier to begin using them. And then the next barrier is a logistical one about how best to apply measurement-based care wherever their setting is, and this setting can change.

Trivedi: I'm going to interrupt you because you stated one of the most important points about measurement-based care. I'd love to get more of your thoughts on it, which is exactly what you mentioned — that measurements are just the beginning. A lot of clinicians say that if you just do measurements, you're not talking to the patient. The other aspect they run into is whether you are repeating yourself with measurements and what the value is. It sounds like what you were saying is measurements bring your conversation to a starting point. Can you talk about how you use these measurements?

Gaynes: That's exactly correct. It begins the conversation, and it does a couple of things. An important one is that it helps identify what some of the more distressing symptoms are for the patient. And this becomes a very useful focus for what you're discussing and when you're trying to decide the best way to modify whatever your treatment is. Someone may have, and may indicate that they have, a mildly depressed mood. But the problems they are having with sleep or maybe with energy are by far the most distressing to them. And they may or may not spontaneously offer this to you. Some clinicians may or may not ask about these things when a patient is filling out a depression symptom measure. This question will always be asked [on the self-report], and you can decide then whether to discuss it more or not. A lot of patients may say things like, “I think my depression is a whole lot better.” But then you look at their self-report and it indicates they're having serious problems with sleep about every day of the week all the time. This gives you something to focus on, and it allows you to do two things. Number one, it makes patients think you're hearing them better. You're actually hearing them more, and you're listening to them more. Number two, you can modify your treatment so what you're doing addresses what's most distressing to them. Then, patients feel not only like you're hearing them but you're also helping them get better in what seems to be the most important area to them.

Trivedi: This also leads to, in terms of how to address workflow time issues, the fact that for some aspects of monitoring disease we do as psychiatrists, self-reports are better able to [inform] us. For me to ask everything about sleep de novo, it takes a lot of time! Instead, patients have filled out a self-report. There's nothing magical about my asking, “Did you sleep 4 hours or 6 hours?” If they're able to self-report this on a rating instrument, it then allows me to say, “It sounds like sleep is not a problem, but this [other issue] is a problem,” like you were saying. Does that make sense?

Gaynes: It does. It helps make your interview time with the patient that much more efficient. You can focus on the things that are distressing them the most. Just to remind our audience, we're certainly not limited to the nine depression items that are listed in any measurement-based scale. You might be using those, and those are part of what we ask. But a lot of times what I'll do to add on to this is to say something like, “We're making these changes; we'll meet up again in 3 or 4 weeks.” How will I know that what we're changing today is actually working 3 or 4 weeks from now? What am I going to see that will help me know the treatment is working? In addition to having the self-report or measurement-based score, it can also give us an important outcome or two to follow. Again, this discussion is something that naturally evolves from talking first about symptoms on a scale and then talking about other symptoms that are important to the patient.

Trivedi: I assume that when you talk about measurement-based care, you are including ratings about depression, anxiety, adverse events, and whether a patient takes their medications regularly or not. Are a number of these aspects included in your approach to measurement-based care?

Gaynes: That's exactly right. When we're looking at ways to systematically approach patient care, there'll be a symptom evaluation. It could be for depression or anxiety or some kind of stress-related disorder. So, for one of the common mental disorders, we're assessing someone's medication toleration by a side effects scale. We haven't found a best scale to use there, but we will ask a couple of specific questions. We have patients rate themselves, and we'll use that to follow [their progress]. We want to have some measure of the level of functional impairment they have, and we'll use that to help gauge where we are. Let me just say something about that first symptom scale — the depression severity scale; we've done a number of comparative reviews about how accurate these different depression scales are, whether they're interview-based or -administered or self-reported. By and large, they all work pretty well, and they all work about the same way. The most important thing is to find one that works best in your setting; for some, it may be the Patient Health Questionnaire–9 (PHQ-9); for some, it might be a quick inventory of depressive symptomatology; for others, it may be something else. I think the key thing is to select one scale, be comfortable with it, use it as a starting point, and then just keep following it over time. It's not something you do once. It's something that helps guide you as you're working with a patient over time to help them feel better.

Trivedi: We'll come back to this. I'd love to for you touch on [the logistics of measurement-based care] because you've done this with a lot of large-scale networks in your studies currently, and we did it with the Texas Medication Algorithm Project (TMAP) and the STAR*D trial. Give us a sense of the logistics. If somebody listening to this got excited and said, “Sure, I'll do it,” but then worries about how best to put it in practice, how should they think about the logistics?

Gaynes: Like we said, you begin after you become comfortable with the screening tool or whatever depression assessment tool you're going to measure with. You implement it and you score it. Essentially, with any of the scales, you'll be able to get some sense of whether the depression is a mild degree of severity, a moderate degree, or something more severe. You are able to categorize these levels for folks who meet the criteria for a major depressive episode, but it's a pretty mild degree. You might talk with them about whether they would prefer to begin with some kind of evidence-based psychotherapy or some kind of medication. If they score as moderate or more, we'll recommend they begin with at least the medication. At that time, we would talk about the risks and benefits of the medication, plan to start it, and educate them about what side effects to expect and how long it might take — 2-3 weeks — before they start to see some benefit. We'll talk about how when we meet back in 3 or 4 weeks, we're going to measure again. In that way, the patient becomes more of an active collaborator in their care. They have some say and some input and are part of assessing how well they're doing. And they are also part of the conversation. They can help identify the things that are most disturbing to them that they need the greatest help with. It's starting to get patients used to the idea of measuring during their meeting with you, and it's also something they can follow when they're not with you.

Trivedi: It almost feels, in our experience together, that it is a self-education tool for the patients. They now begin to recognize the targets for treatment.

Gaynes: Exactly.

Trivedi: And they can, like you're saying, keep self-monitoring between visits. What I also find from time to time, as you just pointed out, is that some patients will then remind you that these measurement tools are wonderful. They may say, “I'm answering the questions. This helps me. But it missed these other aspects that still bother me, like irritability, anger, and attacks.” And maybe you can add your measurements, but even if you don't, recognize that there is more distribution of symptoms in this person's life that is affecting their function. It allows for a broader understanding of the disease and the targets for treatment.

Gaynes: Yeah. What we found is that the more we've used measurement-based care, the more there's a discussion with the patient about what it is that's really disturbing them and the things we need to focus on. It opens up what we've been working on with them rather than shutting it down.

Trivedi: The good news is when we started doing TMAP and the STAR*D studies, everybody was willing to do it. And if you remember the American Psychological Association (APA) guidelines that came out in 2000 — I was on the guideline panel — they allowed for measurement-based care. But the question was whether it was better than the comparator. And now we have randomized controlled trials showing that patients treated using measurement-based care do better than those treated using just expert care. So, measurement-based care really helps more, in my view. What it does is eliminate guesswork. It helps with timeliness in decision-making, whereas without measurements, people would take longer to make treatment changes. Now the scores are in front of you and the patient is discussing with you, so you make decisions faster. Is that fair to say?

Gaynes: That is exactly right. You've talked about what much of the clinical trial work over the last 20 or 25 years has shown. Really, each one of those pieces you've talked about — you know how well the screening works. The screening leads to improved identification of disease. Does it lead to more effective treatment? Does it lead to a better outcome? All these puzzle pieces have a lot of evidence to support them, and that's why the US Preventive Services Task Force now recommends routine screening. The evidence is there. If you screen and monitor, and you have an adequate support system, it allows you to continue to monitor and follow up and make changes when you need to. That's why they recommend this in primary care. That's why, like you're saying, the APA guidelines now support measurement-based care like this. That's why the American College of Physicians has adopted much of what the US Preventive Services Task Force and the Agency for Healthcare Research and Quality identified, which is to use measurement-based care. Do this systematically, discuss things with your patients, and the outcomes will improve.

Trivedi: One final word on this. There has been a lot of attention since we did the STAR*D study on using measurement-based care to drive medication management. But there is now increasing evidence that the same can be applied to psychosocial intervention and psychotherapy patients because you're still monitoring their progression.

Gaynes: It's funny you mentioned this because as I was thinking about what we might discuss today, one of the things I was going to say is that I spent a fair amount of time as a cognitive behavioral therapy scholar learning — in-depth for a number of years — cognitive behavioral therapy. I appreciated how much actually understanding these general precepts about cognitive behavioral therapy made me a better provider of measurement-based care. In fact, like you just said — whether you're treating depression, whether you're treating it with medication, or whether you're treating it with an evidence-based psychotherapy — all these same principles apply, and they work. You get into that same sort of discussion with patients, and patients are an active part of collaborating with you to figure out the next steps. I should also point out that some of the work you do and that I'm doing looks at applying similar measurement-based care principles in low- and middle-income countries. They work there, too. In fact, if you look at a lot of the problem-solving therapies used there, they have common elements. They're quite consistent with measurement-based care and with our approaches to managing illness with psychotherapy or medication. They all kind of fit together.

Trivedi: It sounds simple, but the idea is actually that measurement-based care is routine care for all medical illnesses, and we have been lagging. This really brings us to that point. One of the things that all of my experience using measurement-based care has highlighted from time to time is that patients may come in, and their symptom rating instrument scores improve quite a bit, and they are doing better. But this doesn't always have commensurate functional improvement. Let me highlight, this is a group of patients for whom their symptoms, as outlined by our rating instruments, get better, but then you have to still think about adding interventions to address the functional impairment — things like behavioral activation, etc. Measurement allows us to also think about that.

Gaynes: Measurement allows us to identify in what areas treatment is working, and it can allow us to realize that the areas we're measuring all seem to be better, yet the patient is still not functioning that well. There are additional areas we need to be able to evaluate, and the interventions may be different. Now, it may be that most of the patient's symptoms are better, but their low energy is really preventing them from moving toward recovery, and this might guide what medication we add. Or, it may be that there are other psychological barriers to their improving, and then we might look at the best psychotherapy piece to add or to emphasize, as you mentioned — behavioral activation and motivational interviewing. There are a number of ways to fine-tune or tailor the treatments a particular patient needs in order to recover.

Trivedi: Fantastic. Just for the sake of making sure we're being comprehensive in talking about rating instruments — like you, my answer to the question “Is this better than the other?” is yes because both of them are the same. It seems to me, at least in the majority of cases for depression, that self-ratings perform comparably to clinician ratings. Is that fair to say?

Gaynes: That is correct. When you're thinking about self-rating tools, you'll think about the PHQ-9. That's the one most people are probably familiar with — the quick inventory for depressive severity. There's a self-rating version of that — a 16-item scale that works just as well as the PHQ-9. If you're comparing the two, the 16-item scale is a little bit longer than the PHQ-9. It also provides some information that the PHQ-9 doesn't about better or worse changes in sleep or appetite. So, it offers more information at the cost of a little bit more time. There are clinician-administered tools that are quite common in clinical trials. They take some specific training to be able to administer correctly, and they will take more time than the self-report measures, like the Hamilton Depression Rating Scale or the Montgomery and Åsberg Depression Rating Scale. Those both work as well as each other. In studies where we've compared the accuracy of those clinician-administered scales to the self-report scales, they work about the same. There's no clear difference between the two. So, we're happy with whatever someone wants to use. It's largely a matter of logistically which one works best in your setting. Just make sure you understand the pros and cons of that specific scale; there are lots of options.

Trivedi: They're wonderful. Someday we hope our health systems will get to the point, like we have been arguing for a long time, that primary care communicates with psychiatry and psychology and so on, but also that these measurement tools will provide a much better language to translate across settings.

Gaynes: People are spending a lot of time finding other ways to allow these measurement tools to become a standard part of medical assessment, such as the medical record, and the larger electronic health records. There are ways, too, that this can become a standard part of what a person will fill out when they come in for their primary care, psychiatric care, or HIV care appointment. Follow up to ensure they'll fill out a screening tool right there each time they come in. Then that can get quickly measured and placed into the medical record, and the physician can take a look and say, “Well, well, look at this. This looks a little distressing here. Tell me about how poor your sleep is.” Then this becomes a standard part of what people do. It's built into the system itself.

Trivedi: Thank you so very much, Brad. It's been a wonderful discussion. Maybe give one final thought summarizing your leaving message. What would you say?

Gaynes: I'd say the great benefit of measurement-based care is that it is a nice marriage between a systematic approach we want to make sure every patient will get, and the opportunity to allow things that might be more specific about the patient to filter in. So, it allows you an opportunity to discuss a number of symptoms or targets your patient might want to improve on, and it helps make patients become a more active and collaborative part of what you want to do. This is really what you want to do. You want to be able to identify what's most distressing and what the patient wants out of the encounter. You want a very consistent way of monitoring this, and you want the patient to be a collaborator in their recovery and in measurement-based care. Measurement-based care does all these things wonderfully.

Trivedi: Well, it was a true pleasure. Thank you very much, Brad. I hope everybody finds this discussion very useful.

Gaynes: Thank you.

Resources

Patient Health Questionnaire-9 (PHQ-9)

Clinical Results for Patients With Major Depressive Disorder in the Texas Medication Algorithm Project

Depression, IV: STAR*D Treatment Trial for Depression

APA Clinical Practice Guideline for the Treatment of Depression Across Three Age Cohorts

The Efficacy of Measurement-Based Care for Depressive Disorders: Systematic Review and Meta-analysis of Randomized Controlled Trials

Final Recommendation Statement – Depression in Adults: Screening

Nonpharmacologic Versus Pharmacologic Treatment of Adult Patients With Major Depressive Disorder: A Clinical Practice Guideline From the American College of Physicians

The 16-Item Quick Inventory of Depressive Symptomatology (QIDS), Clinician Rating (QIDS-C), and Self-report (QIDS-SR): A Psychometric Evaluation in Patients With Chronic Major Depression

Hamilton Depression Rating Scale (HAM-D or HDRS)

Montgomery and Åsberg Depression Rating Scale (MADRS)

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