Case-Based Review

Using measurement-based care to improve outcomes for patients with depression

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Ms. H, age 42, is being treated by her family physician for her second episode of major depressive disorder (MDD). When she was 35, Ms. H experienced her first episode of MDD, which was successfully treated with fluoxetine, 20 mg/d, for 9 months. The current episode began approximately 3 months ago, and there were no known precipitating factors. Because Ms. H had responded well to fluoxetine, her physician reinitiates fluoxetine, 20 mg/d, for 8 weeks.

At the 8-week follow-up appointment, the physician notes how much better Ms. H seems to be doing. He says that because she has had such a good response, she should continue the fluoxetine and come back in 3 months. Later that evening, Ms. H reflects on her visit. Although she feels better, she still does not feel normal. In fact, she is not sure that she has really felt normal since before her first depressive episode. Ms. H decides to see a psychiatrist.

At her first appointment, the psychiatrist asks Ms. H to complete the Quick Inventory of Depressive Symptoms–Self Rated (QIDS-SR) scale. Her QIDS-SR score is 6, which is consistent with mild residual symptoms of depression.1 The psychiatrist increases the fluoxetine dosage to 40 mg/d and recommends that she complete a course of cognitive-behavioral therapy (CBT).

Although psychiatry currently does not have tests that provide continuous data such as blood pressure or HbA1c, well-validated rating scales can help clinicians in getting their patients to achieve symptom remission. Measurement-based care is the “systematic use of measurement tools to monitor progress and guide treatment choices.”1 Originally, psychometric rating scales were designed for research; typically, they were administered by the clinician, and were too long to be used in routine outpatient clinical practice. Subsequently, it was determined that patients without psychotic symptoms or cognitive deficits can accurately assess their own symptoms, and this led to the development of short self-assessment scales that have a high level of reliability when compared with longer, clinician-administered instruments. Despite the availability of several validated, brief rating scales, it is estimated that only approximately 18% of psychiatrists use them in clinical practice.2

Self-rated scales for depression have been shown to be as valid as clinician-rated scales. For depression, the Patient Health Questionaire-9 (PHQ-9), based on the 9 symptom criteria associated with a diagnosis of MDD, is likely the most commonly used self-assessment scale.1 However, the QIDS-SR and the Beck Depression Inventory are both well-validated.1 In particular, QIDS-SR scores and score changes have been shown to be comparable with those on the QIDS-Clinician Rating (QIDS-C) scale.3 A 50% decrease in score typically is defined as a clinical response. Remission of symptoms is often defined as a score ≤4 on the PHQ-9 or ≤5 on the QIDS-SR (Table1). Similar to laboratory tests, rating scales are not diagnostic, but are a piece of information for the clinician to use in making diagnostic and treatment decisions.

The use of brief rating scales can help identify symptoms that may not come up in discussion with the patient, and it provides a systematic method of reviewing symptoms. Patients may be encouraged when they see a decrease in their scores after beginning treatment.2 Patients with depression need to complete rating scales frequently, just as a patient with hypertension would need their blood pressure frequently monitored.2 Frequent measurement with rating scales may help identify residual depressive symptoms that indicate the need for additional intervention. Residual depressive symptoms are the best predictor of the recurrence of depression, and treatment to remission is essential in preventing recurrence. In fact, recurrence is 2 to 3 times more likely in patients who do not achieve remission.1

Continue to: Optimizing the use of self-rating scales...


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