Measurement-Based Care for MDD is Essential, Experts Emphasize

"You cannot manage what you do not measure," says Psych Congress Steering Committee Member Saundra Jain, MA, PsyD, LPC. Although studies have shown that the use of measurement-based care in psychiatric treatment drastically increases rates of patient improvement, it is still not a widespread practice. At Psych Congress 2022 in New Orleans, Louisiana, Dr Jain and Manish K. Jha, MBBS, discussed the treatment approach in their session "Measurement-Based Care in Depression and Beyond: What is it and how to make it work for your patients?" Psych Congress Network sat down with them following their presentation to learn what clinical pearls they hoped attendees would glean, what other tools are available to physicians, and how the medical community can improve measurement-based care going forward.

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Saundra Jain, MA, PsyD, LPC, is an adjunct clinical affiliate, school of nursing, at The University of Texas at Austin. She is focused on wellness and the impact of positive psychology on client outcomes. In 1992, she launched a private practice of psychotherapy where she currently provides services for a wide range of mental health issues. Dr Jain is a co-founder of the WILD 5 Wellness Program, which combines five elements of wellness (exercise, mindfulness, sleep, social connectedness, and nutrition) along with positive psychology practices into a prescriptive, simple wellness program. She is co-author of two well-received workbooks written for those interested in improving their mental wellness - KickStart30: A Proven 30-Day Mental Wellness Program and LiveWell90: A Proven 90-Day Mental Wellness Program. Dr. Jain is active in peer-to-peer education especially in the disease states of depression, bipolar disorder, anxiety disorders, and ADHD. Another strong clinical and educational interest involves differential diagnosis of major psychiatric disorders. She serves as a member of the Psych Congress Steering Committee providing direction regarding educational gaps/needs for health care practitioners in the world of mental health. Dr Jain obtained her master's degree from the University of Houston-Clear Lake and a Doctoral degree from Southern California University for professional studies; she is a licensed professional counselor. She demonstrated professional versatility by obtaining an MBA from Texas Woman's University. She was selected for a postgraduate clinical fellowship at the University of Texas Medical Branch, Galveston, Texas where she trained in the division of child and adolescent psychiatry.

Manish Jha, MBBS, is assistant professor of psychiatry at the Center of Depression Research and Clinical Care at UT Southwestern Medical Center, Dallas, Texas. He conducts clinical research that aims to identify the biological mechanisms of depression, anxiety, and substance use disorders in order to inform the development of novel treatments. He received his medical degree from Maulana Azad Medical College in New Delhi, India, and completed his residency training in psychiatry at UT Southwestern Medical Center, Dallas, Texas. He is a member of the Society of Biological Psychiatry and American Society of Clinical Psychopharmacology. In addition to his research and educational activities, Dr Jha maintains an active clinical practice focusing on evidence-based interventions for difficulty-to-treat depressive and anxiety disorders. He has received travel/new investigator awards from several national and international societies. He has authored/co-authored over 100 manuscripts.

Read the Transcript:

Dr Saundra Jain:
Hi, my name is Dr. Saundra Jain, and I'm an adjunct clinical affiliate at the University of Texas in Austin with their School of Nursing. And I also have a private practice in Austin, Texas.

Dr Manish Jha:
Hi, I'm Manish Jha. I'm an assistant professor of psychiatry and an O'Donnell Clinical Neuroscience Scholar at UT Southwestern. And I practice as a psychiatrist at the medical school, too.

Jain:

I thought about this a lot, Manish, after we presented. And I think some of the really important takeaways, the first 1 and the 1 that I think I carry with me is that you cannot manage what you do not measure, and that 1 I think is just solid good advice. I think the other 1 is that measurement-based care is not just about giving a piece of paper to our patients to fill out. It's not like... We had a comment like being a bean counter, like counting the reduction of symptoms. It's really much richer than that. It's an opportunity to really engage with our patients in what you so beautifully talk about, shared decision making. I think that is 1 of the major benefits of measurement-based care. And then I think also we talk a lot in mental health about evidence-based care, evidence-based practices. And what I think is important for you and I and our colleagues to really just carry the torch and share with people is that measurement-based care is evidence-based care. So for me, those are my takeaways from our talk.

Jha:
Right. And I completely agree. And what I took away is that if this was a drug, it would be FDA approved, that is the amount of magnitude of improvement.

And what the piece that we added together is that focusing not just on symptoms, but also on function, also on wellbeing, quality of life, so that we move the needle beyond just focusing on symptoms and moving to what matters to our patients. And within the context of medication management, at least, which is where my practice mostly is, it's also measuring side effects and measuring adherence. So those, the 3 pillars for medication management, measurement-based care, is symptoms plus function, side effect, and adherence.

Jain:
I love that. As you were talking about it during the presentation, I kept thinking, "How much time do I spend in a regular 50-minute session with patients talking about, 'Hey, how's your medication been? Are you taking it? Are you having any difficulty with remembering?'" All sorts of really rich conversation. "And what side effects are you having?" And what I find, I'd be so curious to see what your patients are telling you, but oftentimes they'll say, "Yeah, I've had some side effects. I don't know if I'm going to keep taking the medicine." "Have you called the prescriber's office? Are you..." "Well, no. No, no, I've got an appointment in about 2 weeks, maybe 3 weeks. I'm not really sure. I'm just going to wait."

And I feel like that's just this prime opportunity to say, "Oh, please don't wait. Let's make an agreement that you'll make that call today. Because it's just a missed opportunity to really step in and reevaluate." So I see psychotherapy in some ways as we become this beautiful conduit between patients and the rest of the treatment team, right? I mean...

Jha:
Yeah, no. And I think what you do is amazing because then we are getting multiple sources of information reinforcing the message that we have to. And whenever I start, I often talk about the first thing I would ask you about is not how much better you got with the medication, but what side effects are you having? Because I want to know probably on the third day if you're having any side effects, fourth day, when I'm not expecting any improvement in symptoms with conventional antidepressants. But I definitely want to avoid a side effect that leads to then either too much burden or discontinuation or things like that.

Jain:
And how often patients will tell me, "Nah, I'm not taking it anymore. I got a really bad headache or it really upset my stomach, so I just quit taking it."

Jha:
Yep, yep. I mean, 1 example comes to my mind just now are young individuals from Austin who had initially taken a medication that they said didn't work for them, but that was the only thing they were open to taking again, because they felt like it was helpful. And what had happened was that they had gone up on the dose too fast and found that they couldn't tolerate it. So this time around, we went up gradually and they could tolerate it and they could take it. So the measurement-based piece of monitoring side effect and adherence is a very important aspect for medication management. So that, yeah...

Jain:
I love that. And in preparation for our talk, you mentioned a tool that you use, if I... FIBSER? Would you talk about that? Because I think it's just a great... It just makes it so easy to ask those questions.

Jha:
Well, I do not take any credit for that. This comes from John Rush and Madhukar Trivedi, two of my mentors. And really they created that scale for the STAR*D study because they were talking about these side effect rating scales and what to do. And really the acronym is Frequency, Intensity and Burden of Side Effect Rating scale, so FIBSER. And it's the 3 items that essentially ask about what frequency, what is the intensity, how mild, moderate, severe. And again, we have to keep in mind that the burdensome nature of a side effect may have nothing to do with the frequency or intensity, right?

Because I'm making an example here. If the medication causes diarrhea, right? I mean, an even slight diarrhea, it becomes very burdensome if my employment is driving cars around for Uber and that way if I live in New York City. So that really drives whether a person is going to continue or not, and the skill becomes a starting point for that conversation and not just an end-all that a number gives us what we are going to do. So that misconception that these numbers will drive what I do, they just inform what we do.

Jain:
I like that. And also, what you said about scales being this conversation starter, this way to engage around side effect, burdensome, all those things, adherence. I don't know if you agree with this, but I see them all that way. That certainly we can measure symptom reduction functionality, all those things we've been talking about, but it's a conversation starter.

It's also patient education that they may not really understand what the symptom clustering looks like for any disorder. The one that comes to mind that I think is so common in my practice is for bipolar disorder, that they don't really understand really the breadth of the impairment or the symptomatic presentation. So I see these tools as they're multifaceted, they do a lot of things and do a lot of things very well.

Jha:
I completely agree, completely agree. I just want to add one piece to this conversation, which is when we look at the literature, so we talk about common scale, like the patient health questionnaire 9-item, a score of 10 or more on PHQ-9 has a very high sensitivity specificity for diagnosis of MDD. So often a notion could be generated that that's how we diagnose, but that is not the case. We still need to use our clinical judgment. So a score by itself does not make a diagnosis. That's what we have to... Those measurements inform clinical decision, they do not replace clinical decisions.

Jain:
That's beautifully stated. And I wonder, I mean, I think about the last 20 years of educating clinicians, talking about the importance of differential diagnosis, how we can use measurement-based care to do that. How often do you run into colleagues, people that you meet that are struggling with this idea of measurement-based care? Do they feel like this description, what you just described?

Jha:
So unfortunately it is very, very way more prevalent than I would want to ever acknowledge. And this is even prevalent in places where a lot of measurement-based care work has happened. So if you go around the country, and I do that sometimes doing presentation for the residents, just ask them how often do they have measurements in their clinics? Because third-year psychiatry residents often have an outpatient clinic, and you would invariably find that no measurement is happening there, right? So this is still... And that's why we are having this conversation is the more we talk about it, the more hopefully people will start using it and the more widespread this practice will become.

Jain:
Yeah. I mean, when you were mentioning your mentors, I was reminded of Dr Rush. And early on when he began looking into measurement-based care and he became the spokesperson, if you will, for the importance. I remember once I heard him speak, and I'll never forget this. He said, "In my experience, probably less than 10% of psychiatrists are using measurement-based care." And I remember thinking, "Did he say less than 10%?" And then this morning, Tom Insel at the opening was talking about I think it was maybe up to a little bit less than 20% of psychiatrists are using measurement-based care. So, yay, we've made some movement. But what really spoke to me is, well, we've got 80% room for more improvement. So maybe that really is the reason we're having this conversation and talking with our colleagues.

Jha:
Yeah. And it has to start early. The earlier in our education that we tell talk about it, the better it is. Now I'm reminded of another statistic, we never published it. But more than 5 years ago, let's say, we pulled data from a large health system and how many in their electronic health record, how many PHQ-9s were documented? And there were no more PHQ-9s documented in the urology clinic than in the psychiatry clinic.

So this notion, I completely believe that Dr Rush saying that less than 10% of us do it because the data does support that. We don't see it being often used. So Psych Congress family, we have to be at the vanguard of that, talking about doing measurements that how important it is, because it does help. Even as the treatment-resistant depression expert, when I'm seeing someone who has a 10 year history of treatments, what treatment changed worked is very difficult to gauge without actual PHQ-9 or some rating scale at each of the time point that they were seen.

So I have to say that I've more recently seen those scales. I've seen it more being more implemented. So I'm hopeful that change is happening. And, yeah, we need to do a better job. Yeah.

Jain:
Such a good point. Well, I think we should continue to have these conversations. We should continue to present and really thinking about evidence-based care, we should really partner and start publishing.

Jha:
Definitely. And I think Psych Congress has this unique position to lead the charge so that we are spreading the word about measurement-based care in the whole community and not just at few academy centers.

Jain:
Oh, I like that. Yeah, that's great. I like this idea that it starts in the community.

Jha:
Yeah.

Jain:
Beautifully stated.