Measurement Based Care Controversies

Peter ForsterBest Practices

Measurement Based CareMeasurement based care often evokes controversies. A brilliant colleague, Carol Heckler, who is something of a local expert in psychopharmacology, interrupted a conversation I was having with another psychiatrist to say that she thought that standardized rating scales were useless. Echoing comments that I’ve heard from many of my patients, she said “how can you reduce human experience to a number?”

This sparked a lively conversation at dinner, but the next day I had a clinical example that I think perfectly illustrates the compelling value of doing so, despite all of the flaws inherent in trying to summarize complicated data about mood in a series of numbers.

A woman I’ve been seeing for a couple of years and who had been doing quite a bit better suddenly experienced a dip in mood and a return of suicidal ideation and helplessness. It has been a struggle to help her come out of this chronic depression and she started to feel that the effort was not worth it. She said, “I’m never going to be out of this depression.”

I knew of course that this would inevitably lead her to suicidal thoughts so I found myself suddenly immersed with her in that sense of hopelessness. This process is perhaps more common than you might imagine: pessimism and hopelessness can be quite contagious and even though I’m pretty good at avoiding getting caught up in it, sometimes it feels overwhelming.

Pessimism and hopelessness can be quite contagious.

It has been a lot of hard work for me as well as her trying to find adequate treatments for her depression. That also makes it easier to sink into pessimism.

In our session, I said that I would take some time over the weekend and review the information that we have about her treatments and how she’s been doing over the course of the last couple of years.

Because we have a couple of different ways that we have been keeping track of her mood – she has a daily mood check in, and a weekly Beck Depression Inventory that she fills out, and I also fill out a weekly inventory of depressive symptomatology – this process and the overlaying on it of data about her treatment experience took a couple of hours. It is not something that many or perhaps even most psychiatrists would do.

Analyzing the Data

Before I started the analysis, we thought that we knew one thing – mirtazapine definitely seemed to help her mood a few years ago when we started that medication. I also had a vague sense that there had been progress made since she first came in to see me, although she did not feel that was true.


The easiest first step was to download the daily mood chart that she had been filling out throughout much of the time we saw each other. That chart has “best mood” and “worst mood” of the day where a higher number is better. The result was definitely not encouraging. It seemed to show her mood getting generally worse.  Fortunately I know that daily mood data can lose its validity over time, especially when there are no “data

Daily Patient Mood Ratings. Lower is worse.

anchors” to define what each mood feels like… In other words, ratings tend to gradually go up or down without any change in overall mood…

I was definitely feeling discouraged at this point. Maybe she was right. Nothing was working for her…

Something about this theory just didn’t make sense.

I recalled that she had just finished a period of three months without significant depression. Why was that not showing up in  the results?

I decided to add in her weekly ratings using the Beck Depression Index. This data looked very different. On the graph below you see the opposite trend, one showing improving mood over time (I graphed all the data so that higher means better mood). Why does the Beck Depression weekly data look so different from the daily mood rating? I think it is because the weekly data relied on a series of questions that asked for specific descriptions of mood. How often did she have suicidal thoughts? How long did it take her to get to sleep, etcetera…

Daily Mood Ratings versus Weekly Beck Depression ratingssleep. Anchored questions are one of the reasons that standardized rating scales are often better than just asking “how are you?” The answer “great” or “OK” can mean many many different things.

Finally, we added information about the treatments, including medications, that she had been receiving and this completed the story and allowed us to think much more constructively about what to do next.

The medication information showed that each of those dips was associated with a decrease in her dose of one particular medication (aripriprazole).

Ironically, before we completed this assessment, it was precisely that medication which my patient was wanting to lower again. “Because nothing is working and so I don’t want to be on so many medications.”

Mood Chart with Medication Changes

Aripiprazole reductions were associated with mood worsening.

For More Information

Measurement Based Care Improves Outcomes

Mood Charting