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The role of measurement-based care in supporting communication and clinical decision-making in youth mental health care

Amanda Jensen-Doss, Ph.D.

Professor, University of Miami

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Disclosures

I have no financial conflicts of interest to disclose related to this presentation

Work presented here was funded by the National Institute of Mental Health: R01 MH106657 (MPIs Ehrenreich-May & Jensen-Doss), R01 MH106536 (PI Ginsburg), R34 MH118316 (MPIs Jensen-Doss & Douglas)

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We’ve come a long way.

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What we need now….

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The process of evidence-based practice

Evidence-Based Initial Assessment

Theory-Driven Case Conceptualization

Evidence-Based Treatment

Evidence-Based Ongoing Assessment

Patient Characteristics, Culture and Preferences

Research Base

cite

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What is Measurement-Based Care (MBC)?

Systematic data collection of patient-reported measures to monitor treatment progress and inform clinical and organizational decision-making

Clients fill out regular assessments

Clinicians review progress

Organization reviews practice-level results

(Bickman, 2008; Scott & Lewis, 2015)

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The Role of MBC in Youth Clinical Care

Enhance Communication

Enhance Engagement and Alliance

Identify Target Problems

Multiple Informants

Catching When Treatment is Off Track

Understanding Why Treatment is Off Track

Decisions about Termination

Support case conceptualization

Jensen-Doss, A., Douglas, S., Phillips, D. A., Gencdur, O., Zalman, A., & Gomez, N. E. (2020). Measurement-based care as a practice improvement tool: Clinical and organizational applications in youth mental health. Evidence-based practice in child and adolescent mental health, 5(3), 233-250.

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MBC as a tool to reduce disparities

Barber, J., Childs, A. W., Resnick, S., & Connors, E. H. (2024). Leveraging Measurement-Based Care to Reduce Mental Health Treatment Disparities for Populations of Color. Administration and Policy in Mental Health and Mental Health Services Research. https://doi.org/10.1007/s10488-024-01364-4

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MBC is increasing viewed as an essential part of high quality, evidence-based care

Consensus Statement: Evidence-based practice decision-making for mental and behavioral health care
“….Evidence-based practice includes ongoing measurement and evaluation of the impact of services and, if necessary, outcome-informed adjustments to services that are intended to maximize their effectiveness….”

http://caaps.web.unc.edu/summit-on-mental-health-care/evidence-based-practice-consensus-statement/

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MBC is increasing viewed as an essential part of high quality, evidence-based care

https://www.jointcommission.org/accreditation-and-certification/health-care-settings/behavioral-health-care/outcome-measures-standard/

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But it is still not standard practice

Individualized

Standardized

(Jensen-Doss et al, 2017, 2018)

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A bit about me….

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Key limitations of MBC research

Lack of studies in youth populations
Lack of information on effective MBC implementation strategies
Lack of consensus on what practices comprise fidelity to MBC

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�Does the Research Show that MBC Improve Outcomes?

General consensus: Yes

At least 9 review articles and one recent meta-analysis have found that MBC improves outcomes and decreases treatment dropout
Small effects

Cochrane reviews: ???

Questions about the quality of some studies
Limited number of studies in youth

(e.g., De Jong et al., 2021, Lambert, 2015; Tom & Ronan, 2015; Gondek et al., 2016; Bergman et al., 2018; Kendrick et al., 2016)

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Effectiveness trial in 19 community mental health clinics
196 adolescents with emotional disorders
174 (not a typo!) clinicians
Conditions

Treatment as Usual
Treatment as Usual + MBC (TAU+)
Unified Protocol for the Treatment of Emotional Disorders in Adolescents + MBC (UP-A)

MBC System: OQ Analyst

R01 MH106657 (MPIs: Ehrenreich-May & Jensen-Doss), R01 MH106536 (PI: Ginsburg)

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COMET Adolescent Participants	Whole Sample N = 196	Connecticut Site N = 93	South Florida Site N = 103
Age M (SD)	14.7 (1.7)	15.1 (1.7)	14.3 (1.6)
Gender
Cisgender Male	33.2% (65)	33.3% (31)	33.0% (34)
Cisgender Female	65.3% (128)	64.5% (60)	66.0% (68)
Transgender- Female to Male	1.0% (2)	1.1% (1)	1.0% (1)
Other	0.5% (1)	1.1% (1)	0% (0)
Ethnicity
Hispanic/Latinx	41.3% (81)	28.0% (26)	53.4% (55)
Race
Black	23.5% (46)	11.8% (11)	34.0% (35)
White	60.7% (119)	68.8% (64)	53.4% (55)
Other/multiple	12.2% (24)	16.2% (15)	8.8% (9)
Not reported	3.6% (7)	3.2% (3)	3.9% (4)
Income¹
Low Income, <=FPL	31.6% (62)	18.3% (17)	43.7% (45)
Middle Income, >FPL and <$86,000	38.8% (76)	38.7% (36)	38.8% (40)
High Income, >$86,000	23.5% (46)	38.7% (36)	9.7% (10)
Not reported	6.1% (12)	4.3% (4)	7.8% (8)

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COMET Design

Recruited adolescents and clinicians from community mental health clinics
Randomized adolescents and clinicians
Clinicians trained in workshops and received consultation on cases
Research measures collected at baseline, 8 weeks, 16 weeks, and 28 weeks

Primary outcome: Independent-evaluator rated treatment response (CGI-I = 1 or 2), CGI-S, CGAS
Secondary outcomes: Youth and caregiver-reported SCARED, MFQ, YOQ, SDQ

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Results

No differences on primary outcomes
No differences on caregiver-reported outcomes
Youth Outcomes: UP-A and TAU+ outperformed TAU
Evidence of moderation consistent with feedback theories

Ehrenreich-May, Jensen-Doss, Milgram, Rosenfeld, Shaw, LoCurto, Robinson, Caron, Lee, & Ginsburg (under review). A randomized controlled effectiveness trial of transdiagnostic treatment and measurement-based care in community clinics

Number of diagnoses at baseline similarly moderated group differences between TAU+ and TAU on adolescent-reported symptoms (b=-.08, 95% CI [-.15, -.02], t(455)=-2.60, p=.010, d=0.24). For adolescents with 3 or more diagnoses at baseline, those in TAU+ improved faster than those in TAU (b=-.12, 95% CI [-.20, -.04], t(455)=-3.04, p=.003, d=0.29). These treatments did not differ for adolescents with 2 or fewer diagnoses (b=-.04, 95% CI [-.12, .04], t(465)=-1.02, p=.310, d=0.09).

Baseline severity of the outcome variables in each analysis (e.g., baseline levels of adolescent-reported outcomes in the MMLM for adolescent-reported symptoms, and baseline levels of the caregiver-reported outcomes for the MMLM for caregiver-reported symptoms) was a moderator of group differences between TAU+ and TAU on adolescent-reported outcomes (b=-.09, 95% CI [-.14, -.04], t(1961)=-3.70, p<.001, d=0.17) and on caregiver-reported symptoms (b=-.06, 95% CI [-.10, -.01], t(2004)=-2.19, p=.028, d=0.10).

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Role of MBC Fidelity �

MBC measure administration high (90.8% of TAU+ sessions, 90.3% of UP-A sessions)
Feedback reports viewing lower (73.3% TAU+ reports, 50.9% UP-A reports)
Clinician self-reports of other MBC practices (TAU+ only)

Data sharing: with youth in 34.6% of sessions, with caregivers: 27.4% of sessions
Limited evidence of MBC influencing practice

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Dose-Response Relationship Between TAU+ Consultation and MBC Fidelity

30 Minutes Consultation

2.1% ↑ Measure Administration

7.2% ↑ Report Viewing

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Other Key Takeaways

Challenges recruiting adolescents
Challenges retaining clinicians
Balancing experimental therapeutics expectations with participant burden
Randomization within clinics precluded organizational implementation strategies

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Next Steps…

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Type 1 Effectiveness Implementation Hybrid trial in 4 community mental health clinics
Implementation with all adolescents in outpatient, intensive outpatient, and home-based services
Conditions

Unidimensional MBC
Multidimensional MBC

MBC System: Mirah

R34 MH118316 (MPIs Jensen-Doss & Douglas)

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MBC Fidelity Indicators Grant

R01 ??? (MPIs Jensen-Doss & McLeod)

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Measurement-Based Care Professional Practice Guideline

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Thank you! Questions?