The Brief Symptom Inventory and the Outcome Questionnaire-45 in the Assessment of the Outcome Quality of Mental Health Interventions

Self-report questionnaires are economical instruments for routine outcome assessment. In this study, the performance of the German version of the Outcome Questionnaire-45 (OQ-45) and the Brief Symptom Inventory (BSI) was evaluated when applied in analysis of the outcome quality of psychiatric and psychotherapeutic interventions. Pre-post data from two inpatient samples (N=5711) and one outpatient sample (N=239) were analyzed. Critical differences (reliable change index) and cut-off points between functional and dysfunctional populations were calculated using the Jacobson and Truax method of calculating clinical significance. Overall, the results indicated that the BSI was more accurate than the OQ-45 in correctly classifying patients as clinical subjects. Nonetheless, even with the BSI, about 25% of inpatients with schizophrenia attained a score at admission below the clinical cut-off. Both questionnaires exhibited the highest sensitivity to psychopathology with patients with personality disorders. When considering the differences in the prescores, both questionnaires showed the same sensitivity to change. The advantage of using these self-report measures is observed primarily in assessing outpatient psychotherapy outcome. In an inpatient setting two main problems—namely, the low response rate and the scarce sensitivity to psychopathology with severely ill patients—limit the usability of self-report questionnaires.

An evidence-based approach to routine outcome assessment

SummaryRoutine use of Health of the Nation Outcome Scales (HoNOS) has not produced the anticipated benefits for people using mental health services. Four HoNOS-specific reasons for this are: low relevance to clinical decision-making; not reflecting service user priorities; being staff-rated; and having a focus on deficits. More generally, the imposition of a centrally chosen measure on the mental health system leads to a clash of cultures, since frontline workers do not need a standardised measure to treat individuals. A better approach might be to use research from the emerging academic discipline of implementation science to inform the routine use of a standardised measure that is chosen by the people who will use it and hence is more concordant with existing clinical processes. This is illustrated using a case study of successful implementation of the Camberwell Assessment of Need (CAN) in community mental health services across Ontario, Canada.

Pre-morbid IQ and response to routine outcome assessment

Background. Routine use of standardized outcome measures within adult mental health services is compulsory in many countries, but not common in clinical practice. As well as political and professional factors, one reason may be that there is little empirical evidence of benefit for patients. It is therefore important to identify predictors of response. Pre-morbid intellectual functioning has predicted response to other interventions. This paper tests the hypothesis that pre-morbid IQ impacts on the effectiveness of routine assessment and feedback of outcome measures.Method. The Feedback of Outcomes to Users and Staff (FOCUS) single-blind randomized controlled trial (RCT) investigated routine completion and feedback of outcome measures for 160 (101 intervention, 59 control) adult mental health service patients in Croydon, South London (International Standard RCT Number 16971059).Results. Patients in the top quarter (pre-morbid IQ>110) differentially improved in patient-rated unmet need (adjusted difference 3·4, 95% CI 0·8 to 5·9, p=0·012) and in the top half (pre-morbid IQ>99) in quality of life (adjusted difference −0·6, 95% CI −1·1 to −0·1, p=0·02). The top quarter result remained when controlling for the influence of baseline (p=0·004) and baseline plus follow-up variables (p=0·047).Conclusions. Feedback of routine outcome measures may improve outcome for patients with higher pre-morbid IQ. There is a need to understand more how routine outcome information is used by staff and patients to inform care. If the goal of routine use of outcome measures is to benefit patients directly, then targeted policies are required.

What Outcomes to Measure in Routine Mental Health Services, and How to Assess Them: A Systematic Review

Objective: Routine outcome assessment in adult mental health services involves the ongoing assessment of patient-level outcomes. Use of outcomes to inform treatment is widely recommended, but seldom implemented. The goals of this review were (i) to identify principles that have been proposed for implementing routine outcome assessment, (ii) to identify the full range of outcome domains that have been proposed for assessment, and (iii) to synthesize proposals for specific outcome domains into emergent categories. Method: A systematic review of published and unpublished research was undertaken, using electronic databases, research registers, conference proceedings, expert informants and the World Wide Web. For goal (i) studies were included that proposed principles for implementing routine outcome assessment. For goal (ii) studies were included that identified at least two patient-level outcome domains for patients using adult mental health services and made some reference to a broader literature base. Results: Six thousand four hundred publications matched initial search criteria. Seven distinct sets of principles for choosing patient-level outcomes were located, which showed a fair degree of consensus. Sixteen outcome domain proposals were identified, which were synthesized into seven emergent categories: wellbeing, cognition/emotion, behaviour, physical health, interpersonal, society and services. Conclusions: The findings from this review were used to develop a four-step method for adult mental health services wishing to implement routine outcome assessment.

Routine outcome assessment in mental health services

Measuring and interpreting outcome is more difficult in mental health services than in some other areas of health care, for at least five reasons. First, the effect of the treatment may be to slow decline or to maintain the current level, so the score on the outcome measure itself may not improve (or may even get worse) despite best quality clinical care. Secondly, the best available evidence in the United Kingdom indicates that clinical and social variables predict no more than 30% of the variance in an individual's quality of life (UK700 Group, 1999). Thirdly, different types of outcome are desynchronous (e.g. Drury et al. 1996), changing at different rates during an intervention. Fourthly, there may not be agreement regarding what is a positive change in outcome – the patient who has fewer episodes of mania as a result of treatment may see this as a negative outcome. Finally, three levels of mental health service can be differentiated: treatment (specific interventions); programme (combination of different treatment components); and system (all programmes for a defined target group in a given area) (Burns & Priebe, 1996). The outcome data needed to evaluate each level will be very different.

Feasibility, usefulness, limitations and perspectives of routine outcome assessment: the South Verona Outcome Project

SUMMARYClosing the gap between research and clinical practice is nowadays considered a priority in outcome studies. Survey studies in community settings having as their main aim the multidimensional measure of outcome of mental health care interventions, including the use of standardised instruments administered as part of the routine clinical activities in mental health services, have recently started to be planned in various countries, but have encountered several difficulties. A naturalistic, longitudinal study aimed to assess the outcome of care provided by a community-based mental health service, the South Verona Outcome Project, has been conducted in Italy starting from the beginning of the 90's and is running since then. This paper: a) describes a series of methodological aspects of the South Verona Outcome Project, such as instruments, study design, inclusion and exclusion criteria, training of the staff, and focuses on strategies used so to ensure feasibility of the assessment and good quality of the data; b) summarises some results of the study, characteristics of feed-back provided, and outputs; c) discusses the problems faced, the impact of this approach on service provision, its limitations and future perspectives.