Assessing functional outcomes in clinical practice

Depression is one of the most common chronic health problems in the United States, and primary care providers manage a substantial proportion of these patients. Unfortunately, most current knowledge about treatment effectiveness is limited to the acute phase of treatment for new depressive episodes, although most patients seen in the primary care setting have chronic depressive symptoms, meet criteria for more than one mental health disorder, and have one or more chronic medical conditions. This article examines the shortcomings of our current approach to assessing treatment effectiveness in primary care, despite the availability of good measures of symptom-based recovery, such as the 9-item Patient Health Questionnaire (PHQ-9). Specific emphasis is placed on the need to expand our focus from current symptom-based outcomes of remission and response to measures that can also capture positive emotional recovery, well-being, and functional status, and to integrate these measures into everyday primary care practice. Although there is not yet a standard measure to assess emotional recovery, well-being, or functional recovery, brief measures such as the Sheehan Disability Scale, Quality of Life Enjoyment and Satisfaction Questionnaire, World Health Organization 5-Item Well-Being Index, and new Remission Evaluation and Mood Inventory Tool are available. The opportunity now exists to use these simple tools to integrate outcome monitoring into routine care in the same way other chronic health problems, such as asthma or diabetes, are monitored. Options such as point-of-care outcome assessment with PHQ-9, plus a functional recovery tool; clinician extender ("care manager") monitoring of depressed patients; or a hybrid approach combining both approaches can be practical and effective.