Outcome Measurement in Psychiatry: A Critical Review

Establishing recognized measurements of quality care and treatment of the psychiatrically ill would facilitate many goals in psychiatry, including efforts to reverse the shrinking proportion of the health care dollar going to psychiatric care and treatment. But how to measure quality?

Measuring quality has taken three forms: 1) measuring structure (e.g., number of patients per psychiatrist on an acute care ward), 2) measuring process (e.g., whether a patient with bipolar disorder is evaluated for a substance-related disorder), and 3) measuring outcome (e.g., percentage improvement in the Brief Psychiatric Rating Scale score over a set time period). From the middle of the 19th century to the middle of the 20th, the focus in psychiatry was on measuring structure. Most of the measuring in the last half of the 20th century focused on process, and many hope to see outcome measures dominate in the 21st, spurred on, at the moment, by the interest in “evidence-based” psychiatry.

The hope is not to see structure and process measures disappear. Instead, the hope is to have structure and process tied to outcome, “outcome-based structure” (e.g., in medicine, numbers of nurses per patients needed to save lives on hospital wards, since mortality has been tied to staffing numbers) and “outcome-based process” (e.g., the proportion of patients with unremitting psychotic symptoms who were given a trial of clozapine, since the percentage of such patients remitting has been tied to clozapine trials). Outcome-based structure and outcome-based process measures would replace the structure and process measures of the past that were based on only intuition or a theory. This hope has many dangers of oversimplification. The empirical reach in psychiatry has its limits, especially in a nonresearch setting, where terrible outcomes can occur in high-quality programs and terrific outcomes can occur in the worst of programs. To answer many outcome questions for common clinical settings requires a large, often unattainable, number of subjects.

In this book of 51 authors, the plurality from New York University School of Medicine, the status of this effort is examined critically and directions are provided to establish a firm foundation for the pursuit of high-quality care and treatment in psychiatry. General issues are systematically addressed, and there are also chapters on major disorders for those wanting guidance in, say, assessing quality in mood disorders treatment or assessing quality in forensic settings.

This book provides a constructive review of some vital issues in psychiatry.