Measurement-based care in major depressive disorder (MDD) involves systematically tracking disease status and treatment outcomes using standardized tools rather than relying primarily on trial and error to guide treatment. Quick-to-administer scales such as the 9-item Patient Health Questionnaire (PHQ-9) can help clinicians objectively monitor a patient’s progress and identify symptoms that might otherwise be missed during brief appointments, which can help lead to improved patient outcomes.

The term “measurement-based care” was coined around the time we began the STAR*D trial in the early 2000s. It refers to providing care while keeping track of the level of symptom burden in the disorder. For example, in patients with depression, you should use a simple standard measurement of the core diagnostic criteria for an episode. You should also keep track of treatment tolerability. Patients often tell us that we do not pay enough attention to their side effect burden. And even when we hear them, we do not always take action to lessen that burden. So, measurement-based care is intended to be a user-friendly tool to assess both the symptoms of the illness and the potential side effects of the medication that is being used to treat the patient.

In psychiatric practice, most of us work within a 15- or 30-minute appointment format, so you want to use assessments that do not take up most of those minutes. These include simple validated tools such as the PHQ-9, which can be administered by the rater or filled out by the patient in 3 to 4 minutes. This questionnaire measures the 9 symptoms that make up the Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria for an MDD episode on a scale of 0 (nonexistent) to 3 (severe), up to a maximum total score of 27. The PHQ-9 is available on the internet for free. You can just print a copy of the questionnaire, have your patient fill it out, and track their scores over time.

Unfortunately, there is not a similarly easy scale that can be used to track medication side effects over time. There are so many side effects that could be reported by a patient with MDD, and there is no single scale to assess them all within a 15- to 30-minute visit. So instead, you need to ask the patient, “Are any side effects interfering with your health or complicating your treatment?” The patient might not know what you mean by “side effects,” so you need to first educate them about the likely side effects when they start treatment. Then you can decide which symptoms are medication-related side effects and intervene when a side effect causes difficulty. Insomnia, sexual side effects, gastrointestinal effects, anxiety, and trouble with concentration, attention, focus, and alertness are common complaints with antidepressant therapy.

One of the nuances of caring for patients with depression is that up to 20% can have a history of a “high” side or mania to their illness and may have bipolar disorder. Screening tools such as the Mood Disorder Questionnaire (MDQ) can help identify patients who have bipolar depression, and the Generalized Anxiety Disorder-7 (GAD-7) questionnaire can help measure generalized anxiety symptoms. These may not need to be assessed at every visit but can also be tracked over time.

In real-world studies, using measurement-based care collaboratively has been shown to achieve better outcomes than usual care alone. It provides a convenient way to track whether a patient is approaching or maintaining goal attainment. Depression can often be hard to see subjectively because people with mild to moderate symptoms may be able to raise their spirits, look a little sharper, and look well or nearly well for appointments. However, combining a clinician evaluation with an objective rating, such as a PHQ-9 score, may provide additional context.