Evaluation of Implementation, Effectiveness, and Mechanisms of Change in Measurement-Based Care for Depressive and Anxiety Disorders

Abstract

Measurement-based care (MBC) is an evidence-based practice that centers on routine completion of patient-reported outcome measures (PROMs) and collaborative discussions between clinician and client to inform treatment and clinical decision-making. Despite its known benefits, questions remain regarding MBC's unique added value compared to standard care. Furthermore, the mechanisms of change on how MBC facilitates improvement have yet to be fully investigated. Thus, the current study employed the RE-AIM framework to guide implementation and evaluate MBC's reach, effectiveness, and potential mechanisms of action in adults with depressive and anxiety disorders in an academic medical center. A pragmatic randomized controlled trial compared MBC to treatment as usual (TAU) condition. Clinicians (n = 15) completed standardized MBC training and incorporated MBC into their practice. Fifty-six adults with depressive and/or anxiety disorders were randomized to MBC (n = 27) or TAU (n = 29). Both groups completed weekly PROMs assessing depression, anxiety, and psychological adjustment. Working alliance, psychotherapy processes, and pre- and post-treatment global impressions were also assessed. The results evaluated Implementation (clinician and client attitudes toward MBC, digital training and adherence), Reach (enrollment, attendance and attrition), Effectiveness (symptom change and psychological functioning) of RE-AIM components, alongside an exploratory mediation analysis. Implementation outcomes indicated that MBC was highly acceptable and positively viewed by both clinicians and clients and achieved over 90% adherence. Participants reflected the clinic population but not the broader regional community. Multilevel modeling indicated faster improvements in depression, anxiety, and psychological adjustment among MBC participants compared to TAU. However, hypothesized mediators demonstrated no between-group differences, suggesting that unexamined factors may account for MBC's incremental effectiveness. Overall, findings support the feasibility and added clinical value of MBC when implemented in an outpatient setting within an academic medical center. Results suggest that successful implementation of MBC via the RE-AIM framework facilitates enhanced symptom reduction and psychological adjustment. The absence of group differences in working alliance and psychotherapy processes underscores the need to explore additional factors as possible mechanisms of action. The present study contributes to the field by demonstrating that MBC can be successfully integrated into routine outpatient practice with high fidelity and acceptability, leading to more rapid improvement in symptoms and adjustment.