Using Progress Feedback to Enhance Treatment Outcomes: A Narrative Review.

We face increasing demand for greater access to effective routine mental health services, including telehealth. However, treatment outcomes in routine clinical practice are only about half the size of those reported in controlled trials. Progress feedback, defined as the ongoing monitoring of patients' treatment response with standardized measures, is an evidence-based practice that continues to be under-utilized in routine care. The aim of the current review is to provide a summary of the current evidence base for the use of progress feedback, its mechanisms of action and considerations for successful implementation. We reviewed ten available meta-analyses, which report small to medium overall effect sizes. The results suggest that adding feedback to a wide range of psychological and psychiatric interventions (ranging from primary care to hospitalization and crisis care) tends to enhance the effectiveness of these interventions. The strongest evidence is for patients with common mental health problems compared to those with very severe disorders. Effect sizes for not-on-track cases, a subgroup of cases that are not progressing well, are found to be somewhat stronger, especially when clinical support tools are added to the feedback. Systematic reviews and recent studies suggest potential mechanisms of action for progress feedback include focusing the clinician's attention, altering clinician expectations, providing new information, and enhancing patient-centered communication. Promising approaches to strengthen progress feedback interventions include advanced systems with signaling technology, clinical problem-solving tools, and a broader spectrum of outcome and progress measures. An overview of methodological and implementation challenges is provided, as well as suggestions for addressing these issues in future studies. We conclude that while feedback has modest effects, it is a small and affordable intervention that can potentially improve outcomes in psychological interventions. Further research into mechanisms of action and effective implementation strategies is needed.

A Clinical Leadership Lens on Implementing Progress Feedback in Three Countries: Development of a Multidimensional Qualitative Coding Scheme.

BACKGROUND: Progress feedback, also known as measurement-based care (MBC), is the routine collection of patient-reported measures to monitor treatment progress and inform clinical decision-making. Although a key ingredient to improving mental health care, sustained use of progress feedback is poor. Integration into everyday workflow is challenging, impacted by a complex interrelated set of factors across patient, clinician, organizational, and health system levels. This study describes the development of a qualitative coding scheme for progress feedback implementation that accounts for the dynamic nature of barriers and facilitators across multiple levels of use in mental health settings. Such a coding scheme may help promote a common language for researchers and implementers to better identify barriers that need to be addressed, as well as facilitators that could be supported in different settings and contexts. METHODS: Clinical staff, managers, and leaders from two Dutch, three Norwegian, and four mental health organizations in the USA participated in semi-structured interviews on how intra- and extra-organizational characteristics interact to influence the use of progress feedback in clinical practice, supervision, and program improvement. Interviews were conducted in the local language, then translated to English prior to qualitative coding. RESULTS: A team-based consensus coding approach was used to refine an a priori expert-informed and literature-based qualitative scheme to incorporate new understandings and constructs as they emerged. First, this hermeneutic approach resulted in a multi-level coding scheme with nine superordinate categories and 30 subcategories. Second-order axial coding established contextually sensitive categories for barriers and facilitators. CONCLUSIONS: The primary outcome is an empirically derived multi-level qualitative coding scheme that can be used in progress feedback implementation research and development. It can be applied across contexts and settings, with expectations for ongoing refinement. Suggestions for future research and application in practice settings are provided. Supplementary materials include the coding scheme and a detailed playbook.

The effect of therapist characteristics on the use and outcome of systematic client feedback in outpatient mental healthcare.

OBJECTIVE: Therapist characteristics are known to affect treatment outcome in general and could also influence the use of systematic client feedback (SCF). The current study explores the effect of feedback orientation, regulatory focus, self-efficacy, attitude towards feedback resources and perceived feedback validity on the use and outcome of SCF in outpatient mental healthcare. METHOD: The data of therapists (n = 12) and patients (n = 504) of two outpatient centres offering brief psychological treatment were analysed when SCF, based on the Partners for Change Outcome Management System (PCOMS), was added to treatment as usual. The data of therapists were obtained through a therapist questionnaire composed of relevant characteristics from feedback studies in social and organizational psychology. The effect on the use of SCF was analysed using logistic regression; whereas, the effect on outcome was assessed using a two-level multilevel analysis. Regular use of SCF and the Outcome Questionnaire (OQ-45) were used as outcome variables. DSM-classification, sex and age of each patient were included as covariates. RESULTS: High perceived feedback validity significantly increased the use of SCF. No significant therapist characteristics effects were found on outcome, but high promotion focus was associated with treating more complex patients. CONCLUSIONS: The perceived feedback validity of SCF is likely to have an influence on its use and is probably affected by the changes in the organizational climate.

Enhancing the effect of psychotherapy through systematic client feedback in outpatient mental healthcare: A cluster randomized trial.

Objective: Systematic client feedback (SCF), the regular monitoring and informing of patients' progress during therapy to patient and therapist, has been found to have effects on treatment outcomes varying from very positive to slightly negative. Several prior studies have been biased by researcher allegiance or lack of an independent outcome measure. The current study has taken this into account and aims to clarify the effects of SCF in outpatient psychological treatment.Method: Outpatients (n = 1733) of four centers offering brief psychological treatments were cluster randomized to either treatment as usual (TAU) or TAU with SCF based on the Partners for Change Outcome Management System (PCOMS). Primary outcome measure was the Outcome Questionnaire (OQ-45). Effects of the two treatment conditions on treatment outcome, patient satisfaction, dropout rate, costs, and treatment duration were assessed using a three-level multilevel analysis. DSM-classification, sex, and age of each patient were included as covariates.Results: In both analyses, SCF significantly improved treatment outcome, particularly in the first three months. No significant effects were found on the other outcome variables.Conclusions: Addition of systematic client feedback to treatment as usual, is likely to have a beneficial impact in outpatient psychological treatment. Implementation requires a careful plan of action.Clinical or methodological significance of this article: This study, with large sample size and several independent outcome measures, provides strong evidence that addition of systematic client feedback to outpatient psychological treatment can have a beneficial effect on treatment outcome (symptoms and wellbeing), particularly in the first three months. However, implementation requires a careful plan of action.

Systematic client feedback to brief therapy in basic mental healthcare: study protocol for a four-centre clinical trial.

INTRODUCTION: The Partners for Change Outcome Management System (PCOMS) is a client feedback-system built on two brief visual analogue self-report scales. Prior studies of PCOMS have found effects varying from significant positive to negative. Aims of present study are; to test the predicted beneficial impact of PCOMS, while accounting for methodological flaws in prior studies and to clarify under which circumstances the addition of PCOMS to therapy has a beneficial effect. METHODS AND ANALYSIS: This study focuses on patients applying for brief, time-limited treatments. Four centres will be randomised to either treatment as usual (TAU) or TAU with PCOMS. All participating patients will be assessed four times. The full staff in the experimental condition will be trained in PCOMS. In the second part of this study, all therapists in the PCOMS condition will fill in a questionnaire concerning the influence of regulatory focus, self-efficacy, external or internal feedback orientation and perceived feedback validity of PCOMS. Finally, patients in the PCOMS condition will be asked to give feedback through a structured interview.The primary outcome measure is the Outcome Questionnaire over the period from beginning to end of therapy. The Mental Health Continuum-Short Form and Consumer Quality Index are also completed. In the primary analysis, outcomes of the two treatment conditions on treatment outcome, patient satisfaction, costs, drop-out and duration will be examined with a three-level (within patient, between patients and between therapists) multilevel analysis. The DSM-classification, sex, education level, age of each patient and therapist factors will be included as covariates. ETHICS AND DISSEMINATION: The Medical Ethics Committee of the University of Twente approved this study (K15-11, METC Twente). Data will be included from 1 January 2016 to 1 July 2019. Study results will be disseminated through peer-reviewed journals and conferences. TRIAL REGISTRATION NUMBER: NTR5466; Pre-results.