Outcomes Assessment in Clinical Practice

Drs. Sederer and Dickey are both on the faculty of Harvard Medical School. He is Senior Vice-President for Clinical Services at McLean Hospital; she is Director of McLean’s Department of Mental Health Services Research. They have enlisted 53 additional contributors from the field of outcome research. The material is organized in three sections. The first presents an overview of outcome assessment, its conceptual basis, methodology, and application to clinical practice. The second describes and discusses instruments used for evaluating treatment outcome. The third predicts the future of outcome assessment, its application to practice guidelines, and its relationship with managed care.

The contributors balance idealism and pragmatism in presenting the rationale for studying outcome. They emphasize accountability to third-party payers but also that the patient stands to benefit the most from the information and knowledge that we gather when we rigorously examine the effects of treatment. Some of the chapters in the first section are more hortatory than is necessary, in my opinion, and there is a fair amount of repetition. I found the chapter by the Group for the Advancement of Psychiatry Psychopathology Committee to be the most useful in that it uses a hypothetical case to illustrate the use of the scrutiny of treatment progress and outcome to guide clinical decision making.

Section 2 is devoted to succinct but meticulous descriptions of 16 instruments used in outcome study. Each chapter deals with one of the 16 instruments, and each begins with a list of references pertinent to the instrument’s background. The authors discuss the mechanics of the instruments and parameters such as the target population and the psychometric properties. A summary of the scale’s strengths and limitations appears at the end of the chapter.

The final five chapters are devoted to discussions of not-yet-solved problems in the field and proposals, including work in progress, that address them. One chapter deals with the role of outcome research in the development and validation of practice guidelines. That connection is obvious, but the thrust of the chapter is to explicate the history and the scope of guideline development in medicine in general and psychiatry in particular. There is a chapter on APA’s Practice Research Network, an ambitious project in which practicing psychiatrists, as opposed to career researchers working in tertiary settings, collaborate to study outcome. The authors refer to studies in other specialties that have been done in real-world practice settings. There are about 200 psychiatrists, nationwide, who are now involved in APA’s effort. The authors anticipate that there will be 1,000 eventually.

The appendixes are valuable because they reproduce, to the letter, the 16 scales discussed in section 2. That feature alone makes owning the book worthwhile for a psychiatrist. The scales address diverse outcome dimensions ranging from symptoms and functioning and the effects of mental illness on families to patient satisfaction. Reading them helped me to appreciate how difficult it is to measure and objectify changes in human beings and also to understand the limitations of these instruments.

This volume makes for dry reading, but it is clearly and concisely written, a painless source of information that we all need, whether or not we are affected by managed care. APA’s Practice Research Network is looking for qualified recruits. Ten years ago, one of our colleagues, a pioneer in psychiatry’s quality-assurance efforts, urged us to become familiar with its concepts and practices and also recommended that as many of us as possible get involved in the quality-assurance field (1). Reading this book is a good way to start.