Monitoring outcomes is key to improving mental health treatment in South Africa

Precision medicine matches patients with interventions, rather than just matching treatments to illnesses. Shutterstock

The traditional way of understanding medical treatment is that a doctor matches a particular treatment to a particular illness. The problem is that people with the same illness can respond differently to the same treatment.

Precision medicine – or personalised medicine – is a relatively new approach that takes account of individual differences when planning treatments. Here, doctors individualise interventions by matching patients with appropriate treatments. This entails using evidence to select the most effective intervention for a patient based on their genetic makeup, circumstances, lifestyle and collection of symptoms.

To do this doctors need to collect detailed information about how different patients respond to different treatments.

Many health related disciplines are moving towards the practice of precision medicine. For example, research suggests that about 55% of people who are diagnosed with depression will respond well to antidepressant medication. In precision medicine, doctors try to understand what individual factors predict these different treatment responses. This enables doctors to make evidence based decisions about which patients with depression should be prescribed medication and which should receive other kinds of treatment. Using this approach could help patients recover quicker and can save time and resources

But this approach to collecting and using evidence to plan interventions is not being widely used when it comes to psychological treatments. This is particularly true in developing countries like South Africa where psychologists aren’t routinely monitoring their treatment outcomes and using evidence to improve their practice.

This is a serious problem. A precision approach would enable psychologists to use scarce mental health resources more efficiently, select the most appropriate treatments, and provide better care to the high number of South Africans suffering from mental health problems.

It was in this context that we embarked on a project to implement a routine outcome monitoring system in a community psychology clinic in the Western Cape Province of South Africa. Our results showed that it’s possible to monitor treatment outcomes as part of routine psychological care, although the tools used to achieve this need to be refined.

Giving evidence-based approaches a chance

So why has psychology been so slow to move towards precision medicine?

Research published recently in the South African Journal of Psychology highlights the fact that many psychologists are reluctant to use empirical evidence when treating individual patients. It seems that many psychologists also resist objectively monitoring how their patients respond to psychological interventions and measuring treatment outcomes.

Part of the problem is that many psychologists don’t believe that psychological functioning can be quantified.

It’s true that it can be difficult to measure psychological change and it’s impossible to use a single measure of treatment outcome for all patients. But there are a number of tools that have been developed that can provide useful information about how patients respond to psychotherapy. These tools are more widely used in developed countries and their use is advocated by the American Psychiatric Association as a way of improving standards of care. But this isn’t the case in most developing countries.

We believe that it’s not enough for psychologists to rely heavily on theories which are unsupported by evidence or subjective accounts of recovery. Psychologists in South Africa have a duty to begin thinking about how they can adapt and apply tools that have been developed elsewhere to collect information about treatment outcomes. This will move the practice of psychology in South Africa closer to an evidence-based approach.

Based on this understanding, we implemented a treatment monitoring system at a community psychology clinic. We asked all patients at the clinic to give us regular feedback about their level of emotional and social functioning. Patients were asked to complete short questionnaires about changes in their symptoms, perceptions of their emotional well-being and changes in the quality of their relationships. We encouraged the clinicians working in the clinic to use this patient feedback to monitor patient responses and refine their treatments.

The goal was to see whether a system that has been used to monitor treatment outcomes in other countries, such as the US and Australia, could be usefully incorporated into routine care in a South African context. We found that it is possible to monitor treatment responses as part of routine psychological care and that the tools that currently exist could be used in South Africa. But we may still need to do some work to make sure that these tools are easily understood by patients and correctly used by psychologists.

More work to be done

Monitoring systems like the one we implemented normally rely on patients to self-report their symptoms and level of functioning. One of the challenges we experienced is that patients didn’t always understand what they were being asked. This meant that their responses could not always be accurately interpreted.

More work is clearly needed to refine the system to make it more user-friendly for patients. This will entail more than just directly translating the instruments into local languages. We need to make sure that the words and ideas used are culturally appropriate and meaningful in different South African contexts.

But even if the system is perfected, this will be of little value if psychologists don’t use it. In our research we found that some clinicians did not use the system consistently or correctly, even when they were trained to do so.

More work with practising psychologists is needed to understand their reluctance to monitor treatment outcomes as part of routine patient care. Maybe there are good reasons for their resistance. But it might also simply be that some psychologists need to make an ideological shift in the way they think about their work and the way they understand the importance of evidence-based practice.