Common metrics for mental health? Kate Dalzell responds to new directives from Wellcome and NIMH
Announcing a recent decision by mental health research funders, Professor Miranda Wolpert of the Wellcome Trust states that: “without some common metrics there is no way for mental health scientists to know if they are investigating the same or different things”. To help researchers to compare across studies and to promote shared understanding about the impact of mental health interventions, Wellcome and the National Institute of Mental Health have agreed a small number of metrics which they are highly recommending (and will later to be mandating) for use in research relating to young people with anxiety and depression.
The recommended set of outcome measures includes the Revised Child Anxiety and Depression Scale (RCADS) for child anxiety and depression, as well as the Patient Health Questionnaire (PHQ) and General Anxiety Disorder questionnaire (GAD) for adult depression and adult anxiety respectively. While the World Health Organisation Disability Assessment Schedule (WHODAS) is recommended for adult impact on functioning it is noted that no metric suited for this purpose has been identified for measuring child functioning.
The comparability (or lack thereof!) of metrics in use across child and youth mental health is a familiar challenge. At CORC we get to work with services and funders across the country (and internationally) as they devise outcome and measurement frameworks that reflect their strategic priorities, the work they do, and the people they work with. Where research bodies here helpfully specify that they are honing in on symptoms and functioning, and on mental ill-health (specifically anxiety and depression), the heterogeneity in measure choice that we see at CORC reflects a wider range of intervention benefits, and a sensitivity to service users’ experiences in quite differing contexts. For example, increasingly those considering the system of support for mental health attend to early intervention, resilience and social and emotional skills as well as addressing mental ill-health. Further to that, in considering if a measurement tool is suitable to integrate into routine care, choices might reflect whether the contacts will be brief or longer-term, the age and ability of the children involved, or the level of burden or ‘fit’ it represents in the context of the work.
At CORC we are also increasingly interested in whether we are picking up on what young people feel it is important to measure – does what we measure address their aims in seeking support, and what they find services useful for? We know that many children attending services don’t see an improvement against a symptom measure, although questionnaires suggest their experience of the services they receive are overwhelmingly positive. Analysis of young people’s goals in attending mental health services suggest that their aims often relate to other facets of coping or quality of life, such as self-understanding or relationships (Jacob et al, 2016). In the autumn, CORC will be holding a number of focus groups with young people to understand more about what they consider to be most important and meaningful to measure, and the most helpful way to do this to support their recovery or growth.
Nonetheless, seeing the ‘big picture’ can be as much an aspiration for routinely collected data as it is in projects with a research focus. CORC has always played a central role in developing approaches and systems through which its membership can benchmark against one another, consider the impact of their care in context, and use the collective power of their ‘real-world’ data to address research questions. The evolution of this work, and the learning from the CYP IAPT (the Children and Young People’s Improving Access to Psychological Therapies project), has prompted another response to the challenge of a diversity of measurement tools: the national outcome metric recently rolled out by the NHS for child and youth mental health provides an over-arching picture by looking at the number of children and young people that show measurable improvement in symptoms and functioning against any one of a number of validated child and young person outcome metrics included in the Mental Health Services Data-set. Public Health England are similarly helping to build a more coherent picture, currently in developing an outcomes framework for assessing the mental health and wellbeing of children and young people (CYP) in England.
I really welcome the possibilities and enhanced potential offered by all of the developments reflected here. The leadership and clarity offered by research funders in their recent statement reflects the growing momentum, energy - and crucially investment - in advancing understanding of mental health. The national outcome metric raises the profile of outcomes in care while attending to the diversity of needs and provisions. Outcomes frameworks promote shared understanding and refine thinking. Alongside this, the broadening of perspectives about what matters in the relationship between mental health and quality of life, and the increasing exploration of approaches that reach outside of traditional healthcare to support this – to wider educational, social and community settings – also help us to improve the way we support young people to fulfil their potential in life.
I see a dynamic equilibrium at play here, the potential and collective power of big data sitting alongside the creative and innovatory potential of a thousand flowers blooming – and it feels exciting at CORC to see how increased attention to child and youth mental health is driving this dialogue and momentum. As we look forward to our annual Member Forum in November, we hope to debate these issues with colleagues across the sector: If you are interested in a dialogue about we navigate the best future for outcome measurement in child and youth mental health, get in touch with us at firstname.lastname@example.org if you would like to help us frame the debate.