Therapeutic change processes link and clarify targets and outcomes

Abstract

287 “diagnosis” relying on current classification systems. We still need to figure out what constitutes a meaningful change in scores and we might have to stick with relatively arbitrary clinical indices such as response (for example, the 50% reduction in scores often used in depression trials) which are also used for other dimensional health conditions (such as hypertension), or we could calibrate a meaningful change in scores against patient-defined global ratings to generate a “minimal clinically important difference”. Outcomes may, in turn, vary across the severity dimension of the psychopathology; for example, the primary domain of concern may be symptom experience at one stage, but may shift to social functioning at another. Another implication of adopting dimensional approaches is that new kinds of outcomes, amenable to remote monitoring, may become a reality, for example real-time passive assessment of digital behavioural markers. In this context, outcome assessments are not only useful as end-points to evaluate the effectiveness of psychotherapy, but also as dynamic decision points for guiding treatment choices which can allocate more intensive interventions as per patient trajectories, for example to distiguish early responders to low-intensity interventions from those who need more intensive treatments. In short, reimagining outcomes and targets must require a reimagining of the nature of mental health conditions. We must invest in clinical research paradigms which adopt novel, dimensional, approaches to characterizing these conditions, offering new approaches to defining targets and outcomes. The current system which has been the foundation of psychiatric research, and which historically was envisioned to lead to an elucidation of etiology, mechanisms and therapeutics, has brought us to a dead-end.