by Ahmed Aboraya, MD, DrPH; Daniel Elswick, MD; James Berry, DO; Dilip Chandran, MD; Cheryl Hill, MD; Wanhong Zheng, MD; Jeremy D. Hustead, MD; Dorothy Van Oppen, MD; Vishal Patel, MD; Sara Berzingi, MD; Karen Wang, MD; Daniel Grimes, MD; Gerard Gallucci, MD; Dolly Mishra, MD; Ramita Shrestha, MD; John Justice, MD; Paramjit Chumber, MD; Abid Rizvi, MD; Deep Yadava, MD; Issaiah Wallace, DNP; Joy Parks, MD; Tina Spence, DMSc; Morsi Abdallah, MD; Jehad Albitar, MD; Ryan Murphy, DO; Olwy Aboelnour, MD; Mohamed Sakr, MD; Richard Cadenas, MD; Amanda Durazo, MD; Albaraa Badawood, MD; Luke Stover, MD; Richard Burd, MD; Christopher Feghali, MD; Sunanda Mattancheril, MD; Triet Tran, MD; Seth Moomaw, DO; Salwa Nubani, MD; Venkat Mokkapati, MD; Talha Siddiqui, MD; Naveed Shaikh, MD; Uzma Ansari, MD; Abby Chainani, MD; Krystle Mishra, MD; Krupa Patel, MD; Sara Perez-Pujols, MD; Khadija Siddiqui, MD; Sona Xavier, MD; Emeka Boka, MD; and Jonathan Hyacinthe, MD

Drs. Aboraya, Elswick, Berry, Chandran, Hill, Zheng, Hustead, Van Oppen, Patel, Berzingi, Justice, Chumber, Rizvi, Yadava, Wallace, Parks, Spence, Albitar, Murphy, Cadenas, Durazo, Badawood, Stover, Burd, Feghali, Mattancheril, Tran, Moomaw, and Nubani are with West Virginia University in Morgantown, West Virginia. Dr. Wang is with the University of Toronto in Ontario, Canada. Drs. Grimes, Gallucci, Mishra, Shrestha, Mokkapati, T. Siddiqui, Shaikh, Ansari, Chainani, Mishra, Patel, Perez-Pujols, K. Siddiqui, Xavier, Boka, and Hyacinthe are with the Delaware Psychiatric Center in New Castle, Delaware. Dr. Abdallah is with Ludenscheid Teaching Hospital in Ludenscheid, Germany. Drs. Aboelnour and Sakr are with private practice in Cairo, Egypt.

FUNDING: No funding was provided for this article.

DISCLOSURES: The authors declare no conflicts of interest relevant to the content of this article.

Innov Clin Neurosci. 2025;22(4–6):20–26.

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Abstract

Objective: In 2019, the authors began implementing a measurement-based care (MBC) curriculum into two residency programs at West Virginia University (WVU) and Delaware Psychiatric Center (DPC). The authors present findings from the four-year implementation period and describe a web-based MBC course that aims to train attendings and residents across the United States (US) and abroad. Methods: The web-based MBC course includes four readings (the MBC instruction manual, the Standard for Clinicians’ Interview in Psychiatry [SCIP] glossary, clinician-administered [CA] scales, and self-administered [SA] scales), four didactic presentations (MBC basics, psychopathology assessment, epidemiological concepts, and psychiatric measures), and four video interviews. The web-based MBC course is accessible through the WVU online continuing medical education (CME) web courses. The modified MBC psychiatry residency training curriculum includes four didactic lectures taught by MBC-trained faculty members and attendings. Residents practice using the scales during their inpatient and outpatient rotations and complete the web-based MBC course before graduation. Results: The web-based MBC course was used to train most of the attendings in the WVU and DPC residency programs. Both programs now require residents to complete the web-based MBC course before graduation. Of the 52 residents in both programs, 26 residents (50%) had completed the training at the time of writing this article. Conclusion: The web-based MBC course was successfully implemented in two US residency programs and is now available for clinicians around the world to access. Free access to the SCIP scales will be granted to psychiatry residency programs implementing the MBC curriculum.

Keywords: Rating scales, measurement-based care curriculum, web-based measurement-based care course, psychopathology, assessment

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Measurement-based care (MBC) was first defined as “the routine measurement of symptoms and side effects at each treatment visit and the use of a treatment manual describing when and how to modify medication doses based on these measures.”¹ MBC has also been described as “the systematic administration of symptom rating scales and use of the results to drive clinical decision making at the level of the individual patient.”² While other similar definitions have been proposed, they all refer to two processes: routine assessments, such as the measurement of symptom severity with rating scales, and the use of assessments in decision-making. Clinicians, including psychiatrists, have been trained to evaluate patients and make decisions about their treatment for centuries. In psychiatry, for example, Hardcastle et al³ studied the presenting conditions of the first 100 patients (adults and children) who attended the department of psychological medicine at Guy’s Hospital in London in 1931. They evaluated the patients and grouped them into four main groups: much improved, improved, unchanged, and worse. Based on their evaluations, they decided to admit or treat the patients accordingly.³

Recent research has shown that the use of MBC in clinical practice can improve the accuracy of clinical judgment, improve outcomes in psychotherapy and pharmacotherapy, identify patients who are improving and those who are deteriorating, increase satisfaction with care, and enhance quality of care and quality of life.^2,4–13 The publication of the Kennedy Forum report in 2015 added momentum to the use of MBC in clinical practice.¹⁴ The report states that “one of the main contributors to poor outcomes in routine care is that providers do not typically use symptom rating scales in a systematic way to determine quantitatively whether their patients are improving.”¹⁵

The innovation of rating scales in psychiatry is attributed to Father Thomas Verner Moore, a psychologist and psychiatrist who created the first psychiatric rating scales in 1933.¹⁶ Over decades and with the development of the Diagnostic and Statistical Manual of Mental Disorders (DSM) and International Classification of Disease (ICD) diagnostic criteria, more psychiatric scales and measures were invented. The Handbook of Psychiatric Measures, initially published in 2000 by the American Psychiatric Association Task Force, includes more than 240 measures covering diagnostic interviews for adults and children, general psychiatric symptoms, general health status and mental health status, functioning and disability, quality of life, adverse effects and patient perceptions of care, stress and life events, suicide and aggression, personality disorders and personality traits, and measures specific to diagnostic categories.¹⁷

Despite the plethora of symptom rating scales with good psychometric properties, the use of these scales in clinical practice is limited. Aboraya et al¹⁸ identified 15 barriers to the use of rating scales. Arbuckle et al¹⁹ sent a confidential, web-based survey to residents and faculty supervisors at the New York State Psychiatric Institute (NYSPI) and the Department of Psychiatry at Columbia University regarding barriers to using measures in practice. The top five barriers identified by residents and faculty members were limited formal training, lack of time, lack of requirement to use scales in clinical work, limited access to scales, and lack of consensus as to which instrument to use.¹⁹ After the first author (AA) finished his master’s and doctoral degrees at Johns Hopkins University in 1991, he began his psychiatry residency training with a goal of incorporating psychiatric measures into clinical settings. After 10 years of trying to use almost all of the relevant existing scales and standardized diagnostic interviews for adult psychiatric disorders, AA concluded that existing measures were not practical for use in real-world psychiatric practice. Consequently, AA embarked on developing the Standard for Clinicians’ Interview in Psychiatry (SCIP) as a measurement-based care tool for use by clinicians in real-world settings. The SCIP assessment tool includes a glossary of 230 reliable psychopathology items, 18 clinician-administered (CA) scales, and 15 self-administered (SA) scales covering most adult symptom domains, including anxiety, panic, phobias, obsessions, compulsions, post-traumatic stress, depression, mania, delusions, hallucinations, disorganized thoughts, aggression, negative symptoms, alcohol use, drug use, attention deficit, hyperactivity, anorexia, binge eating, and bulimia. The SCIP scales are reliable, validated, and published.^18,20,21 The SCIP has simple and unified rules of measurement that apply to all 33 SCIP scales, which allow trained clinicians to use the scales for most adult psychiatric disorders.

The SCIP glossary and a set of 33 SCIP scales provided the core of the web-based MBC course. In addition to the SCIP scales, other non-SCIP scales, such as the Alcohol Use Disorders Identification Test (AUDIT),²² Generalized Anxiety Disorder-7 (GAD-7),²³ Patient Health Questionnaire (PHQ-9),²⁴ Clinically Useful Depression Outcome (CUDOS),²⁵ Clinically Useful Anxiety Outcome (CUXOS),²⁶ and other published scales^27,28 are discussed in the MBC course.

The MBC curriculum described in our first article⁴ included two instruction manuals (the SCIP instruction manual and the MBC instruction manual), four didactic lectures, and 12 videos. The MBC curriculum materials were hosted in the shared drive of West Virgina University (WVU) and Delaware Psychiatric Center (DPC) computers. Attendings and residents had access to the curriculum materials, and AA gave didactic lectures in both programs in-person and via Zoom. With the long-term goal of promoting MBC implementation in all residency programs in United States (US) and abroad, AA also designed the web-based MBC course that can be used to train clinicians and residents across the globe. Clinicians seeking training in MBC can access the course anytime from anywhere. This article discusses findings from the four-year implementation period and describes the first comprehensive web-based MBC course with recommendations for future implementation.

Methods

Ethics. The project of training clinicians in MBC was reviewed by the WVU Institutional Review Board (IRB) and determined to be a program evaluation, classified as “Not Human Subject Research.” The authors of the manuscript met the four authorship criteria set by the International Committee of Medical Journal Editors (ICMJE).²⁹ The MBC web course was approved by the WVU Continuing Medical Education (CME) office and is available at https://ce.wvu.edu/web-course-list/mbc-training/.

MBC implementation Phase I (2019–2023): lessons learned. The MBC curriculum implemented at WVU and DPC since 2019 followed the nine principles described in our first article to ensure that the implementation process was gradual and not disruptive to the extensive didactic requirements for program accreditation or to the normal flow of patient care operations.⁴ Residents were instructed to use the measures with appropriate patients when time permitted. First-year residents were required to read the SCIP instruction manual (about 1 hour of reading) and watch video 1 (40-minute video). No didactic lectures or practice with the scales were administered during the first year. Senior residents were given the didactic lectures and practiced using the scales in inpatient and outpatient settings.

Our experience showed that first-year residents were as enthusiastic as senior residents to learn about MBC and use the measures. Once the web-based MBC course was available online on May 17, 2023, seven postgraduate year 1 (PGY1) residents in both programs successfully completed the formal web-based MBC course. A recommendation is to have the web-based MBC course available on-demand and to advise residents to complete the course as soon as possible. The web-based course has 10 steps that can be completed at different times, meaning the resident can finish one step, then return to finish the other steps at any time. In the same vein, it is recommended to give the first two didactic lectures of the MBC curriculum during the first year. The other two didactic lectures can be given during the second or third years of residency. This will allow more time for residents to learn and practice using the scales during their four years of residency training.

The original MBC curriculum included 12 video interviews that were available on the shared drive. Residents were assigned to watch the videos, but this was determined to be unnecessary since residents already have a tremendous amount of experience in interviewing and interview real patients soon after beginning residency. The web-based course has four videos: video 1 (a 40-minute video of expert clips), video 2 (a 20-minute practice video), video 3 (a 40-minute practice video), and video 4 (a 20-minute test video). The four videos in the web-based course are sufficient to train and test experienced clinicians, such as residents.

The use of the SA scales was useful and appeared to save time in an institution with an advanced electronic medical record system, such as EpicCare. At WVU, all the SCIP scales are uploaded into EpicCare, and the clinician can send the SA scales to patients prior to the visit. Most patients completed the scales and returned them to the clinician through the patient portal (MyChart), which helped prepare the clinician for their subsequent appointment. Once the web-based course was available in May 2023, some first- and second-year residents started to send the SA scales to their patients.

MBC implementation Phase II (2023/2024 and beyond). The modified MBC curriculum used in Phase II implementation has three components: completion of the web-based MBC course, MBC scale practice, and MBC didactics.

Completion of the web-based MBC course. Beginning in academic year 2023/2024, all psychiatry residents were required to complete the web-based MBC course before graduation. It is recommended that residents complete the MBC course as early as possible, preferably before the end of their first year of residency. The MBC course can be completed in steps over time.

MBC scale practice. For inpatient rotations, residents practice scales with two patients per one-month rotation on inpatient units, such as adult and dual-diagnosis units. For outpatient rotations, residents choose two appropriate patients with whom to complete the SA scales per month.

MBC didactics. MBC didactics are taught by faculty members and attendings who are MBC trainers by experienced or newly trained attendings who have completed the web-based MBC course. First-year residents receive didactic lecture 1 (MBC basics) and didactic lecture 2 (assessment of psychopathology). Second-year residents receive didactic lecture 3 (epidemiological concepts) and didactic lecture 4 (psychiatric measures). Alternatively, didactic lectures 3 and 4 can be given to third-year residents. Fourth-year residents typically do electives and see patients in different settings (eg, inpatients, day hospitals, and outpatients). Fourth-year residents should use the scales more often when they have appropriate patients and when time permits.

Description of the Web-based MBC Course 

Course objectives. Following this activity, participants should be able to:

• Discuss the definition of MBC, advantages of MBC, criteria of MBC tools, and barriers to MBC implementation in clinical practice;
• Describe the types of psychiatric measures, such as screening questionnaires, diagnostic interviews (fully structured vs. semistructured), and rating scales (CA vs. SA);
• Recognize scales that are commonly used in MBC, such as GAD-7, PHQ-9, AUDIT, and other scales;
• Identify the psychometric properties of measures, such as validity (content, criterion, and construct validity), reliability (inter-rater, test-retest, and internal consistency reliability), and other important indices (sensitivity, specificity, kappa statistic);
• Recognize the SCIP principles of assessment of psychopathology and the SCIP scales; and
• Practice using scales by watching and rating videotaped interviews with feedback from experts.

Course content. The web-based MBC course includes four readings, four didactic presentations, and four videos.

Reading 1. The MBC instruction manual is a 27-page document prepared by the first author and contains an introduction to MBC, trainer and trainee qualifications, psychiatric interview contribution to MBC, evaluation of episodes, approaches to psychiatric diagnosis, principles of assessment of psychopathology, and guidelines for timing and frequency of scale use.

Reading 2. The SCIP glossary is a 40-page document that includes 30 screening items and 200 psychopathology items. Each item has a code, item definition, item question, and kappa statistic. The 230 items are reliable and published, and they cover panic, phobias, generalized anxiety, obsessions, compulsions, post-traumatic stress, depression, mania, hallucinations, delusions, disorganized thoughts, agitation and aggression, negative symptoms, alcohol and drug use, anorexia, binge eating, bulimia, attention deficit, and hyperactivity.³⁰

Reading 3. The 18 SCIP CA scales include a generalized anxiety scale (9 items), panic scale (5 items), phobia scale (9 items), obsessive-compulsive disorder (OCD) scale (18 items), post-traumatic stress disorder (PTSD) scale (16 items), depression scale (14 items), mania scale (13 items), hallucinations scale (9 items), delusions scale (9 items), disorganization scale (5 items), aggression scale (6 items), negative symptoms scale (8 items), alcohol scale (8 items), drug scale (7 items), attention deficit hyperactivity disorder (ADHD) scale (20 items), anorexia scale (9 items), binge eating and bulimia scale (17 items), and SCIP screen scale (30 items).

Reading 4. The 15 SCIP SA scales include a generalized anxiety scale (9 items), panic scale (5 items), phobia scale (9 items), OCD scale (18 items), PTSD scale (16 items), depression scale (12 items), mania scale (11 items), hallucinations scale (9 items), delusions scale (9 items), alcohol scale (8 items), drug scale (7 items), ADHD scale (20 items), anorexia scale (9 items), binge eating and bulimia scale (17 items), and intake scale (18 items).

Didactic presentations. Four didactic presentations (presentation 1: MBC basics, presentation 2: psychopathology assessment, presentation 3: epidemiological concepts, and presentation 4: non-SCIP scales) were prepared by the first author and can be modified for use by faculty who teach MBC didactics. 

Video interviews. Video 1 is a 40-minute video and includes an introduction to MBC and seven video clips of interviews with real patients. The video clips show examples of the ratings for generalized anxiety; attention impairment; startle response; depressed mood; anhedonia; expansive, irritable and mixed mood swings; racing thoughts; auditory hallucinations; and paranoid delusions, with the rationale for choosing ratings explained by experts. Video 2 is a 20-minute interview that focuses on depression, mania, hallucinations, delusions, and anxiety scales. Trainees rate the scales and have the chance to compare their ratings with experts’ ratings. Video 3 is a 40-minute typical psychiatric interview, which includes a screening scale and a mania scale. Trainees rate the interview and have the chance to compare their ratings with experts’ ratings. Video 4 is a 20-minute test interview which includes ADHD and depression scales. After viewing the video, trainees rate the scales.

The 10-step Web-based MBC Course

Trainees begin with the four readings, then complete steps 1 to 10 (Table 1). The online interface allows trainees to finish the 10 steps as their time allows. Trainees who pass the competency test will be awarded the 10 CME credit hours and MBC certificate. Table 1 shows the 10 steps required to complete the web-based MBC training with the title, mode, and name of the files of each step.

Results

Starting in the 2023 to 2024 academic year, all psychiatry residents in both programs (a total of 52 residents) were required to complete the MBC course before graduation. Since the launch of the web-based MBC course on May 17, 2023, 44 trainees from the WVU and DPC residency programs have completed the course. Additionally, four trainees outside of these programs have completed it, including two psychiatrists in private practice in Egypt, one psychologist in California, and one psychiatrist in Germany.

Fourteen faculty members from WVU and four attending physicians from DPC have also completed the course. Among the 34 residents in the WVU program, 14 (41%) completed the course. In the DPC program, 12 out of 18 residents (67%) completed the course. Residents who had not completed the course at the time of writing this manuscript will be required to do so before the end of PGY4. Table 2 provides a breakdown of the number of trainees who completed the course by institution and rank. Tables 3A and 3B present the outcomes of the course evaluation and the assessment of the learning objectives for the web-based MBC course.

Discussion

Dr. Melissa Arbuckle, the first educator to implement a curriculum in MBC for depression in a psychiatric resident clinic, found that MBC was feasible and improved depression screening and monitoring.³¹ A few years later, the SCIP assessment tool was published and validated.^18,20,21 The availability of the SCIP glossary with 230 psychopathology items and a set of 33 SCIP scales covering most adult psychopathology allowed the first author to develop the first comprehensive MBC curriculum for adult psychiatry and adapt the curriculum to implement in residency programs.³²

Many teaching faculty members, especially in prominent academic institutions, have tremendous expertise with research, securing funding grants, and publishing in major journals. These experienced faculty members are MBC trainers by default and do not need to be trained in MBC. However, most faculty and attendings across the 379 residency programs in the US have limited experience in research or MBC. An essential objective of the web-based MBC course is to initially train faculty and attending physicians. This training can equip them with the necessary knowledge and skills to subsequently instruct new residents on the fundamentals of MBC and mentor them on effectively implementing these measures in clinical practice. At the time of writing this manuscript, most of the faculty and attendings at the WVU and DPC programs had completed the MBC course. Starting in the 2024 to 2025 academic year, the trained faculty and attendings in both programs will assume the responsibilities of teaching the MBC didactics to new residents and will aim to create a culture of MBC in the future generations of psychiatrists.

In 2011, Harding⁶ wrote: 

To expedite and sustain quality improvement efforts going forward, psychiatric residency must include MBC training. Patterns learned during professional development are often incorporated into lifelong clinical practices, so residency training offers a unique opportunity to influence the adoption of evidence-based practices within the field…Meeting this expectation suggests psychiatric training programs develop comprehensive programs in MBC with didactic lectures, skill-building exercises, and clinical experience. Given most teaching faculty are unfamiliar with MBC or quality improvement initiatives, a necessity may exist for adopting prepackaged curricula and educating faculty supervisors through continuing medical education (CME) workshops.

Harding’s vision as described in 2011 is a reality today through the web-based MBC course. Trainees can access the web-based MBC course, and those who successfully complete the training are awarded an MBC certificate and 10 CME credit hours.

Most barriers identified by the faculty members and residents at NYSPI and Columbia University are now resolved.¹⁹ There is a formal web-based MBC course that can be accessed at anytime from anywhere. To provide access to the scales, AA has designated the 15 SA SCIP scales—covering anxiety, panic, phobia, OCD, PTSD, depression, mania, hallucinations, delusions, alcohol use, drug use, ADHD, anorexia, binge eating, bulimia, and intake screening—as public domain. Mental health professionals and researchers can use the paper versions of these scales for research and education at no cost and with no expiration date. Psychiatry residency programs implementing the MBC curriculum are permitted to upload the 15 SA SCIP scales into the electronic health records (such as EpicCare and Oracle Health) of their program hospitals and clinics. Appendix 1 includes the 15 SA SCIP scales.

The Accreditation Council for Graduate Medical Education (ACGME) has requirements for research literacy, scholarly activity, and research training.³³ Balon’s editorial on research training and education³⁴ points out that many small programs do not have the research faculty to accomplish the ACGME requirement. A benefit of implementing the MBC curriculum is that it can help small programs achieve the research requirement of the ACGME. First, residents and faculty of small programs, as well as larger programs, can access the MBC course anytime from anywhere. Second, the basics of research, including research designs, validity, reliability, and important research topics, are part of the MBC didactics. Third, as residents use scales while they are treating patients, they accumulate research data that can be used in case report publications and other projects.

Limitations. One limitation of MBC implementation Phase I (2019–2023) is the lack of accurate data on the frequency and extent of scale use by residents. Informally, attending physicians who oversee residents are aware that many residents utilized the scales. The authors learned that some residents were actually using scales before 2019, and some residents had even created smart phrases for measures, such as the GAD-7 and PHQ-9, in EpicCare. The authors also know that, unfortunately, a minority of residents chose not to learn or practice MBC. Going forward with Phase II (2023–2024 and beyond), data can be collected to describe the frequency and extent of scale use by residents.

When AA designed the MBC curriculum, the term “recommend” was used, and residents were not required to use a certain number of scales during their inpatient or outpatient service. The main goal of the MBC curriculum is to teach the new generations of psychiatrists the basics of MBC and give them a chance to practice using the scales during rotations when they have the appropriate patients and time. The literature shows that new methods learned by trainees during early career training are more likely to be incorporated into their lifelong career.^35–37 The hope is that residents trained in MBC will continue to use the measures in clinical practice after the training.

Another limitation of the MBC curriculum implementation is that it is a recent project, and it is therefore too early to evaluate its long-term impact on clinician’s views of MBC training or on their clinical practice. A future confidential, web-based survey to faculty and residents can potentially answer these questions. Future work can also compare a cohort of resident graduates with and without MBC training completion.

Conclusion

MBC training is available for clinicians through the WVU continuing medical education web courses and can be accessed anytime from anywhere at no cost. Psychiatry residency programs implementing the MBC curriculum can access the SCIP scales and use them for teaching and providing evidence-based clinical care. The four-year process of integrating the MBC curriculum into the WVU and DPC programs might set a precedent for other programs in the US and internationally to follow suit. The MBC training curriculum is in the public domain and can be utilized and adapted by clinicians to suit their specific programs. It is time to implement MBC in residency programs and in broader clinical practice in an effort to provide patients with the highest quality of care.

AddItional information

Access to WVU CME courses: http://ce.wvu.edu/

Informational page for MBC training: https://ce.wvu.edu/web-course-list/mbc-training/

Instructions to register for SOLE for users outside West Virginia University:

Download an authenticator app on your cellphone beforehand. Any authenticator app (eg, Authy) will suffice.

Go to the following link: https://ce.wvu.edu/web-course-list/mbc-training/

Upon clicking the link, you will be prompted to self-enroll; you will be required to provide your name, email, and phone number.

After enrolling, an email containing a link will be sent to the provided address. Click on this link to create a password.

Upon completing the password creation, a QR code will be displayed. Use your cellphone’s camera to scan this QR code, which will link the authenticator app to SOLE, providing a login code with each login.

Input the code provided by the authenticator app to access the course material.

Appendix

To access Appendix 1, please visit https://innovationscns.com/wp-content/uploads/SCIP_SCALES_SA.docx.

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