ORIGINAL RESEARCH article
Front. Psychiatry
Sec. Digital Mental Health
Volume 16 - 2025 | doi: 10.3389/fpsyt.2025.1667897
This article is part of the Research TopiceHealth and Personalized Medicine in Mental Health and Neurodevelopmental Disorders: Digital Innovation for Diagnosis, Care, and Clinical ManagementView all 10 articles
Guideline Adherence in Depression Outcome Measurement: A Retrospective Cohort Study from Swedish Psychiatric Outpatient Care
Provisionally accepted
- Karolinska Institutet (KI), Solna, Sweden
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Background Routine outcome measurement is a core element of measurement-based care (MBC), yet its use in everyday psychiatric practice remains limited. Even minimal follow-up assessment is often missing despite explicit clinical guideline recommendations. Methods We conducted a retrospective cohort study of 2,431 adult outpatient episodes of depression treatment within Stockholm’s public mental health system (2020–2023). Guideline-concordant outcome measurement was defined as documentation of at least one Patient Health Questionnaire-9 (PHQ-9) or clinician-rated Montgomery–Åsberg Depression Rating Scale (MADRS) within 60 days of treatment initiation for all modalities, or within ten sessions for psychotherapy. Adherence rates were compared across antidepressant pharmacotherapy, face-to-face psychotherapy, and internet-based cognitive behavioral therapy (iCBT). Results Among treatment episodes lasting ≥ 30 days (n = 2,242), 28.2 % included a PHQ-9 or MADRS within 60 days. Adherence was higher in psychological treatments (71.6 %) than in pharmacotherapy (10.2 %), χ²(1, N = 2,242) = 865.14, p < .001, Cramer’s V = .62. Within psychotherapy, iCBT showed markedly greater adherence (80.1 %) than traditional psychotherapy (18.0 %), χ²(1, N = 656) = 146.00, p < .001, V = .47. When iCBT was excluded, adherence fell to 10.6 % overall. Among psychotherapy episodes with ≥ 10 sessions (n = 482), 73.4 % met the ten-session guideline, with 79.5 % adherence in iCBT and 23.1 % in traditional psychotherapy, χ²(1, N = 482) = 75.82, p < .001, V = .40. Younger clinicians (M = 39.8 vs. 46.8 years, p < .001) and psychologists (73 %) showed higher adherence than physicians (10 %) or other professions. Conclusion Even under conservative criteria, minimal outcome measurement was documented in fewer than one-third of depression treatment episodes. Adherence was particularly low in pharmacotherapy and traditional psychotherapy but substantially higher in iCBT, reflecting the advantages of automated, integrated digital workflows. These findings underscore that policy guidelines alone are insufficient; scalable implementation of MBC requires integrated digital systems, structured workflows, and targeted clinician support.
Keywords: Measurement-based care, Routine outcome monitoring, Depression, digital mental health, Internet-based cognitive behavioral therapy, implementation science, Electronic Health Records
Received: 17 Jul 2025; Accepted: 21 Oct 2025.
Copyright: © 2025 El Alaoui, Jayaram-Lindstrom and Bohman. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence: Samir El Alaoui, samir.el.alaoui@ki.se
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