
==== Front
Aust N Z J Psychiatry
Aust N Z J Psychiatry
ANP
spanp
The Australian and New Zealand Journal of Psychiatry
0004-8674
1440-1614
SAGE Publications Sage UK: London, England

39054785
10.1177/00048674241266057
10.1177_00048674241266057
Editorials
In Brief
Facilitating routine data collection to improve clinical quality and research in Interventional Psychiatry: The CARE Network
https://orcid.org/0009-0004-7918-3782
Dong Vanessa 12
https://orcid.org/0009-0002-1027-9837
Brettell Louise 12
Massaneda-Tuneu Clara 12
Rita Barreiros Ana 1234
Vinh Cao Thanh 2
Kelly Catherine 12
https://orcid.org/0009-0009-2114-5157
Zeng Yucheng 12
Aoki Nobuatsu 125
https://orcid.org/0000-0001-7972-3030
Tor Phern-Chern 6
https://orcid.org/0000-0002-2976-822X
Bayes Adam 12
https://orcid.org/0000-0001-6578-2718
Branjerdporn Grace 789
https://orcid.org/0000-0003-0113-7415
Sarma Shanthi 78
https://orcid.org/0000-0002-3295-4015
Kwan Elaine 1
Waite Sue 10
Mohan Titus 11
https://orcid.org/0000-0002-9055-0510
Hussain Salam 1213
Gálvez Verónica 1415
Weiss Alan 16
Bull Michael 21718
https://orcid.org/0000-0003-4902-9448
Lou Chatterton Mary 19
Mihalopoulos Cathrine 19
https://orcid.org/0000-0002-0476-9146
Glozier Nick 2021
Hadzi-Pavlovic Dusan 1
https://orcid.org/0000-0001-6004-4521
Hopwood Malcolm 22
Mitchell Philip 1
Power Brian 23
https://orcid.org/0000-0002-3762-1711
Sara Grant 12425
Wells Karen 26
https://orcid.org/0000-0003-3267-0554
Loo Colleen 12*
https://orcid.org/0000-0002-8452-0390
Martin Donel 12*
1 Discipline of Psychiatry and Mental Health, School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
2 Black Dog Institute, Randwick, NSW, Australia
3 Brain Dynamics Centre, The Westmead Institute for Medical Research, Westmead, NSW, Australia
4 Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
5 Department of Neuropsychiatry, Faculty of Medicine, Kansai Medical University, Osaka, Japan
6 Department of Mood & Anxiety, Institute of Mental Health, Singapore
7 Gold Coast Hospital and Health Service, Southport, QLD, Australia
8 Bond University, Robina, QLD, Australia
9 Mater Research Institute, The University of Queensland, Brisbane, QLD, Australia
10 The Queen Elizabeth Hospital, Woodville South, SA, Australia
11 Flinders University, Adelaide, SA, Australia
12 Division of Psychiatry, School of Medicine, The University of Western Australia, Perth, WA, Australia
13 Mental Health Service, Sir Charles Gairdner Hospital, Nedlands, WA, Australia
14 Mental Health and Addiction Service, Hospital Universitari Parc Taulí, Sabadell, Spain
15 I3PT CERCA, Sabadell, Spain
16 School of Medicine and Public Health, The University of Newcastle, Callaghan, NSW, Australia
17 Ramsay Clinic Northside, St Leonards, NSW, Australia
18 Ramsay Clinic Lakeside, Warners Bay, NSW, Australia
19 School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
20 Central Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
21 ARC Centre of Excellence for Children and Families over the Life Course, Brisbane, QLD, Australia
22 Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
23 School of Medicine Fremantle, The University of Notre Dame, Fremantle, WA, Australia
24 System Information and Analytics Branch, NSW Ministry of Health, St Leonards, NSW, Australia
25 Northern Clinical School, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
26 Faculty of Health Sciences, The University of Sydney, Sydney, NSW, Australia
Donel Martin, Black Dog Institute, Hospital Road, Randwick 2031, NSW, Australia. Email: donel.martin@unsw.edu.au
* These authors served as co-senior authors.

25 7 2024
9 2024
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© The Royal Australian and New Zealand College of Psychiatrists 2024
2024
The Royal Australian and New Zealand College of Psychiatrists
https://creativecommons.org/licenses/by-nc/4.0/ This article is distributed under the terms of the Creative Commons Attribution-NonCommercial 4.0 License (https://creativecommons.org/licenses/by-nc/4.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access page (https://us.sagepub.com/en-us/nam/open-access-at-sage).
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pmcMental health disorders are a leading contributor to the global burden of disease. Although a wide array of pharmacological and psychological therapies is used, a substantial number of individuals either do not respond or experience only modest benefits. In recent years, several promising treatments within Interventional Psychiatry have entered clinical practice. Interventional Psychiatry treatments are defined primarily by their procedural nature and include neurostimulation techniques such as transcranial magnetic stimulation (TMS) and transcranial direct current stimulation (tDCS), and the novel use of ‘old drugs’ such as ketamine and psychedelics. While the efficacy and safety of these interventions have been studied in clinical trials, findings can be difficult to generalise to clinical practice because of restrictive eligibility criteria, highly protocolised research methodology, short follow-up periods and a lack of head-to-head comparisons. Clinicians are thus faced with uncertainties, including: (1) how these interventions perform and compare in real-world conditions, (2) which interventions are best suited to each individual, (3) the optimisation of clinical treatment protocols, including how and when to stop, (4) how to accommodate broader populations seen in clinical practice compared to research trials (e.g. those with comorbidities, receiving concurrent treatments), (5) the relative cost-effectiveness of different treatments, and (6) whether new safety concerns may emerge as treatments are provided to a larger number of patients or for a longer-time (e.g. maintenance treatment).

High-quality ‘phase 4’ data derived from real-world clinical settings are essential to address questions of this nature. Indeed, governments are increasingly recommending data collection in their clinical policies and guidelines, in recognition of the critical role of real-world data in ongoing service improvement, funding, and research. However, these health datasets often fail to capture important treatment and outcome variables, and end up being a step removed from clinical practice. For example, outcome measures included in Australia’s Mental Health National Outcomes and Casemix Collection are used for reporting and activity-based funding purposes at a service level but are not sufficiently sensitive or administered frequently enough to be used for clinical management or research within Interventional Psychiatry.

Clinical networks play a critical role in addressing this issue, facilitating the creation of routine data collection frameworks that are relevant to clinicians, and which meaningfully inform evidence-based practices and policies. One such example is the Clinical Alliance and Research Excellence in Electroconvulsive Therapy (ECT) and Interventional Psychiatry (CARE) Network. Initially established in 2015 with the aim of improving clinical practice and facilitating research in ECT (Martin et al., 2018), the CARE Network has subsequently expanded to incorporate other treatment modalities, including TMS, transcranial electrical stimulation (tES; which includes tDCS), ketamine, and psychedelic-assisted therapy, reflecting their incorporation into everyday clinical practice.

As part of CARE, clinicians and academics collaborate to develop standardised data collection frameworks for each treatment modality (termed a ‘module’), in consultation with consumers with lived experience. Each module comprises a suite of measurement scales to capture clinical, cognitive, quality of life and functional outcomes in a structured manner, with minimum ‘core’ and optional ‘additional’ measurement scales. Patient demographics, clinical characteristics, and treatment parameters are also captured. Modules are tailored to each intervention and indication, but the recommended measurement scales are kept consistent across modalities where possible, for ease of use and to facilitate comparison between modalities.

Services use pre-designed forms and databases to collect data at specified time points, in accordance with the CARE framework. Importantly, each service maintains ownership of their own local data but may then voluntarily ‘opt-in’ to share their anonymised, individual patient data for use in specific multi-site research and benchmarking projects, in accordance with local governance restrictions. This allows CARE to provide the benefits of a clinical registry (i.e. a common suite of data variables which facilitates benchmarking and research) without the privacy/data ownership complexities and costs associated with maintaining a single overarching data repository.

The involvement of different types of clinical services (e.g. outpatient/inpatient, public/private) across different states and countries makes it possible to capture wider variations in clinical practice and policy, which enriches the Network by enabling better comparison of different treatment approaches. The Network also facilitates the development of a collaborative community for knowledge exchange among experienced clinicians and world-renowned experts in the field, advancing both research and clinical development. Ultimately, the core aim is a shared commitment to excellence in treatment delivery and patient care across different healthcare systems.

Adopting the CARE Network data collection framework provides services with immediate benefits for enhancing patient care and evidence-based practice in Interventional Psychiatry. Not only does the use of validated outcome measures facilitate the evaluation and improvement of clinical protocols and procedures, the data collected can also support clinical decision-making to improve treatment for individual patients and contribute to the future development of predictive algorithms for personalised precision treatment. For example, ECT services have reported that implementing CARE-recommended clinical and cognitive measures has helped optimise ECT dosing and reduced retrograde amnesia risk via improved patient monitoring. Some centres have implemented CARE modules within a digitised framework (e.g. Microsoft Teams, Research Electronic Data Capture [REDCap]), reporting that having access to real-time summaries of individual patient outcomes allows clinicians to better track clinical improvements and adverse effects, and thus adjust treatment parameters accordingly.

Involvement in the CARE Network also provides services with medium and longer-term benefits, with the data facilitating quality improvement, benchmarking, and clinical research. To date, the CARE Network has conducted benchmarking activities in ECT and TMS and facilitated multisite international research. Some of the research projects completed have allowed services to examine the impact of COVID-19 on ECT service delivery (Kwan et al., 2022), and the utility of certain measurement tools in clinical care (Martin et al., 2022; Waite et al., 2022).

Research derived from data collected using the CARE Network framework has also played an important role in informing government policies at the state and national level. For example, two of the validated cognitive screening tests for ECT developed based on research by the CARE Network (10-Item Orientation and Brief ECT Cognitive Screen) will be mandated in incoming NSW Health ECT Treatment Guidelines/Handbooks. Furthermore, by helping to generate real-world data on resource use, the Network also facilitates economic analyses of the relative cost and outcomes of different treatments, which is crucial for reimbursement decisions made by regulatory advisory committees. Indeed, a service in Singapore which systematically collected symptom, cognition, and quality-of-life outcomes for both ECT and TMS using the CARE Network framework, was able to produce cost-effectiveness data that were pivotal in the Singapore government’s decision to subsidise TMS treatment for depression in January 2022 (Tor et al., 2024).

Promoting clinical excellence via routine data collection and analysis needs to become the norm rather than the exception in psychiatry. This is particularly important in Interventional Psychiatry, given the growing number of emerging treatments entering clinical practice in recent years. The CARE Network helps services to embrace routine data collection and measurement-based care, with further optional participation in benchmarking and research. It is free to join and provides resources for clinical use at no cost. All clinical services from public and private sectors in Australia, New Zealand, and overseas, are welcome. Further information about the materials available for use, and how to join the network, can be found at: https://www.carenetwork.unsw.edu.au/.

Not applicable.

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: E.K. declares honoraria from the Lundbeck institute outside the submitted work. S.H. declares honoraria from the Lundbeck Institute for a conference scientific committee. N.G. declares honoraria from Servier Laboratories and Lundbeck Institute, has served on advisory boards for Servier Laboratories, Esia, Seqirus and Lundbeck, and is supported by grants from the NHMRC (grant nos. 1105089 and 2014381) and ARC (grant no. CE20010025). M.H. declares honoraria and research funding from Janssen Australia outside of this work. P.M. declares remuneration from Janssen Australia for lectures and advisory board membership. All other authors declare no conflict of interest.

Funding: The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: Seed funding to set-up the CARE Network was received from the New South Wales Mental Health Commission (grant no. RG150545), with ongoing funding provided by the National Health and Medical Research Council (grant no. APP1195643), and the Ramsay Hospitals Research Foundation (grant no. GNT1195643).

Ethics Approval and Informed Consent: There are no human participants in this article; ethics approval and informed consent is not required.

ORCID iDs: Vanessa Dong https://orcid.org/0009-0004-7918-3782

Louise Brettell https://orcid.org/0009-0002-1027-9837

Yucheng Zeng https://orcid.org/0009-0009-2114-5157

Phern-Chern Tor https://orcid.org/0000-0001-7972-3030

Adam Bayes https://orcid.org/0000-0002-2976-822X

Grace Branjerdporn https://orcid.org/0000-0001-6578-2718

Shanthi Sarma https://orcid.org/0000-0003-0113-7415

Elaine Kwan https://orcid.org/0000-0002-3295-4015

Salam Hussain https://orcid.org/0000-0002-9055-0510

Mary Lou Chatterton https://orcid.org/0000-0003-4902-9448

Nick Glozier https://orcid.org/0000-0002-0476-9146

Malcolm Hopwood https://orcid.org/0000-0001-6004-4521

Grant Sara https://orcid.org/0000-0002-3762-1711

Colleen Loo https://orcid.org/0000-0003-3267-0554

Donel Martin https://orcid.org/0000-0002-8452-0390
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References

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Martin DM Gálvez V Lauf S , et al . (2018) The Clinical Alliance and Research in Electroconvulsive Therapy Network: An Australian initiative for improving service delivery of electroconvulsive therapy. The Journal of ECT 34 : 7–13.28658011
Martin DM Tor PC Waite S , et al . (2022) The utility of the brief ECT cognitive screen (BECS) for early prediction of cognitive adverse effects from ECT: A CARE Network study. Journal of Psychiatric Research 145 : 250–255.
Tor PC Barreiros AR Cao TV , et al . (2024) Why you should collect routine clinical data for ECT: A Singapore story from the CARE Network. The Journal of ECT. Epub ahead of print 8 April. DOI: 10.1097/YCT.0000000000001012.
Waite S Tor PC Mohan T , et al . (2022) The utility of the Sydney Melancholia Prototype Index (SMPI) for predicting response to electroconvulsive therapy in depression: A CARE Network study. Journal of Psychiatric Research 155 : 180–185.36054966
