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Curth NK, Hjorthøj C, Brinck-Claussen U, Jørgensen KB, Rosendal S, Bojesen AB, Nordentoft M, Eplov LF. The effects of collaborative care versus consultation liaison for anxiety disorders and depression in Denmark: two randomised controlled trials. Br J Psychiatry 2023; 223:430-437. [PMID: 37395101 PMCID: PMC10895499 DOI: 10.1192/bjp.2023.77] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 03/23/2023] [Accepted: 05/09/2023] [Indexed: 07/04/2023]
Abstract
BACKGROUND Collaborative care (CC) and consultation liaison (CL) are two conceptual models aiming to improve mental healthcare in primary care. The effects of these models have not been compared in a Danish setting. AIMS To examine the effects of CC versus CL for persons with anxiety and depression in Danish general practices (trial registration: NCT03113175 and NCT03113201). METHOD Two randomised parallel superiority trials for anxiety disorders and depression were carried out in 2018-2019. In the CC-group, care managers collaborated with general practitioners (GPs) to provide evidence-based treatment according to structured treatment plans. They followed up and provided psychoeducation and/or cognitive-behavioural therapy. The GPs initiated pharmacological treatment if indicated, and a psychiatrist provided supervision. In the CL-group, the intervention consisted of the GP's usual treatment. However, the psychiatrist and care manager could be consulted. Primary outcomes were depression symptoms (Beck Depression Inventory-II, BDI-II) in the depression trial and anxiety symptoms (Beck Anxiety Inventory, BAI) in the anxiety trial at 6-month follow-up. RESULTS In total, 302 participants with anxiety disorders and 389 participants with depression were included. A significant difference in BDI-II score was found in the depression trial, with larger symptom reductions in the CC-group (CC: 12.7, 95% CI 11.4-14.0; CL: 17.5, 95% CI 16.2-18.9; Cohen's d = -0.50, P ≤ 0.001). There was a significant difference in BAI in the anxiety trial (CC: 14.9, 95% CI 13.5-16.3; CL: 17.9, 95% CI 16.5-19.3; Cohen's d = -0.34, P ≤ 0.001), with larger symptom reductions in the CC-group. CONCLUSIONS Collaborative care was an effective model to improve outcomes for persons with depression and anxiety disorders.
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Affiliation(s)
- Nadja Kehler Curth
- Copenhagen Research Center for Mental Health, Mental Health Center Copenhagen, Copenhagen University Hospital, Mental Health Services - Capital Region of Denmark, Hellerup, Denmark
| | - Carsten Hjorthøj
- Copenhagen Research Center for Mental Health, Mental Health Center Copenhagen, Copenhagen University Hospital, Mental Health Services - Capital Region of Denmark, Hellerup, Denmark; and Department of Public Health, Section of Epidemiology, University of Copenhagen, Copenhagen, Denmark
| | - Ursula Brinck-Claussen
- Copenhagen Research Center for Mental Health, Mental Health Center Copenhagen, Copenhagen University Hospital, Mental Health Services - Capital Region of Denmark, Hellerup, Denmark
| | - Kirstine Bro Jørgensen
- Copenhagen Research Center for Mental Health, Mental Health Center Copenhagen, Copenhagen University Hospital, Mental Health Services - Capital Region of Denmark, Hellerup, Denmark
| | - Susanne Rosendal
- Psychotherapeutic Clinic, Mental Health Center Copenhagen, Copenhagen University Hospital, Mental Health Services - Capital Region of Denmark, Copenhagen, Denmark
| | - Anders Bo Bojesen
- Copenhagen Research Center for Mental Health, Mental Health Center Copenhagen, Copenhagen University Hospital, Mental Health Services - Capital Region of Denmark, Hellerup, Denmark
| | - Merete Nordentoft
- Copenhagen Research Center for Mental Health, Mental Health Center Copenhagen, Copenhagen University Hospital, Mental Health Services - Capital Region of Denmark, Hellerup, Denmark; and Institute of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Lene Falgaard Eplov
- Copenhagen Research Center for Mental Health, Mental Health Center Copenhagen, Copenhagen University Hospital, Mental Health Services - Capital Region of Denmark, Hellerup, Denmark
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Petersson EL, Forsén E, Björkelund C, Hammarbäck L, Hessman E, Weineland S, Svenningsson I. Examining the description of the concept "treatment as usual" for patients with depression, anxiety and stress-related mental disorders in primary health care research - A systematic review. J Affect Disord 2023; 326:1-10. [PMID: 36708952 DOI: 10.1016/j.jad.2023.01.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 01/10/2023] [Accepted: 01/21/2023] [Indexed: 01/26/2023]
Abstract
BACKGROUND In randomized controlled trials (RCTs) within medical research, applied interventions are compared to treatment-as-usual (TAU) as the control condition. The aim of the current study was to examine how the concept of TAU is described when used as control condition in RCTs evaluating treatments for depression, anxiety syndromes, and stress-related mental disorders in primary care. METHOD A systematic review of RCTs utilizing TAU as control group in the RCT in accordance with PRISMA standards was conducted. We used one multidisciplinary database (Scopus), one database focused on nursing (Cinahl), and one medical database (PubMed). The searches were conducted in November 2021 and May 2022. RESULTS The included 32 studies comprised of 7803 participants. The content of TAU was classified as follows: 1) Basic descriptions of TAU lacking a detailed account as well as reference to local or national guidelines, 2) Moderate description of TAU including reference to national or local guidelines or a detailed description 3) Advanced description of TAU including references to national guidelines and a detailed description containing five key concepts: early assessment, accessibility, psychological treatment, medication, somatic examination. 18 studies had basic, 11 moderate, and 3 advanced descriptions of TAU. LIMITATIONS The limitations were that only studies published in English were included. CONCLUSIONS The current study provides an assessment tool with three classification levels for TAU. The description of TAU is still insufficient in RCT studies conducted in primary care, which may affect the interpretation of results. In future research a detailed description of TAU is recommended.
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Affiliation(s)
- E-L Petersson
- Primary Health Care/School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
| | - E Forsén
- Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden
| | - C Björkelund
- Primary Health Care/School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - L Hammarbäck
- Biomedical Library, Gothenburg University Library, University of Gothenburg, Gothenburg, Sweden
| | - E Hessman
- Biomedical Library, Gothenburg University Library, University of Gothenburg, Gothenburg, Sweden
| | - S Weineland
- Primary Health Care/School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden; Department of Psychology, University of Gothenburg, Gothenburg, Sweden
| | - I Svenningsson
- Primary Health Care/School of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; Research, Education, Development & Innovation, Primary Health Care, Region Västra Götaland, Sweden.
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Rivero-Santana A, Perestelo-Perez L, Alvarez-Perez Y, Ramos-Garcia V, Duarte-Diaz A, Linertova R, Garcia-Perez L, Serrano-Aguilar P. Stepped care for the treatment of depression: a systematic review and meta-analysis. J Affect Disord 2021; 294:391-409. [PMID: 34315101 DOI: 10.1016/j.jad.2021.07.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 06/17/2021] [Accepted: 07/10/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND The Stepped Care Model (SCM) proposes a sequential approach in the treatment of depression, applying interventions of increasing intensity according to the level of severity of the individual. METHODS A systematic review was carried out until January 2020 in eight electronic databases. We included randomized (RCT) and non-randomized controlled trials comparing the SCM to usual non-sequential care. RESULTS Eighteen RCT with patients with confirmed or probable depression diagnosis were included. Meta-analyses yielded high heterogeneity, and subgroup analyses showed significant effects of the SCM only in studies with baseline moderately severe symptoms on average, compared to samples with mild/moderate depression. In the former subgroup, effects at 3-6 and 9-12 months were small for symptoms' reduction (g = -0.33, 95%CI: -0.55, -0.17 and -0.34, 95%CI: -0.53, -0.16) and moderate-to-strong in response and remission (Risk Ratios between 1.70-1.90). Overall, a significant benefit on quality of life was also observed (6 months: g = 0.31, 95%CI: 0.12, 0.49; 12 months: g = 0.18, 95%CI: 0.06, 0.31). More patients in the SCM groups were prescribed antidepressants at 6 months (RR = 1.31, 95%CI: 1.09, 1.57; I² = 87%). LIMITATIONS The search does not guarantee the identification of all the relevant literature. Most included studies show uncertain or high risk of bias. CONCLUSIONS The SCM seems to outperform usual care in populations with at least moderately severe symptoms on average. Results show high heterogeneity and future research should explore its sources.
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Affiliation(s)
- Amado Rivero-Santana
- Canary Islands Health Research Institute Foundation, Tenerife, Spain (FIISC), Spain; Health Services Research on Chronic Patients Network (REDISSEC). Tenerife, Spain
| | - Lilisbeth Perestelo-Perez
- Health Services Research on Chronic Patients Network (REDISSEC). Tenerife, Spain; Evaluation Unit (SESCS), Canary Islands Health Service (SCS), Tenerife, Spain..
| | | | - Vanesa Ramos-Garcia
- Canary Islands Health Research Institute Foundation, Tenerife, Spain (FIISC), Spain
| | - Andrea Duarte-Diaz
- Canary Islands Health Research Institute Foundation, Tenerife, Spain (FIISC), Spain
| | - Renata Linertova
- Canary Islands Health Research Institute Foundation, Tenerife, Spain (FIISC), Spain; Health Services Research on Chronic Patients Network (REDISSEC). Tenerife, Spain
| | - Lidia Garcia-Perez
- Canary Islands Health Research Institute Foundation, Tenerife, Spain (FIISC), Spain; Health Services Research on Chronic Patients Network (REDISSEC). Tenerife, Spain
| | - Pedro Serrano-Aguilar
- Health Services Research on Chronic Patients Network (REDISSEC). Tenerife, Spain; Evaluation Unit (SESCS), Canary Islands Health Service (SCS), Tenerife, Spain
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The effectiveness of enhanced evidence-based care for depressive disorders: a meta-analysis of randomized controlled trials. Transl Psychiatry 2021; 11:531. [PMID: 34657142 PMCID: PMC8520525 DOI: 10.1038/s41398-021-01638-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 08/13/2021] [Accepted: 09/08/2021] [Indexed: 11/26/2022] Open
Abstract
Several care models have been developed to improve treatment for depression, all of which provide "enhanced" evidence-based care (EEC). The essential component of these approaches is Measurement-Based Care (MBC). Specifically, Collaborative Care (CC), and Algorithm-guided Treatment (AGT), and Integrated Care (IC) all use varying forms of rigorous MBC assessment, care management, and/or treatment algorithms as key instruments to optimize treatment delivery and outcomes for depression. This meta-analysis systematically examined the effectiveness of EEC versus usual care for depressive disorders based on cluster-randomized studies or randomized controlled trials (RCTs). PubMed, the Cochrane Library, and PsycInfo, EMBASE, up to January 6th, 2020 were searched for this meta-analysis. The electronic search was supplemented by a manual search. Standardized mean difference (SMD), risk ratio (RR), and their 95% confidence intervals (CIs) were calculated and analyzed. A total of 29 studies with 15,255 participants were analyzed. EEC showed better effectiveness with the pooled RR for response of 1.30 (95%CI: 1.13-1.50, I2 = 81.9%, P < 0.001, 18 studies), remission of 1.35 (95%CI: 1.11-1.64, I2 = 85.5%, P < 0.001, 18 studies) and symptom reduction with a pooled SMD of -0.42 (95%CI: -0.61-(-0.23), I2 = 94.3%, P < 0.001, 19 studies). All-cause discontinuations were similar between EEC and usual care with the pooled RR of 1.08 (95%CI: 0.94-1.23, I2 = 68.0%, P = 0.303, 27 studies). This meta-analysis supported EEC as an evidence-based framework to improve the treatment outcome of depressive disorders.Review registration: PROSPERO: CRD42020163668.
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Grigoroglou C, van der Feltz-Cornelis C, Hodkinson A, Coventry PA, Zghebi SS, Kontopantelis E, Bower P, Lovell K, Gilbody S, Waheed W, Dickens C, Archer J, Blakemore A, Adler DA, Aragones E, Björkelund C, Bruce ML, Buszewicz M, Carney RM, Cole MG, Davidson KW, Gensichen J, Grote NK, Russo J, Huijbregts K, Huffman JC, Menchetti M, Patel V, Richards DA, Rollman B, Smit A, Zijlstra-Vlasveld MC, Wells KB, Zimmermann T, Unutzer J, Panagioti M. Effectiveness of collaborative care in reducing suicidal ideation: An individual participant data meta-analysis. Gen Hosp Psychiatry 2021; 71:27-35. [PMID: 33915444 DOI: 10.1016/j.genhosppsych.2021.04.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/15/2021] [Accepted: 04/18/2021] [Indexed: 10/21/2022]
Abstract
UNLABELLED To assess whether CC is more effective at reducing suicidal ideation in people with depression compared with usual care, and whether study and patient factors moderate treatment effects. METHOD We searched Medline, Embase, PubMed, PsycINFO, CINAHL, CENTRAL from inception to March 2020 for Randomised Controlled Trials (RCTs) that compared the effectiveness of CC with usual care in depressed adults, and reported changes in suicidal ideation at 4 to 6 months post-randomisation. Mixed-effects models accounted for clustering of participants within trials and heterogeneity across trials. This study is registered with PROSPERO, CRD42020201747. RESULTS We extracted data from 28 RCTs (11,165 patients) of 83 eligible studies. We observed a small significant clinical improvement of CC on suicidal ideation, compared with usual care (SMD, -0.11 [95%CI, -0.15 to -0.08]; I2, 0·47% [95%CI 0.04% to 4.90%]). CC interventions with a recognised psychological treatment were associated with small reductions in suicidal ideation (SMD, -0.15 [95%CI -0.19 to -0.11]). CC was more effective for reducing suicidal ideation among patients aged over 65 years (SMD, - 0.18 [95%CI -0.25 to -0.11]). CONCLUSION Primary care based CC with an embedded psychological intervention is the most effective CC framework for reducing suicidal ideation and older patients may benefit the most.
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Affiliation(s)
- Christos Grigoroglou
- Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, England.
| | | | - Alexander Hodkinson
- National Institute of Health Research School for Primary Care Research, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, England
| | - Peter A Coventry
- Department of Health Sciences, University of York, York, England
| | - Salwa S Zghebi
- National Institute of Health Research School for Primary Care Research, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, England
| | - Evangelos Kontopantelis
- Faculty of Biology, Medicine and Health, Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, England
| | - Peter Bower
- National Institute of Health Research School for Primary Care Research, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, England
| | - Karina Lovell
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, England; Greater Manchester Mental Health NHS Foundation Trust, Manchester, England
| | - Simon Gilbody
- Department of Health Sciences, Hull York Medical School, HYMS, University of York, York, England
| | - Waquas Waheed
- National Institute of Health Research School for Primary Care Research, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, England
| | | | - Janine Archer
- School of Health and Society, School of Health and Society, University of Salford, England
| | - Amy Blakemore
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, England
| | - David A Adler
- Departments of Psychiatry and Medicine, Tufts Medical Center and Tufts University School of Medicine, England
| | - Enric Aragones
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAPJGol), Barcelona, Spain
| | - Cecilia Björkelund
- Primary Health Care School of Public Health and Community Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Martha L Bruce
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Marta Buszewicz
- Institute of Epidemiology and Health, Faculty of Population and Health Sciences, University College London, London, England
| | - Robert M Carney
- Department of Psychiatry, Washington University in St. Louis (WUSTL), St. Louis, Missouri, USA
| | - Martin G Cole
- Department of Psychiatry, St. Mary's Hospital Center, McGill University, Montreal, Quebec, Canada
| | - Karina W Davidson
- Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Jochen Gensichen
- Institute of General Practice and Family Medicine, LMU Klinikum, Ludwig-Maximilians, University Munich Pettenkoferstr. 10, 80336 Munich, Germany
| | - Nancy K Grote
- School of Social Work, University of Washington, Seattle, USA
| | - Joan Russo
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, USA
| | - Klaas Huijbregts
- Department of Psychiatry and Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Jeff C Huffman
- Harvard Medical School, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Marco Menchetti
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Vikram Patel
- The Pershing Square Professor of Global Health, Harvard Medical School, Boston, MA, USA
| | - David A Richards
- Institute of Health Research, University of Exeter College of Medicine and Health, Exeter, England; Western University of Norway, Bergen, Norway
| | - Bruce Rollman
- Center for Behavioral Health, Media and Technology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Annet Smit
- HAN University of Applied Sciences, Nijmegen, Netherlands
| | | | - Kenneth B Wells
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, USA; Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, USA
| | - Thomas Zimmermann
- Department of General Practice / Primary Care, Centre for Psychosocial Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Jurgen Unutzer
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, USA
| | - Maria Panagioti
- National Institute of Health Research School for Primary Care Research, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, England
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Heissel A, Bollmann J, Kangas M, Abdulla K, Rapp M, Sanchez A. Validation of the German version of the work and social adjustment scale in a sample of depressed patients. BMC Health Serv Res 2021; 21:593. [PMID: 34154599 PMCID: PMC8218495 DOI: 10.1186/s12913-021-06622-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 05/21/2021] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Depression is one of the key factors contributing to difficulties in one's ability to work, and serves as one of the major reasons why employees apply for psychotherapy and receive insurance subsidization of treatments. Hence, an increasing and growing number of studies rely on workability assessment scales as their primary outcome measure. The Work and Social Assessment Scale (WSAS) has been documented as one of the most psychometrically reliable and valid tools especially developed to assess workability and social functioning in patients with mental health problems. Yet, the application of the WSAS in Germany has been limited due to the paucity of a valid questionnaire in the German language. The objective of the present study was to translate the WSAS, as a brief and easy administrable tool into German and test its psychometric properties in a sample of adults with depression. METHODS Two hundred seventy-seven patients (M = 48.3 years, SD = 11.1) with mild to moderately severe depression were recruited. A multistep translation from English into the German language was performed and the factorial validity, criterion validity, convergent validity, discriminant validity, internal consistency, and floor and ceiling effects were examined. RESULTS The confirmatory factor analysis results confirmed the one-factor structure of the WSAS. Significant correlations with the WHODAS 2-0 questionnaire, a measure of functionality, demonstrated good convergent validity. Significant correlations with depression and quality of life demonstrated good criterion validity. The WSAS also demonstrated strong internal consistency (α = .89), and the absence of floor and ceiling effects indicated good sensitivity of the instrument. CONCLUSIONS The results of the present study demonstrated that the German version of the WSAS has good psychometric properties comparable to other international versions of this scale. The findings recommend a global assessment of psychosocial functioning with the sum score of the WSAS. TRIAL REGISTRATION ISRCTN identifier: ISRCTN28972230 . Date of registration June 26th 2018.
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Affiliation(s)
- A. Heissel
- Department of Sport and Health Sciences, Intra-faculty Cognition Sciences, Faculty of Human Science, and Faculty of Health Sciences Brandenburg, Research Area Services Research and e-Health, University of Potsdam, Potsdam, Germany
| | - J. Bollmann
- Social and Preventive Medicine, Department of Sports and Health Sciences, University of Potsdam, Potsdam, Germany
| | - M. Kangas
- Maria Kangas, Department of Psychology, Centre for Emotional Health, Macquarie University, Sydney, 2109 Australia
| | - K. Abdulla
- Social and Preventive Medicine, Department of Sports and Health Sciences, University of Potsdam, Potsdam, Germany
| | - M. Rapp
- Department of Sport and Health Sciences, Intra-faculty Cognition Sciences, Faculty of Human Science, and Faculty of Health Sciences Brandenburg, Research Area Services Research and e-Health, University of Potsdam, Potsdam, Germany
| | - A. Sanchez
- Social and Preventive Medicine, Department of Sports and Health Sciences, University of Potsdam, Potsdam, Germany
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Fletcher S, Spittal MJ, Chondros P, Palmer VJ, Chatterton ML, Densley K, Potiriadis M, Harris M, Bassilios B, Burgess P, Mihalopoulos C, Pirkis J, Gunn J. Clinical efficacy of a Decision Support Tool (Link-me) to guide intensity of mental health care in primary practice: a pragmatic stratified randomised controlled trial. Lancet Psychiatry 2021; 8:202-214. [PMID: 33571453 DOI: 10.1016/s2215-0366(20)30517-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 11/09/2020] [Accepted: 11/13/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The volume and heterogeneity of mental health problems that primary care patients present with is a substantial challenge for health systems, and both undertreatment and overtreatment are common. We developed Link-me, a patient-completed Decision Support Tool, to predict severity of depression or anxiety, identify priorities, and recommend interventions. In this study, we aimed to examine if Link-me reduces psychological distress among individuals predicted to have minimal/mild or severe symptoms of anxiety or depression. METHODS In this pragmatic stratified randomised controlled trial, adults aged 18-75 years reporting depressive or anxiety symptoms or use of mental health medication were recruited from 23 general practices in Australia. Participants completed the Decision Support Tool and were classified into three prognostic groups (minimal/mild, moderate, severe), and those in the minimal/mild and severe groups were eligible for inclusion. Participants were individually and randomly assigned (1:1) by a computer-generated allocation sequence to receive either prognosis-matched care (intervention group) or usual care plus attention control (control group). Participants were not blinded but intervention providers were only notified of those allocated to the intervention group. Outcome assessment was blinded. The primary outcome was the difference in the change in scores between the intervention and control group, and within prognostic groups, on the 10-item Kessler Psychological Distress Scale at 6 months post randomisation. The trial was registered on the Australian and New Zealand Clinical Trials Registry, ACTRN12617001333303. OUTCOMES Between Nov 21, 2017, and Oct 31, 2018, 24 616 patients were invited to complete the eligibility screening survey. 1671 of these patients were included and randomly assigned to either the intervention group (n=834) or the control group (n=837). Prognosis-matched care was associated with greater reductions in psychological distress than usual care plus attention control at 6 months (p=0·03), with a standardised mean difference (SMD) of -0·09 (95% CI -0·17 to -0·01). This reduction was also seen in the severe prognostic group (p=0·003), with a SMD of -0·26 (-0·43 to -0·09), but not in the minimal/mild group (p=0·73), with a SMD of 0·04 (-0·17 to 0·24). In the complier average causal effect analysis in the severe prognostic group, differences were larger among those who received some or all aspects of the intervention (SMD range -0·58 to -1·15). No serious adverse effects were recorded. INTERPRETATION Prognosis-based matching of interventions reduces psychological distress in patients with anxiety or depressive symptoms, particularly in those with severe symptoms, and is associated with better outcomes when patients access the recommended treatment. Optimisation of the Link-me approach and implementation into routine practice could help reduce the burden of disease associated with common mental health conditions such as anxiety and depression. FUNDING Australian Government Department of Health.
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Affiliation(s)
- Susan Fletcher
- Department of General Practice, The University of Melbourne, Melbourne, VIC, Australia
| | - Matthew J Spittal
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia.
| | - Patty Chondros
- Department of General Practice, The University of Melbourne, Melbourne, VIC, Australia
| | - Victoria J Palmer
- Department of General Practice, The University of Melbourne, Melbourne, VIC, Australia
| | - Mary Lou Chatterton
- School of Health and Social Development, Deakin University, Melbourne, VIC, Australia
| | - Konstancja Densley
- Department of General Practice, The University of Melbourne, Melbourne, VIC, Australia
| | - Maria Potiriadis
- Department of General Practice, The University of Melbourne, Melbourne, VIC, Australia
| | - Meredith Harris
- School of Public Health, The University of Queensland, Brisbane, QLD, Australia
| | - Bridget Bassilios
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Philip Burgess
- School of Public Health, The University of Queensland, Brisbane, QLD, Australia
| | - Cathrine Mihalopoulos
- School of Health and Social Development, Deakin University, Melbourne, VIC, Australia
| | - Jane Pirkis
- Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, VIC, Australia
| | - Jane Gunn
- Department of General Practice, The University of Melbourne, Melbourne, VIC, Australia
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John JR, Jani H, Peters K, Agho K, Tannous WK. The Effectiveness of Patient-Centred Medical Home-Based Models of Care versus Standard Primary Care in Chronic Disease Management: A Systematic Review and Meta-Analysis of Randomised and Non-Randomised Controlled Trials. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E6886. [PMID: 32967161 PMCID: PMC7558011 DOI: 10.3390/ijerph17186886] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 09/14/2020] [Accepted: 09/18/2020] [Indexed: 12/20/2022]
Abstract
Patient-centred care by a coordinated primary care team may be more effective than standard care in chronic disease management. We synthesised evidence to determine whether patient-centred medical home (PCMH)-based care models are more effective than standard general practitioner (GP) care in improving biomedical, hospital, and economic outcomes. MEDLINE, CINAHL, Embase, Cochrane Library, and Scopus were searched to identify randomised (RCTs) and non-randomised controlled trials that evaluated two or more principles of PCMH among primary care patients with chronic diseases. Study selection, data extraction, quality assessment using Joanna Briggs Institute (JBI) appraisal tools, and grading of evidence using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach were conducted independently. A quantitative synthesis, where possible, was pooled using random effects models and the effect size estimates of standardised mean differences (SMDs) and odds ratios (ORs) with 95% confidence intervals were reported. Of the 13,820 citations, we identified 78 eligible RCTs and 7 quasi trials which included 60,617 patients. The findings suggested that PCMH-based care was associated with significant improvements in depression episodes (SMD -0.24; 95% CI -0.35, -0.14; I2 = 76%) and increased odds of remission (OR 1.79; 95% CI 1.46, 2.21; I2 = 0%). There were significant improvements in the health-related quality of life (SMD 0.10; 95% CI 0.04, 0.15; I2 = 51%), self-management outcomes (SMD 0.24; 95% CI 0.03, 0.44; I2 = 83%), and hospital admissions (OR 0.83; 95% CI 0.70, 0.98; I2 = 0%). In terms of biomedical outcomes, with exception to total cholesterol, PCMH-based care led to significant improvements in blood pressure, glycated haemoglobin, and low-density lipoprotein cholesterol outcomes. The incremental cost of PCMH care was identified to be small and significantly higher than standard care (SMD 0.17; 95% CI 0.08, 0.26; I2 = 82%). The quality of individual studies ranged from "fair" to "good" by meeting at least 60% of items on the quality appraisal checklist. Additionally, moderate to high heterogeneity across studies in outcomes resulted in downgrading the included studies as moderate or low grade of evidence. PCMH-based care has been found to be superior to standard GP care in chronic disease management. Results of the review have important implications that may inform patient, practice, and policy-level changes.
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Affiliation(s)
- James Rufus John
- Translational Health Research Institute, Western Sydney University, Sydney, NSW 2560, Australia; (H.J.); (K.A.); (W.K.T.)
- Rozetta Institute, Level 4, 55 Harrington Street, Sydney, NSW 2000, Australia
| | - Hir Jani
- Translational Health Research Institute, Western Sydney University, Sydney, NSW 2560, Australia; (H.J.); (K.A.); (W.K.T.)
| | - Kath Peters
- School of Nursing and Midwifery, Western Sydney University, Sydney, NSW 2560, Australia;
| | - Kingsley Agho
- Translational Health Research Institute, Western Sydney University, Sydney, NSW 2560, Australia; (H.J.); (K.A.); (W.K.T.)
- School of Science and Health, Western Sydney University, Sydney, NSW 2560, Australia
| | - W. Kathy Tannous
- Translational Health Research Institute, Western Sydney University, Sydney, NSW 2560, Australia; (H.J.); (K.A.); (W.K.T.)
- School of Business, Western Sydney University, Sydney, NSW 2150, Australia
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9
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Shrestha M, Ng AH, Gray RJ. Association between subthreshold depression and self-care behaviours in adults with type 2 diabetes: A protocol for a cross-sectional study. J Clin Nurs 2020; 30:2453-2461. [PMID: 32415880 DOI: 10.1111/jocn.15250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 02/05/2020] [Accepted: 03/14/2020] [Indexed: 11/30/2022]
Abstract
AIMS AND OBJECTIVES To examine the association between subthreshold depression and self-care behaviours in adults with type 2 diabetes (T2D) attending a tertiary healthcare service. BACKGROUND Diabetes is a global public health problem. Self-care behaviours are a fundamental element in managing diabetes as adherence to self-care activities is associated with improved glycaemic control. Depression in T2D is associated with decreased adherence to self-care behaviours. Adults with subthreshold depression in diabetes may have difficulties in achieving metabolic control. Further, people with subthreshold depression have an increased risk of developing major depression. Few studies have examined the association between subthreshold depression and self-care behaviours. DESIGN A cross-sectional study. METHODS The study will be conducted among 384 adults diagnosed with T2D for at least a year attending their routine outpatient appointment at Tribhuvan University Teaching Hospital in Nepal. Convenience sampling will be used to recruit study participants. Data will be collected via face-to-face interviews and a medical record review. Self-care behaviours will be assessed using the Summary of Diabetes Self-care activities and subthreshold depression will be determined using the Patient Health Questionnaire- 9. Covariates in the study include sociodemographic and clinical factors, diabetes knowledge, perceived social support and self-efficacy. This paper complies with the STROBE reporting guideline for cross-sectional studies. RESULTS We will use multiple linear regression to examine the association between subthreshold depression and each self-care behaviours (i.e. diet, physical activity, foot care, blood glucose testing and medication) and total self-care behaviour. CONCLUSIONS Effective management of diabetes requires adherence to self-care behaviours. The findings of the study will help in identifying an effective way to improve diabetes self-care. RELEVANCE TO CLINICAL PRACTICE Our observations will inform nursing research and practice by providing evidence about how subthreshold depression may influence self-care behaviours.
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Affiliation(s)
- Monika Shrestha
- School of Nursing and Midwifery, La Trobe University, Bundoora, Australia
| | - Ashley H Ng
- Department of Dietetics, Human Nutrition and Sport, La Trobe University, Bundoora, Australia
| | - Richard J Gray
- School of Nursing and Midwifery, La Trobe University, Bundoora, Australia
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10
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Moriarty AS, Coventry PA, Hudson JL, Cook N, Fenton OJ, Bower P, Lovell K, Archer J, Clarke R, Richards DA, Dickens C, Gask L, Waheed W, Huijbregts KM, van der Feltz-Cornelis C, Ali S, Gilbody S, McMillan D. The role of relapse prevention for depression in collaborative care: A systematic review. J Affect Disord 2020; 265:618-644. [PMID: 31791677 DOI: 10.1016/j.jad.2019.11.105] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 10/01/2019] [Accepted: 11/21/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Relapse (the re-emergence of depression symptoms before full recovery) is common in depression and relapse prevention strategies are not well researched in primary care settings. Collaborative care is effective for treating acute phase depression but little is known about the use of relapse prevention strategies in collaborative care. We undertook a systematic review to identify and characterise relapse prevention strategies in the context of collaborative care. METHODS We searched for Randomised Controlled Trials (RCTs) of collaborative care for depression. In addition to published material, we obtained provider and patient manuals from authors to provide more detail on intervention content. We reported the extent to which collaborative care interventions addressed four relapse prevention components. RESULTS 93 RCTs were identified. 31 included a formal relapse prevention plan; 42 had proactive monitoring and follow-up after the acute phase; 39 reported strategies for optimising sustained medication adherence; and 20 of the trials reported psychological or psycho-educational treatments persisting beyond the acute phase or focussing on long-term health/relapse prevention. 30 (32.3%) did not report relapse prevention approaches. LIMITATIONS We did not receive trial materials for approximately half of the trials, which limited our ability to identify relevant features of intervention content. CONCLUSION Relapse is a significant risk amongst people treated for depression and interventions are needed that specifically address and minimise this risk. Given the advantages of collaborative care as a delivery system for depression care, there is scope for more consistency and increased effort to implement and evaluate relapse prevention strategies.
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Affiliation(s)
- Andrew S Moriarty
- Department of Health Sciences and the Hull York Medical School, University of York, Heslington, York, YO10 5DD, UK.
| | - Peter A Coventry
- Department of Health Sciences and Centre for Reviews and Dissemination, University of York, Heslington, York, YO10 5DD, UK.
| | - Joanna L Hudson
- King's College London, Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, 16 De Crespigny Park, London, SE5 8AF, UK.
| | - Natalie Cook
- Department of Health Sciences and the Hull York Medical School, University of York, Heslington, York, YO10 5DD, UK.
| | - Oliver J Fenton
- Tees, Esk and Wear Valleys NHS Foundation Trust, South and West Community Mental Health Team, Acomb Garth, 2 Oak Rise, York, YO24 4LJ, UK.
| | - Peter Bower
- NIHR School for Primary Care Research, Centre for Primary Care, Manchester Academic Health Science Centre, University of Manchester, Oxford Rd, Manchester, M13 9PL, UK.
| | - Karina Lovell
- Division of Nursing, Midwifery & Social Work, University of Manchester, Oxford Rd, Manchester, M13 9PL, UK.
| | - Janine Archer
- School of Health and Society, University of Salford, Mary Seacole Building, Broad St, Frederick Road Campus, Salford, M6 6PU, UK.
| | - Rose Clarke
- Sheffield IAPT, St George's Community Health Centre, Winter Street, Sheffield, South Yorkshire, S3 7ND, UK.
| | - David A Richards
- Institute of Health Research, College of Medicine and Health, University of Exeter, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK.
| | - Chris Dickens
- Institute of Health Research, College of Medicine and Health, University of Exeter, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK.
| | - Linda Gask
- NIHR School for Primary Care Research, Centre for Primary Care, Manchester Academic Health Science Centre, University of Manchester, Oxford Rd, Manchester, M13 9PL, UK.
| | - Waquas Waheed
- NIHR School for Primary Care Research, Centre for Primary Care, Manchester Academic Health Science Centre, University of Manchester, Oxford Rd, Manchester, M13 9PL, UK.
| | - Klaas M Huijbregts
- GGNet, Mental Health, RGC SKB Winterswijk, Beatrixpark 1, 7101 BN Winterswijk, The Netherlands.
| | | | - Shehzad Ali
- Epidemiology and Biostatistics Department, Schulich School of Medicine & Dentistry, Western University, Kresge Building, Room K201, London, Ontario, N6A 5C1, Canada; Department of Health Sciences, University of York, Heslington, York, YO10 5DD, UK.
| | - Simon Gilbody
- Department of Health Sciences and the Hull York Medical School, University of York, Heslington, York, YO10 5DD, UK.
| | - Dean McMillan
- Department of Health Sciences and the Hull York Medical School, University of York, Heslington, York, YO10 5DD, UK.
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11
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Lunghi C, Antonazzo IC, Burato S, Raschi E, Zoffoli V, Forcesi E, Sangiorgi E, Menchetti M, Roberge P, Poluzzi E. Prevalence and Determinants of Long-Term Utilization of Antidepressant Drugs: A Retrospective Cohort Study. Neuropsychiatr Dis Treat 2020; 16:1157-1170. [PMID: 32440131 PMCID: PMC7213896 DOI: 10.2147/ndt.s241780] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 04/09/2020] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Antidepressant consumption has risen in recent years, driven by longer treatment duration. The objective of this study was to measure the prevalence of antidepressant long-term and chronic use in the Bologna area, Italy, and to identify their main determinants. MATERIALS AND METHODS We conducted a retrospective claims-based cohort study by using the Bologna Local Health Authority data. A cohort of 18,307 incident users of antidepressant drugs in 2013 was selected, and subjects were followed for three years. A long-term utilization was defined as having at least one prescription claimed during each year of follow-up, while chronic utilization was defined as claiming at least 180 defined daily doses per year. Factors associated with chronic and long-term use were identified by univariate and multivariate logistic regressions. RESULTS In our cohort, 5448 (29.8%) and 1817 (9.9%) subjects were dispensed antidepressants for a long-term course and in a chronically way, respectively. Older age, antidepressant polytherapy, polypharmacy, and being prescribed the first antidepressant by a hospital physician were all factors independently associated with chronic and long-term prescriptions of antidepressant drugs. Results were reported separately for men and women. CONCLUSION Antidepressant long-term and chronic prescriptions are common in the Bologna area. Because longer treatment should be clinically motivated, these results strongly prompt the need to evaluate the actual relevance, as they may indicate potentially inappropriate prescription patterns.
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Affiliation(s)
- Carlotta Lunghi
- Department of Health Sciences, Université Du Québec À Rimouski, Lévis, Québec, Canada.,Department of Medical and Surgical Sciences, Pharmacology Unit, Alma Mater Studiorum, University of Bologna, Bologna, Italy.,Groupe De Recherche PRIMUS, Centre De Recherche Du CHUS, Université De Sherbrooke, Sherbrooke, Canada
| | - Ippazio Cosimo Antonazzo
- Department of Medical and Surgical Sciences, Pharmacology Unit, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Sofia Burato
- Department of Medical and Surgical Sciences, Pharmacology Unit, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Emanuel Raschi
- Department of Medical and Surgical Sciences, Pharmacology Unit, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Violetta Zoffoli
- Department of Medical and Surgical Sciences, Pharmacology Unit, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Emanuele Forcesi
- Department of Medical and Surgical Sciences, Pharmacology Unit, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Elisa Sangiorgi
- Drug Policy Service, Emilia Romagna Region Health Authority, Bologna, Italy
| | - Marco Menchetti
- Department of Biomedical and Neuromotor Sciences, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Pasquale Roberge
- Groupe De Recherche PRIMUS, Centre De Recherche Du CHUS, Université De Sherbrooke, Sherbrooke, Canada.,Faculty of Medicine and Health Sciences, Université De Sherbrooke, Sherbrooke, Québec, Canada
| | - Elisabetta Poluzzi
- Department of Medical and Surgical Sciences, Pharmacology Unit, Alma Mater Studiorum, University of Bologna, Bologna, Italy
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Yan C, Rittenbach K, Souri S, Silverstone PH. Cost-effectiveness analysis of a randomized study of depression treatment options in primary care suggests stepped-care treatment may have economic benefits. BMC Psychiatry 2019; 19:240. [PMID: 31382932 PMCID: PMC6683422 DOI: 10.1186/s12888-019-2223-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 07/29/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The stepped-care pathway (SCP) model has previously been found to be clinically effective for depressive disorder in some studies, but not all. Several groups have suggested that a stepped-care approach is the most appropriate in primary care. There is relatively little information, however, regarding which specific stepped-care pathway may be best. This analysis aimed to determine cost-effectiveness of a stepped-care pathway for depression in adults in primary care versus standard care (SC), treatment-as-usual (TAU), and online cognitive behavioural therapy (CBT). METHODS We conducted a randomized trial with 1400 participants and 12-week follow-up to assess the impact of the four treatment options on health-related quality of life and depression severity. Costs for the groups were calculated on the basis of physician, outpatient, and inpatient services using administrative data. We then calculated the incremental cost-effectiveness ratios using this information. Cost-effectiveness acceptability curves and incremental cost-effectiveness scatterplots were created using Monte Carlo simulation with 10,000 replications. A subgroup analysis was conducted for participants who screened as depressed at baseline. RESULTS For all participants, TAU was the most expensive followed by CBT, SC, and SCP. QALYs were highest in SCP, followed by SC, CBT, and TAU. In the depressed subgroup, TAU was still the most expensive, followed by SC, SCP, and CBT, while QALYs were still highest in SCP, followed by SC, CBT, and TAU. The cost-effectiveness acceptability curves suggested that SCP had a higher probability for cost-effectiveness than the other three alternatives in all participants. In the depressed subgroup, CBT was associated with the highest probability of cost-effectiveness for a willingness-to-pay cut-off of less than approximately $50,000, while SCP was the highest at a cut-off higher than $50,000. There is considerable uncertainty around the cost-effectiveness estimates. CONCLUSIONS Our analysis showed that even where there are no clinically significant differences in health outcomes between treatment approaches, there may be economic benefit from implementing the stepped-care model. While more work is required to identify the most clinically effective versions of a stepped-care pathway, our findings suggest that the care pathway may have potential to improve health care system value. TRIAL REGISTRATION NCT01975207 . The trial was prospectively registered on 4 November 2013.
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Affiliation(s)
- Charles Yan
- Institute of Health Economics, 1200 - 10405 Jasper Avenue, Edmonton, Alberta, T5J 3N4, Canada.
| | - Katherine Rittenbach
- grid.17089.37Department of Psychiatry, Addiction & Mental Health Strategic Clinical Network, Alberta Health Services, University of Alberta, 10030 107 St, NW, Edmonton, Alberta T5J 3E4 Canada
| | - Sepideh Souri
- 0000 0004 1936 7697grid.22072.35Cumming School of Medicine, University of Calgary, 3330 Hospital Drive NW, Calgary, Alberta T2N 4N1 Canada
| | - Peter H. Silverstone
- grid.17089.37Department of Psychiatry, University of Alberta, 8440 112 St NW, Edmonton, Alberta T6G 2B7 Canada
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13
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Maehder K, Löwe B, Härter M, Heddaeus D, Scherer M, Weigel A. Management of comorbid mental and somatic disorders in stepped care approaches in primary care: a systematic review. Fam Pract 2019; 36:38-52. [PMID: 30535053 DOI: 10.1093/fampra/cmy122] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Stepped care models comprise a graded treatment intensity and a systematic monitoring. For an effective implementation, stepped care models have to account for the high rates of mental and somatic comorbidity in primary care. OBJECTIVES The aim of the systematic review was to take stock of whether present stepped care models take comorbidities into consideration. A further aim was to give an overview on treatment components and involved health care professionals. METHODS A systematic literature search was performed using the databases PubMed, PsycINFO, Cochrane Library and Web of Science. Selection criteria were a randomized controlled trial of a primary-care-based stepped care intervention, adult samples, publication between 2000 and 2017 and English or German language. RESULTS Of 1009 search results, 39 studies were eligible. One-third of the trials were conceived for depressive disorders only, one-third for depression and further somatic and/or mental comorbidity and one-third for conditions other than depression. In 39% of the studies comorbidities were explicitly integrated in treatment, mainly via transdiagnostic self-management support, interprofessional collaboration and digital approaches for treatment, monitoring and communication. Most care teams were composed of a primary care physician, a care manager and a psychiatrist and/or psychologist. Due to the heterogeneity of the addressed disorders, no meta-analysis was performed. CONCLUSIONS Several stepped care models in primary care already account for comorbidities, with depression being the predominant target disorder. To determine their efficacy, the identified strategies to account for comorbidities should be investigated within stepped care models for a broader range of disorders.
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Affiliation(s)
- Kerstin Maehder
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Germany
| | - Bernd Löwe
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Germany
| | - Martin Härter
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Germany
| | - Daniela Heddaeus
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Germany
| | - Martin Scherer
- Department of General Practice/Primary Care, University Medical Center Hamburg-Eppendorf, Germany
| | - Angelika Weigel
- Department of Psychosomatic Medicine and Psychotherapy, University Medical Center Hamburg-Eppendorf, Germany
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14
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Petersen I, Bhana A, Folb N, Thornicroft G, Zani B, Selohilwe O, Petrus R, Mntambo N, Georgeu-Pepper D, Kathree T, Lund C, Lombard C, Bachmann M, Gaziano T, Levitt N, Fairall L. Collaborative care for the detection and management of depression among adults with hypertension in South Africa: study protocol for the PRIME-SA randomised controlled trial. Trials 2018; 19:192. [PMID: 29566730 PMCID: PMC5863904 DOI: 10.1186/s13063-018-2518-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 09/08/2017] [Indexed: 12/15/2022] Open
Abstract
Background The high co-morbidity of mental disorders, particularly depression, with non-communicable diseases (NCDs) such as cardiovascular disease (CVD), is concerning given the rising burden of NCDs globally, and the role depression plays in confounding prevention and treatment of NCDs. The objective of this randomised control trial (RCT) is to determine the real-world effectiveness of strengthened depression identification and management on depression outcomes in hypertensive patients attending primary health care (PHC) facilities in South Africa (SA). Methods/design The study design is a pragmatic, two-arm, parallel-cluster RCT, the unit of randomisation being the clinics, with outcomes being measured for individual participants. The 20 largest eligible clinics from one district in the North West Province are enrolled in the trial. Equal numbers of hypertensive patients (n = 50) identified as having depression using the Patient Health Questionnaire (PHQ-9) are enrolled from each clinic, making up a total of 1000 participants with 500 in each arm. The nurse clinicians in the control facilities receive the standard training in Primary Care 101 (PC101), a clinical decision support tool for integrated chronic care that includes guidelines for hypertension and depression care. Referral pathways available include referrals to PHC physicians, clinical or counselling psychologists and outpatient psychiatric and psychological services. In the intervention clinics, this training is supplemented with strengthened training in the depression components of PC101 as well as training in clinical communication skills for nurse-led chronic care. Referral pathways are strengthened through the introduction of a facility-based behavioural health counsellor, trained to provide structured manualised counselling for depression and adherence counselling for all chronic conditions. The primary outcome is defined as at least 50% reduction in PHQ-9 score measured at 6 months. Discussion This trial should provide evidence of the real world effectiveness of strengtheneddepression identification and collaborative management on health outcomes of hypertensive patients withcomorbid depression attending PHC facilities in South Africa. Trial registration South African National Clinical Trial Register: SANCTR (http://www.sanctr.gov.za/SAClinicalTrials) (DOH-27-0916-5051). Registered on 9 April 2015. ClinicalTrials.gov: ID: NCT02425124. Registered on 22 April 2015. Electronic supplementary material The online version of this article (10.1186/s13063-018-2518-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Inge Petersen
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu- Natal, Durban, South Africa.
| | - Arvin Bhana
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu- Natal, Durban, South Africa.,Health Systems Research Unit, South African Medical Research Council, Durban, South Africa
| | - Naomi Folb
- Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa
| | - Graham Thornicroft
- Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, Kings College, London, UK
| | - Babalwa Zani
- Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa
| | - One Selohilwe
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu- Natal, Durban, South Africa
| | - Ruwayda Petrus
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu- Natal, Durban, South Africa
| | - Ntokozo Mntambo
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu- Natal, Durban, South Africa
| | | | - Tasneem Kathree
- Centre for Rural Health, School of Nursing and Public Health, University of KwaZulu- Natal, Durban, South Africa
| | - Crick Lund
- Centre for Global Mental Health, Institute of Psychiatry, Psychology and Neuroscience, Kings College, London, UK.,Alan J Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa
| | - Carl Lombard
- Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa.,School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
| | - Max Bachmann
- Department of Population Health and Primary Care, Norwich Medical School, University of East Anglia, Norwich, UK
| | - Thomas Gaziano
- Department of Health Policy and Management, Harvard University, Cambridge, USA
| | - Naomi Levitt
- Department of Diabetic Medicine and Endocrinology, University of Cape Town, Cape Town, South Africa
| | - Lara Fairall
- Knowledge Translation Unit, University of Cape Town, Cape Town, South Africa
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15
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Collaborative care for the detection and management of depression among adults receiving antiretroviral therapy in South Africa: study protocol for the CobALT randomised controlled trial. Trials 2018; 19:193. [PMID: 29566739 PMCID: PMC5863840 DOI: 10.1186/s13063-018-2517-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 02/02/2018] [Indexed: 01/15/2023] Open
Abstract
Background The scale-up of antiretroviral treatment (ART) programmes has seen HIV/AIDS transition to a chronic condition characterised by high rates of comorbidity with tuberculosis, non-communicable diseases (NCDs) and mental health disorders. Depression is one such disorder that is associated with higher rates of non-adherence, progression to AIDS and greater mortality. Detection and treatment of comorbid depression is critical to achieve viral load suppression in more than 90% of those on ART and is in line with the recent 90-90-90 Joint United Nations Programme on HIV/AIDS (UNAIDS) targets. The CobALT trial aims to provide evidence on the effectiveness and cost-effectiveness of scalable interventions to reduce the treatment gap posed by the growing burden of depression among adults on lifelong ART. Methods The study design is a pragmatic, parallel group, stratified, cluster randomised trial in 40 clinics across two rural districts of the North West Province of South Africa. The unit of randomisation is the clinic, with outcomes measured among 2000 patients on ART who screen positive for depression using the Patient Health Questionnaire (PHQ-9). Control group clinics are implementing the South African Department of Health’s Integrated Clinical Services Management model, which aims to reduce fragmentation of care in the context of rising multimorbidity, and which includes training in the Primary Care 101 (PC101) guide covering communicable diseases, NCDs, women’s health and mental disorders. In intervention clinics, we supplemented this with training specifically in the mental health components of PC101 and clinical communications skills training to support nurse-led chronic care. We strengthened the referral pathways through the introduction of a clinic-based behavioural health counsellor equipped to provide manualised depression counselling (eight sessions, individual or group), as well as adherence counselling sessions (one session, individual). The co-primary patient outcomes are a reduction in PHQ-9 scores of at least 50% from baseline and viral load suppression rates measured at 6 and 12 months, respectively. Discussion The trial will provide real-world effectiveness of case detection and collaborative care for depression including facility-based counselling on the mental and physical outcomes for people on lifelong ART in resource-constrained settings. Trial registration ClinicalTrials.gov (NCT02407691) registered on 19 March 2015; Pan African Clinical Trials Registry (201504001078347) registered on 19/03/2015; South African National Clinical Trials Register (SANCTR) (DOH-27-0515-5048) NHREC number 4048 issued on 21/04/2015. Electronic supplementary material The online version of this article (10.1186/s13063-018-2517-7) contains supplementary material, which is available to authorized users.
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Abstract
BACKGROUND Task shifting approaches (rational redistribution of tasks among health workforce teams) to train lay professionals to assist with integrating mental health treatment in primary care has been recommended to close the mental health treatment gap for depression in low- and middle-income countries. This study aims to examine the a new model for depression care in a low-resource environment compared to enhanced treatment at usual (E-TAU). METHODS We trained non-specialist community health workers (local lay employees of the public health system) to provide Interpersonal Counseling (IPC) to treat depressive symptoms in the Brazilian, São Paulo city, family health strategy (FHS). We conducted a randomized controlled trial involving 86 patients with a current major depressive disorder or dysthymia (based on DSM-IV) recruited from an FHS clinic. Participants were randomized to IPC intervention (n = 43) or E-TAU (n = 43). Participants allocated to IPC received 3-4 sessions provided by community health workers; research psychologists followed the E-TAU participants to facilitate their referral to specialized mental health care within the public system. Reduction of depressive symptoms was assessed using the Hamilton Rating Scale (HDRS-17) and the Patient Health Questionnaire (PHQ-9); minor psychiatric symptomatology (including depression, anxiety and somatoform symptoms) were measured using the Self Reporting Questionnaire (SRQ); and functioning was measured by the Clinical Global Impression Scale over a 2-month period. RESULTS Intention-to-treat analysis showed significant improvement on symptoms for both groups over 2 months, without significant differences between them. Per-protocol analysis showed significant better HDRS-17 outcomes for the IPC group. CONCLUSIONS Training non-specialist community health workers in low- and middle-income countries to provide IPC could be a successful strategy in reducing the burden of depression and also potentially a low-cost and effective alternative to specialist-led services that might not be possible in low income settings. TRIAL REGISTRATION Brazilian Clinical Trials, number RBR-5qhmb5 (trial url: http://www.ensaiosclinicos.gov.br/rg/RBR-5qhmb5/) , retrospectively registered after May 1, 2013.
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Smith SM, Cousins G, Clyne B, Allwright S, O'Dowd T. Shared care across the interface between primary and specialty care in management of long term conditions. Cochrane Database Syst Rev 2017; 2:CD004910. [PMID: 28230899 PMCID: PMC6473196 DOI: 10.1002/14651858.cd004910.pub3] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Shared care has been used in the management of many chronic conditions with the assumption that it delivers better care than primary or specialty care alone; however, little is known about the effectiveness of shared care. OBJECTIVES To determine the effectiveness of shared care health service interventions designed to improve the management of chronic disease across the primary/specialty care interface. This is an update of a previously published review.Secondary questions include the following:1. Which shared care interventions or portions of shared care interventions are most effective?2. What do the most effective systems have in common? SEARCH METHODS We searched MEDLINE, Embase and the Cochrane Library to 12 October 2015. SELECTION CRITERIA One review author performed the initial abstract screen; then two review authors independently screened and selected studies for inclusion. We considered randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after studies (CBAs) and interrupted time series analyses (ITS) evaluating the effectiveness of shared care interventions for people with chronic conditions in primary care and community settings. The intervention was compared with usual care in that setting. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data from the included studies, evaluated study quality and judged the certainty of the evidence using the GRADE approach. We conducted a meta-analysis of results when possible and carried out a narrative synthesis of the remainder of the results. We presented the results in a 'Summary of findings' table, using a tabular format to show effect sizes for all outcome types. MAIN RESULTS We identified 42 studies of shared care interventions for chronic disease management (N = 18,859), 39 of which were RCTs, two CBAs and one an NRCT. Of these 42 studies, 41 examined complex multi-faceted interventions and lasted from six to 24 months. Overall, our confidence in results regarding the effectiveness of interventions ranged from moderate to high certainty. Results showed probably few or no differences in clinical outcomes overall with a tendency towards improved blood pressure management in the small number of studies on shared care for hypertension, chronic kidney disease and stroke (mean difference (MD) 3.47, 95% confidence interval (CI) 1.68 to 5.25)(based on moderate-certainty evidence). Mental health outcomes improved, particularly in response to depression treatment (risk ratio (RR) 1.40, 95% confidence interval (CI) 1.22 to 1.62; six studies, N = 1708) and recovery from depression (RR 2.59, 95% CI 1.57 to 4.26; 10 studies, N = 4482) in studies examining the 'stepped care' design of shared care interventions (based on high-certainty evidence). Investigators noted modest effects on mean depression scores (standardised mean difference (SMD) -0.29, 95% CI -0.37 to -0.20; six studies, N = 3250). Differences in patient-reported outcome measures (PROMs), processes of care and participation and default rates in shared care services were probably limited (based on moderate-certainty evidence). Studies probably showed little or no difference in hospital admissions, service utilisation and patient health behaviours (with evidence of moderate certainty). AUTHORS' CONCLUSIONS This review suggests that shared care improves depression outcomes and probably has mixed or limited effects on other outcomes. Methodological shortcomings, particularly inadequate length of follow-up, may account in part for these limited effects. Review findings support the growing evidence base for shared care in the management of depression, particularly stepped care models of shared care. Shared care interventions for other conditions should be developed within research settings, with account taken of the complexity of such interventions and awareness of the need to carry out longer studies to test effectiveness and sustainability over time.
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Affiliation(s)
- Susan M Smith
- RCSI Medical SchoolHRB Centre for Primary Care Research, Department of General Practice123 St Stephens GreenDublinIreland
| | - Gráinne Cousins
- Royal College of Surgeons in IrelandSchool of Pharmacy123 St. Stephens GreenDublinIrelandDublin 2
| | - Barbara Clyne
- RCSI Medical SchoolHRB Centre for Primary Care Research, Department of General Practice123 St Stephens GreenDublin 2Ireland
| | - Shane Allwright
- Trinity College Centre for Health SciencesDepartment of Public Health and Primary CareDublinIreland
| | - Tom O'Dowd
- Trinity College Centre for Health SciencesDepartment of Public Health and Primary CareDublinIreland
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Grassi L, Costantini A, Caruso R, Brunetti S, Marchetti P, Sabato S, Nanni MG. Dignity and Psychosocial-Related Variables in Advanced and Nonadvanced Cancer Patients by Using the Patient Dignity Inventory-Italian Version. J Pain Symptom Manage 2017; 53:279-287. [PMID: 27810569 DOI: 10.1016/j.jpainsymman.2016.09.009] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Revised: 09/04/2016] [Accepted: 09/07/2016] [Indexed: 12/20/2022]
Abstract
CONTEXT The Patient Dignity Inventory (PDI) is a valid and reliable instrument to measure dignity, as a state of physical, mental, social, and spiritual well-being in palliative care patients and an essential dimension for a comprehensive patient-centered approach. OBJECTIVES We examined the factor structure and correlation of the Italian version of the PDI (PDI-IT) with psychosocial variables among advanced and nonadvanced cancer outpatients in two Italian centers. METHODS In a sample of 194 patients, principal component analysis, reliability analysis (Cronbach's coefficient alpha), and correlation analysis of the PDI-IT were performed. Concurrent validity was evaluated with respect to the Italian versions of Patient Health Questionnaire-9 (PHQ-9), as a measure of depression, the Mini-Mental Adjustment to Cancer-Hopelessness Scale, as a measure of dysfunctional coping, and the Demoralization Scale (DS-IT), as a measure of demoralization. RESULTS Three factors were extracted by exploratory factor analysis, which accounted for 64.38% of the variance, namely existential distress (Cronbach's α = 0.95), psychological distress (Cronbach's α = 0.88), and physical distress (Cronbach's α = 0.81), with a Cronbach's α coefficient for the PDI-IT total score of 0.96. PDI-IT factors were significantly intercorrelated and shared between 42% and 53% of the variance. Higher scores on all the PDI-IT factors and PDI-IT total were found among patients who were clinically depressed (PHQ-9) and among those who were demoralized on the DS-IT. Significant correlations were also found between all PDI-IT and the DS-IT, PHQ-9, and the Mini-Mental Adjustment to Cancer-Hopelessness Scale. CONCLUSIONS The study confirmed that the PDI-IT is a valid instrument to be applied in oncology and measuring three factors, namely existential, psychological, and physical distress, as core dimensions of dignity, to be monitored and treated in clinical settings.
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Affiliation(s)
- Luigi Grassi
- Department of Biomedical and Specialty Surgical Science, Institute of Psychiatry, University of Ferrara, Ferrara, Italy; University Hospital Psychiatry Unit, Program on Psycho-Oncology and Psychiatry in Palliative Care, Integrated Department of Mental Health and Addictive Disorders, Health Authorities and University S. Anna Hospital, Ferrara, Italy.
| | - Anna Costantini
- Psychoncology Unit, Sant'Andrea Hospital La Sapienza, University of Rome, Rome, Italy
| | - Rosangela Caruso
- Department of Biomedical and Specialty Surgical Science, Institute of Psychiatry, University of Ferrara, Ferrara, Italy; University Hospital Psychiatry Unit, Program on Psycho-Oncology and Psychiatry in Palliative Care, Integrated Department of Mental Health and Addictive Disorders, Health Authorities and University S. Anna Hospital, Ferrara, Italy
| | - Serena Brunetti
- Psychoncology Unit, Sant'Andrea Hospital La Sapienza, University of Rome, Rome, Italy
| | - Paolo Marchetti
- Medical Oncology, Sapienza University of Rome and IDI - IRCCS, Rome, Italy
| | - Silvana Sabato
- Department of Biomedical and Specialty Surgical Science, Institute of Psychiatry, University of Ferrara, Ferrara, Italy
| | - Maria Giulia Nanni
- Department of Biomedical and Specialty Surgical Science, Institute of Psychiatry, University of Ferrara, Ferrara, Italy; University Hospital Psychiatry Unit, Program on Psycho-Oncology and Psychiatry in Palliative Care, Integrated Department of Mental Health and Addictive Disorders, Health Authorities and University S. Anna Hospital, Ferrara, Italy
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19
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Silverstone PH, Rittenbach K, Suen VYM, Moretzsohn A, Cribben I, Bercov M, Allen A, Pryce C, Hamza DM, Trew M. Depression Outcomes in Adults Attending Family Practice Were Not Improved by Screening, Stepped-Care, or Online CBT during a 12-Week Study when Compared to Controls in a Randomized Trial. Front Psychiatry 2017; 8:32. [PMID: 28373846 PMCID: PMC5357781 DOI: 10.3389/fpsyt.2017.00032] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Accepted: 02/15/2017] [Indexed: 11/13/2022] Open
Abstract
There is uncertainty regarding possible benefits of screening for depression in family practice, as well as the most effective treatment approach when depression is identified. Here, we examined whether screening patients for depression in primary care, and then treating them with different modalities, was better than treatment-as-usual (TAU) alone. Screening was carried out for depression using the 9-item Patient Health Questionnaire (PHQ-9), with a score of ≥10 indicating significant depressive symptoms. PHQ-9 scores were given to family physicians prior to patients being seen (except for the Control group). Patients (n = 1,489) were randomized to one of four groups. Group #1 were controls (n = 432) in which PHQ-9 was administered, but results were not shared. Group #2 was screening followed by TAU (n = 426). Group #3 was screening followed by both TAU and the opportunity to use an online cognitive behavioral therapy (CBT) treatment program (n = 440). Group #4 utilized an evidence-based Stepped-care pathway for depression (n = 191, note that this was not available at all clinics). Of the study sample 889 (60%) completed a second PHQ-9 rating at 12 weeks. There were no statistically significant differences in baseline PHQ-9 scores between these groups. Compared to baseline, mean PHQ-9 scores decreased significantly in the depressed patients over 12 weeks, but there were no statistically significant differences between any groups at 12 weeks. Thus, for those who were depressed at baseline Control group (Group #1) scores decreased from 15.3 ± 4.2 to 4.0 ± 2.6 (p < 0.001), Screening group (Group #2) scores decreased from 15.5 ± 3.9 to 4.6 ± 3.0 (p < 0.001), Online CBT group (Group #3) scores decreased from 15.4 ± 3.8 to 3.4 ± 2.7 (p < 0.01), and the Stepped-care pathway group (Group #4) scores decreased from 15.3 ± 3.6 to 5.4 ± 2.8 (p < 0.05). In conclusion, these findings from this controlled randomized study do not suggest that using depression screening tools in family practice improves outcomes. They also suggest that much of the depression seen in primary care spontaneously resolves and do not support suggestions that more complex treatment programs or pathways improve depression outcomes in primary care. Replication studies are required due to study limitations.
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Affiliation(s)
- Peter H Silverstone
- Department of Psychiatry, University of Alberta, Edmonton, AB, Canada; Strategic Clinical Network for Addiction and Mental Health, Alberta Health Services, Edmonton, AB, Canada; Department of Finance and Statistical Analysis, University of Alberta, Edmonton, AB, Canada
| | - Katherine Rittenbach
- Strategic Clinical Network for Addiction and Mental Health, Alberta Health Services , Edmonton, AB , Canada
| | - Victoria Y M Suen
- Strategic Clinical Network for Addiction and Mental Health, Alberta Health Services , Edmonton, AB , Canada
| | | | - Ivor Cribben
- Department of Finance and Statistical Analysis, University of Alberta , Edmonton, AB , Canada
| | - Marni Bercov
- Strategic Clinical Network for Addiction and Mental Health, Alberta Health Services , Edmonton, AB , Canada
| | - Andrea Allen
- Strategic Clinical Network for Addiction and Mental Health, Alberta Health Services , Edmonton, AB , Canada
| | - Catherine Pryce
- Strategic Clinical Network for Addiction and Mental Health, Alberta Health Services , Edmonton, AB , Canada
| | - Deena M Hamza
- Department of Psychiatry, University of Alberta , Edmonton, AB , Canada
| | - Michael Trew
- Strategic Clinical Network for Addiction and Mental Health, Alberta Health Services , Edmonton, AB , Canada
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20
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Van den Broeck K, Remmen R, Vanmeerbeek M, Destoop M, Dom G. Collaborative care regarding major depressed patients: A review of guidelines and current practices. J Affect Disord 2016; 200:189-203. [PMID: 27136418 DOI: 10.1016/j.jad.2016.04.044] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Major Depressive Disorder (MDD) is a severe and common mental disorder. A growing body of evidence suggests that stepped and/or collaborative care treatment models have several advantages for severely depressed patients and caretakers. However, despite the availability of these treatment strategies and guidance initiatives, many depressive patients are solely treated by the general practitioner (GP), and collaborative care is not common. In this paper, we review a selected set of international guidelines to inventory the best strategies for GPs and secondary mental health care providers to collaborate when treating depressed patients. Additionally, we systematically searched the literature, listing potential ways of cooperation, and potentially supporting tools. We conclude that the prevailing guidelines only include few and rather vague directions regarding the cooperation between GPs and specialised mental health practitioners. Inspiring recent studies, however, suggest that relatively little efforts may result in effective collaborative care and a broader implementation of the guidelines in general.
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Affiliation(s)
- Kris Van den Broeck
- Collaborative Antwerp Psychiatric Research Institute, University of Antwerp, Antwerp, Belgium.
| | - Roy Remmen
- General Practice, Department of Primary and Interdisciplinary Care, University of Antwerp, Antwerp, Belgium
| | - Marc Vanmeerbeek
- Département de Médecine Générale, University of Liège, Liège, Belgium
| | - Marianne Destoop
- Collaborative Antwerp Psychiatric Research Institute, University of Antwerp, Antwerp, Belgium; Psychiatric Centre Brothers Alexianen, Boechout, Belgium
| | - Geert Dom
- Collaborative Antwerp Psychiatric Research Institute, University of Antwerp, Antwerp, Belgium; Psychiatric Centre Brothers Alexianen, Boechout, Belgium
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21
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Picardi A, Lega I, Tarsitani L, Caredda M, Matteucci G, Zerella MP, Miglio R, Gigantesco A, Cerbo M, Gaddini A, Spandonaro F, Biondi M. A randomised controlled trial of the effectiveness of a program for early detection and treatment of depression in primary care. J Affect Disord 2016; 198:96-101. [PMID: 27015158 DOI: 10.1016/j.jad.2016.03.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 02/13/2016] [Accepted: 03/07/2016] [Indexed: 10/22/2022]
Abstract
OBJECTIVE There is considerable uncertainty about whether depression screening programs in primary care may improve outcomes and what specific features of such programs may contribute to success. We tested the effectiveness of a program involving substantial commitment from local mental health services. METHODS Prospective, randomised, patient- and evaluator-masked, parallel-group, controlled study. Participants were recruited in several urban primary care practices where they completed the PC-SAD screener and WHOQOL-Bref. Those who screened positive and did not report suicidal ideation (N=115) were randomised to an intervention group (communication of the result and offer of psychiatric evaluation and treatment free of charge; N=56) or a control group (no feedback on test result for 3 months; N=59). After 3 months, 100 patients agreed to a follow-up telephone interview including the administration of the PC-SAD5 and WHOQOL-Bref. RESULTS Depression severity and quality of life improved significantly in both groups. Intent-to-treat analysis showed no effect of the intervention. As only 37% of patients randomised to the intervention group actually contacted the study outpatient clinic, we performed a per-protocol analysis to determine whether the intervention, if delivered as planned, had been effective. This analysis revealed a significant positive effect of the intervention on severity of depressive symptoms, and on response and remission rate. Complier average causal effect analysis yielded similar results. CONCLUSION Due to the relatively small sample size, our findings should be regarded as preliminary and have limited generalizability. They suggest that there are considerable barriers on the part of many patients to the implementation of depression screening programs in primary care. While such programs can be effective, they should be designed based on the understanding of patients' perspectives.
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Affiliation(s)
- A Picardi
- Mental Health Unit, Centre of Epidemiology, Surveillance and Health Promotion, Italian National Institute of Health, Rome, Italy.
| | - I Lega
- Mental Health Unit, Centre of Epidemiology, Surveillance and Health Promotion, Italian National Institute of Health, Rome, Italy
| | - L Tarsitani
- Department of Psychiatric Sciences and Psychological Medicine, 'Sapienza' University of Rome, Rome, Italy
| | - M Caredda
- Department of Psychiatric Sciences and Psychological Medicine, 'Sapienza' University of Rome, Rome, Italy
| | - G Matteucci
- Department of Psychiatric Sciences and Psychological Medicine, 'Sapienza' University of Rome, Rome, Italy
| | - M P Zerella
- Department of Psychiatric Sciences and Psychological Medicine, 'Sapienza' University of Rome, Rome, Italy
| | - R Miglio
- Department of Statistics, University of Bologna, Italy
| | - A Gigantesco
- Mental Health Unit, Centre of Epidemiology, Surveillance and Health Promotion, Italian National Institute of Health, Rome, Italy
| | - M Cerbo
- National Agency for Regional Health Services, Rome, Italy
| | - A Gaddini
- Agency for Public Health, Lazio Region, Italy
| | | | - M Biondi
- Department of Psychiatric Sciences and Psychological Medicine, 'Sapienza' University of Rome, Rome, Italy
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22
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Gillies D, Buykx P, Parker AG, Hetrick SE. Consultation liaison in primary care for people with mental disorders. Cochrane Database Syst Rev 2015; 2015:CD007193. [PMID: 26384252 PMCID: PMC6463953 DOI: 10.1002/14651858.cd007193.pub2] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Approximately 25% of people will be affected by a mental disorder at some stage in their life. Despite the prevalence and negative impacts of mental disorders, many people are not diagnosed or do not receive adequate treatment. Therefore primary health care has been identified as essential to improving the delivery of mental health care. Consultation liaison is a model of mental health care where the primary care provider maintains the central role in the delivery of mental health care with a mental health specialist providing consultative support. Consultation liaison has the potential to enhance the delivery of mental health care in the primary care setting and in turn improve outcomes for people with a mental disorder. OBJECTIVES To identify whether consultation liaison can have beneficial effects for people with a mental disorder by improving the ability of primary care providers to provide mental health care. SEARCH METHODS We searched the EPOC Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL), and bibliographic databases: MEDLINE, EMBASE, CINAHL and PsycINFO, in March 2014. We also searched reference lists of relevant studies and reviews to identify any potentially relevant studies. SELECTION CRITERIA We included randomised controlled trials (RCTs) which compared consultation liaison to standard care or other service models of mental health care in the primary setting. Included participants were people attending primary care practices who required mental health care or had a mental disorder, and primary care providers who had direct contact with people in need of mental health care. DATA COLLECTION AND ANALYSIS Two review authors independently screened the titles and abstracts of identified studies against the inclusion criteria and extracted details including the study design, participants and setting, intervention, outcomes and any risk of bias. We resolved any disagreements by discussion or referral to a third author. We contacted trial authors to obtain any missing information.We collected and analysed data for all follow-up periods: up to and including three months following the start of treatment; between three and 12 months; and more than 12 months following the start of therapy.We used a random-effects model to calculate the risk difference (RD) for binary data and number needed to treat for an additional beneficial outcome (NNTB), if differences between groups were significant. The mean difference (MD) or standardised mean difference (SMD) was calculated for continuous data. MAIN RESULTS There were 8203 citations identified from database searches and reference lists. We included 12 trials with 2605 consumer participants and more than 905 primary care practitioner participants. Eleven trials compared consultation liaison to standard care and one compared consultation liaison to collaborative care, with a case manager co-ordinating mental health care. People with depression were included in eight trials; and one trial each included people with a variety of disorders: depression, anxiety and somatoform disorders; medically unexplained symptoms; and drinking problems. None of the included trials reported separate data for children or older people.There was some evidence that consultation liaison improved mental health up to three months following the start of treatment (two trials, n = 445, NNTB 8, 95% CI 5 to 25) but there was no evidence of its effectiveness between three and 12 months. Consultation liaison also appeared to improve consumer satisfaction (up to three months: one trial, n = 228, NNTB 3, 95% CI 3 to 5; 3 to 12 months: two trials, n = 445, NNTB 8, 95% CI 5 to 17) and adherence (3 to 12 months: seven trials, n = 1251, NNTB 6, 95% CI 4 to 13) up to 12 months. There was also an improvement in the primary care provider outcomes of providing adequate treatment between three to 12 months (three trials, n = 797, NNTB 7, 95% CI 4 to 17) and prescribing pharmacological treatment up to 12 months (four trials, n = 796, NNTB 13, 95% CI 7 to 50). There was also some evidence that consultation liaison may not be as effective as collaborative care in regards to symptoms of mental disorder, disability, general health status, and provision of treatment.The quality of these findings were low for all outcomes however, apart from consumer adherence from three to 12 months, which was of moderate quality. Eight trials were rated a high risk of performance bias because consumer participants were likely to have known whether or not they were allocated to the intervention group and most outcomes were self reported. Bias due to attrition was rated high in eight trials and reporting bias was rated high in six. AUTHORS' CONCLUSIONS There is evidence that consultation liaison improves mental health for up to three months; and satisfaction and adherence for up to 12 months in people with mental disorders, particularly those who are depressed. Primary care providers were also more likely to provide adequate treatment and prescribe pharmacological therapy for up to 12 months. There was also some evidence that consultation liaison may not be as effective as collaborative care in terms of mental disorder symptoms, disability, general health status, and provision of treatment. However, the overall quality of trials was low particularly in regards to performance and attrition bias and may have resulted in an overestimation of effectiveness. More evidence is needed to determine the effectiveness of consultation liaison for people with mental disorders particularly for those with mental disorders other than depression.
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Affiliation(s)
- Donna Gillies
- Western Sydney Local Health District ‐ Mental HealthCumberland HospitalLocked Bag 7118ParramattaNSWAustralia2124
| | - Penny Buykx
- University of SheffieldSchool of Health and Related Research (ScHARR)Regents CourtSheffieldSouth YorkshireUKS1 4DA
- Monash University School of Rural HealthPO Box 666BendigoVictoriaAustralia3552
| | - Alexandra G Parker
- University of MelbourneOrygen Youth Health Research Centre, Centre for Youth Mental HealthLocked Bag 10, 35 Poplar RoadParkvilleMelbourneVICAustralia3054
| | - Sarah E Hetrick
- Orygen, The National Centre of Excellence in Youth Mental Health and The Centre of Youth Mental Health, University of Melbourne35 Poplar RoadParkvilleMelbourneVictoriaAustralia3054
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Yamada J, Shorkey A, Barwick M, Widger K, Stevens BJ. The effectiveness of toolkits as knowledge translation strategies for integrating evidence into clinical care: a systematic review. BMJ Open 2015; 5:e006808. [PMID: 25869686 PMCID: PMC4401869 DOI: 10.1136/bmjopen-2014-006808] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES The aim of this systematic review was to evaluate the effectiveness of toolkits as a knowledge translation (KT) strategy for facilitating the implementation of evidence into clinical care. Toolkits include multiple resources for educating and/or facilitating behaviour change. DESIGN Systematic review of the literature on toolkits. METHODS A search was conducted on MEDLINE, EMBASE, PsycINFO and CINAHL. Studies were included if they evaluated the effectiveness of a toolkit to support the integration of evidence into clinical care, and if the KT goal(s) of the study were to inform, share knowledge, build awareness, change practice, change behaviour, and/or clinical outcomes in healthcare settings, inform policy, or to commercialise an innovation. Screening of studies, assessment of methodological quality and data extraction for the included studies were conducted by at least two reviewers. RESULTS 39 relevant studies were included for full review; 8 were rated as moderate to strong methodologically with clinical outcomes that could be somewhat attributed to the toolkit. Three of the eight studies evaluated the toolkit as a single KT intervention, while five embedded the toolkit into a multistrategy intervention. Six of the eight toolkits were partially or mostly effective in changing clinical outcomes and six studies reported on implementation outcomes. The types of resources embedded within toolkits varied but included predominantly educational materials. CONCLUSIONS Future toolkits should be informed by high-quality evidence and theory, and should be evaluated using rigorous study designs to explain the factors underlying their effectiveness and successful implementation.
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Affiliation(s)
- Janet Yamada
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | | | - Melanie Barwick
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Kimberley Widger
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Bonnie J Stevens
- The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Knowles SE, Chew-Graham C, Adeyemi I, Coupe N, Coventry PA. Managing depression in people with multimorbidity: a qualitative evaluation of an integrated collaborative care model. BMC FAMILY PRACTICE 2015; 16:32. [PMID: 25886864 PMCID: PMC4355419 DOI: 10.1186/s12875-015-0246-5] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/12/2014] [Accepted: 02/20/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND Patients with comorbid depression and physical health problems have poorer outcomes compared with those with single long term conditions (LTCs), or multiple LTCs without depression. Primary care has traditionally struggled to provide integrated care for this group. Collaborative care can reduce depression in people with LTCs but evidence is largely based on trials conducted in the United States that adopted separate treat to target protocols for physical and mental health. Little is known about whether collaborative care that integrates depression care within the management of LTCs is implementable in UK primary care, and acceptable to patients and health care professionals. METHODS Nested interview study within the COINCIDE trial of collaborative care for patients with depression and diabetes/CHD (ISRCTN80309252). The study was conducted in primary care practices in North West England. Professionals delivering the interventions (nurses, GPs and psychological well-being practitioners) and patients in the intervention arm were invited to participate in semi-structured qualitative interviews. RESULTS Based on combined thematic analysis of 59 transcripts, we identified two major themes: 1) Integration: patients and professionals valued collaborative ways of working because it enhanced co-ordination of mental and physical health care and provided a sense that patients' health was being more holistically managed. 2) Division: patients and professionals articulated a preference for therapeutic and spatial separation between mental and physical health. Patients especially valued a separate space outside of their LTC clinic to discuss their emotional health problems. CONCLUSION The COINCIDE care model, that sought to integrate depression care within the context of LTC management, achieved service level integration but not therapeutic integration. Patients preferred a protected space to discuss mental health issues, and professionals maintained barriers around physical and mental health expertise. Findings therefore suggest that in the context of mental-physical multimorbidity, collaborative care can facilitate access to depression care in ways that overcome stigma and enhance the confidence of multidisciplinary health teams to work together. However, such care models need to be flexible and patient centred to accommodate the needs of patients for whom their depression may be independent of their LTC.
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Affiliation(s)
- Sarah E Knowles
- NIHR School for Primary Care Research and Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PL, UK.
| | - Carolyn Chew-Graham
- Primary Care and Health Sciences, University of Keele, and NIHR Collaboration for Leadership in Applied Health Research and Care West Midlands, Keele, ST5 5BG, UK.
| | - Isabel Adeyemi
- NIHR Collaboration for Leadership in Applied Health Research and Care Greater Manchester and Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PL, UK.
| | - Nia Coupe
- NIHR Collaboration for Leadership in Applied Health Research and Care Greater Manchester and Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PL, UK.
| | - Peter A Coventry
- NIHR Collaboration for Leadership in Applied Health Research and Care Greater Manchester and Manchester Academic Health Science Centre, University of Manchester, Manchester, M13 9PL, UK.
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Sighinolfi C, Nespeca C, Menchetti M, Levantesi P, Belvederi Murri M, Berardi D. Collaborative care for depression in European countries: a systematic review and meta-analysis. J Psychosom Res 2014; 77:247-63. [PMID: 25201482 DOI: 10.1016/j.jpsychores.2014.08.006] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 08/07/2014] [Accepted: 08/14/2014] [Indexed: 10/24/2022]
Abstract
OBJECTIVES This is a systematic review and meta-analysis of randomized controlled trials (RCTs) investigating the effectiveness of collaborative care compared to Primary Care Physician's (PCP's) usual care in the treatment of depression, focusing on European countries. METHODS A systematic review of English and non-English articles, from inception to March 2014, was performed using database PubMed, British Nursing Index and Archive, Ovid Medline (R), PsychINFO, Books@Ovid, PsycARTICLES Full Text, EMBASE Classic+Embase, DARE (Database of Abstract of Reviews of Effectiveness) and the Cochrane Library electronic database. Search term included depression, collaborative care, physician family and allied health professional. RCTs comparing collaborative care to usual care for depression in primary care were included. Titles and abstracts were independently examined by two reviewers, who extracted from the included trials information on participants' characteristics, type of intervention, features of collaborative care and type of outcome measure. RESULTS The 17 papers included, regarding 15 RCTs, involved 3240 participants. Primary analyses showed that collaborative care models were associated with greater improvement in depression outcomes in the short term, within 3 months (standardized mean difference (SMD) -0.19, 95% CI=-0.33; -0.05; p=0.006), medium term, between 4 and 11 months (SMD -0.24, 95% CI=-0.39; -0.09; p=0.001) and medium-long term, from 12 months and over (SMD -0.21, 95% CI=-0.37; -0.04; p=0.01), compared to usual care. CONCLUSIONS The present review, specifically focusing on European countries, shows that collaborative care is more effective than treatment as usual in improving depression outcomes.
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Affiliation(s)
- Cecilia Sighinolfi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Claudia Nespeca
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Marco Menchetti
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | - Paolo Levantesi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | | | - Domenico Berardi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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