The changing nature of consultation-liaison in primary care: bridging the gap between research and practice

Primary care patients' experiences of video consultations for depression and anxiety: a qualitative interview study embedded in a randomized feasibility trial

BACKGROUND

Integrated mental health care models that provide rapid access to video consultations with mental health specialists for primary care patients are a promising short-term, low-threshold treatment option and may reduce waiting times for specialist care. This qualitative study, nested within a randomized feasibility trial, aimed to explore participants' views on this type of care model, its influence on the lived experience of patients, and barriers and facilitators for its delivery.

METHODS

In five primary care practices, 50 adults with depression and/or anxiety were randomly assigned to either an integrated care model (maximum of five video consultations with a mental health specialist) or usual care (primary care or another treatment option). Prior to obtaining the trial results, interviews were held with participants who had received video consultations. Interviews were transcribed and analysed thematically.

RESULTS

Twenty of the 23 patients who received video consultations participated in the interviews. Patients engaged well with the care model and reported positive effects on their most pressing needs, while denying safety concerns. Generally, they perceived the usability of video consultations as high, and temporary connectivity failures were not considered a substantial barrier. We identified two key mechanisms of impacts on the patients' lived experience: fast access to specialist mental healthcare and the emerging rapport with the specialist. In particular, patients with no prior mental healthcare experience indicated that familiarity with the primary practice and their physician as a gatekeeper were important facilitators of proactive treatment.

CONCLUSIONS

From the patients' perspective, mental health care models integrating video consultations with mental health specialists into primary care are linked to positive lived experiences. Our findings imply that primary care physicians should promote their role as gatekeepers to (1) actively engage patients, (2) apply integrated care models to provide a familiar and safe environment for conducting mental health care video consultations, and (3) be able to regularly assess whether certain patients need in-person services. Scaling up such models may be worthwhile in real-world service settings, where primary care physicians are faced with high workloads and limited specialist services.

TRIAL REGISTRATION

DRKS00015812.

Mental health specialist video consultations versus treatment as usual in patients with depression or anxiety disorders in primary care: study protocol for an individually randomised superiority trial (the PROVIDE-C trial)

BACKGROUND

Most people with mental disorders, including those with severe and chronic disorders, are treated solely by their general practitioner (GP). Nevertheless, specialised mental health care may be required for specific patients. Notably, the accessibility of mental health specialist care is mainly complicated by (a) long waiting times for an appointment with specialists, (b) long travel distances to specialists, particularly in rural and remote areas, and (c) patients' reservations about mental health specialist care (including fear of being stigmatised by seeking such care). To mitigate those barriers, technology-based integrated care models have been proposed. The purpose of this study is to examine the effectiveness and cost-effectiveness of a mental health specialist video consultations model versus treatment as usual in patients with depression or anxiety disorders in primary care.

METHODS

In an individually randomised, prospective, two-arm superiority trial with parallel group design, N = 320 patients with anxiety and/or depressive disorder will be recruited in general practices in Germany. The intervention includes a newly developed treatment model based on video consultations with focus on diagnostics, treatment planning, and short-term intervention by mental health specialists. We will systematically compare the effectiveness, cost-effectiveness, and adverse effects of this new model with usual care by the GP: the primary outcome is the absolute change in the mean depressive and anxiety symptom severity measured on the Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS) from baseline to 6 months after baseline assessment. Follow-up in both groups will be conducted by blinded outcome assessors at 6 months and 12 months after baseline. The main analysis will be based on the intention-to-treat principle. We will optimise the likelihood of treatment effectiveness by strict inclusion criteria for patients, enhanced intervention integrity, and conducting a process evaluation.

DISCUSSION

To the best of our knowledge, this is the first confirmatory study on a video-based, integrated care model for the treatment of anxiety and depressive disorders in GP patients in Germany.

TRIAL REGISTRATION

ClinicalTrials.gov, United States National Institutes of Health NCT04316572 . Prospectively registered on 20 March 2020.

Mental Health Specialist Video Consultations Versus Treatment-as-Usual for Patients With Depression or Anxiety Disorders in Primary Care: Randomized Controlled Feasibility Trial

BACKGROUND

Most people affected by depression or anxiety disorders are treated solely by their primary care physician. Access to specialized mental health care is impeded by patients' comorbidity and immobility in aging societies and long waiting times at the providers' end. Video-based integrated care models may leverage limited resources more efficiently and provide timely specialized care in primary care settings.

OBJECTIVE

The study aims to evaluate the feasibility of mental health specialist video consultations with primary care patients with depression or anxiety disorders.

METHODS

Participants were recruited by their primary care physicians during regular practice visits. Patients who had experienced at least moderate symptoms of depression and/or anxiety disorders were considered eligible for the study. Patients were randomized into 2 groups receiving either treatment-as-usual as provided by their general practitioner or up to 5 video consultations conducted by a mental health specialist. Video consultations focused on systematic diagnosis and proactive monitoring using validated clinical rating scales, the establishment of an effective working alliance, and a stepped-care algorithm within integrated care adjusting treatments based on clinical outcomes. Feasibility outcomes were recruitment, rate of loss to follow-up, acceptability of treatment, and attendance at sessions. Effectiveness outcomes included depression (Patient Health Questionnaire-9), anxiety (Generalized Anxiety Disorder-7), burden of specific somatic complaints (Somatic Symptom Disorder-B Criteria Scale-12), recovery (Recovery Assessment Scale-German [RAS-G]), and perception of chronic illness care (Patient Assessment of Chronic Illness Care), which were measured at baseline and 16 weeks postallocation by assessors blinded to the group allocation.

RESULTS

A total of 50 patients with depression and/or anxiety disorders were randomized, 23 in the intervention group and 27 in the treatment-as-usual group. The recruitment yield (number randomized per number screened) and the consent rate (number randomized per number eligible) were 69% (50/73) and 86% (50/58), respectively. Regarding acceptability, 87% (20/23) of the participants in the intervention group completed the intervention. Of the 108 planned video consultations, 102 (94.4%) were delivered. Follow-up rates were 96% (22/23) and 85% (23/27) for the intervention and control groups, respectively. The change from baseline scores at postmeasurement for the No Domination by Symptoms domain of recovery (RAS-G) was somewhat higher in the intervention group than in the control group (Mann-Whitney U test: rank-biserial r=0.19; 95% CI -0.09 to 0.46; P=.18). We did not detect any notable differences between the intervention and control groups in terms of other effectiveness outcomes. We did not observe any serious adverse events related to the trial.

CONCLUSIONS

The intervention and study procedures were found to be feasible for patients, primary care practice staff, and mental health specialists. A sufficiently powered pragmatic trial on mental health specialist video consultations should be conducted to investigate their effectiveness in routine care.

TRIAL REGISTRATION

German Clinical Trials Register DRKS00015812; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00015812.

Atenção básica e cuidado colaborativo na atenção psicossocial de crianças e adolescentes: facilitadores e barreiras

Resumo Considerando a lacuna assistencial no campo da atenção psicossocial infanto-juvenil, a articulação da rede intrassetorial se configura como uma importante estratégia para promover fluxos assistenciais menos fragmentados. O estudo analisa os facilitadores e as barreiras para o cuidado colaborativo entre a Estratégia de Saúde da Família (ESF) e um Centro de Atenção Psicossocial intanto-juvenil (CAPSi), no Rio de Janeiro/RJ. Trata-se de estudo exploratório, de abordagem qualitativa, no qual as principais ferramentas metodológicas foram grupos focais e de intervenção. A partir dos eixos temáticos propostos, identificou-se que a percepção dos problemas de saúde mental infanto-juvenil pelos trabalhadores das ESF foi nomeada pelas alterações de comportamento situadas em contexto de vulnerabilidade. As principais barreiras para implementação das ações foram: desconhecimento sobre o modo de cuidado; problemas relacionados ao processo de trabalho; e desarticulação da rede. Ainda que os profissionais da ESF consigam identificar os problemas de saúde mental de crianças e adolescentes, as ações de cuidado são frágeis e a articulação da rede praticamente inexistente. O cuidado colaborativo foi reconhecido como uma estratégia para qualificação da atenção psicossocial infanto-juvenil.

The Rise of Primary Care Physicians in the Provision of US Mental Health Care

Primary care physicians have assumed an increasingly important role in US outpatient mental health care. They are providing an increasing volume of outpatient mental health services, prescribing a growing number and variety of psychotropic medications, and treating patients with a broader array of mental health conditions. These trends, which run counter to a general trend toward specialization and subspecialization within US health care, place new strains on the clinical competencies of primary care physicians. They also underscore the importance of implementing more effective models of collaboration between primary care physicians and mental health specialists. Several elements of the Affordable Care Act provide options for financing and organizing the delivery of integrated general medical and behavioral services. Such integrated services have the potential to improve access and quality of outpatient mental health care for a range of psychiatric disorders. Because people with severe and persisting mental disorders commonly require a higher-level medical expertise than is readily available within primary care as well as a complex array of social services, separate specialized mental health will likely continue to play a vitally important role in caring for this population.

Interpersonal Counseling (IPC) for Depression in Primary Care

Interpersonal Counseling (IPC) comes directly from interpersonal psychotherapy (IPT), an evidenced-based psychotherapy developed by Klerman and Weissman. It [IPC?] is a briefer, more structured version for use primarily in non-mental health settings, such as primary care clinics when treating patients with symptoms of depression. National health-care reform, which will bring previously uninsured persons into care and provide mechanisms to support mental health training of primary care providers, will increase interest in briefer psychotherapy. This paper describes the rationale, development, evidence for efficacy, and basic structure of IPC and also presents an illustrated clinical vignette. The evidence suggests that IPC is efficacious in reducing symptoms of depression; that it can be used by mental health personnel of different levels of training, and that the number of sessions is flexible depending on the context and resources. More clinical trials are needed, especially ones comparing IPC to other types of care used in the delivery of mental health services in primary care.

Evaluation of a mental health training intervention for multidisciplinary teams in primary care in Brazil: a pre- and posttest study

OBJECTIVES

The aim of this research was to investigate whether a training intervention to enhance collaboration between mental health and primary care professionals improved the detection and management of mental health problems in primary health care in four large cities in Brazil. The training intervention was a multifaceted program over 96 h focused on development of a shared care model.

METHOD

A quasiexperimental study design was undertaken with assessment of performance by nurse and general practitioners (GPs) pre- and postintervention. Rates of recognition of mental health disorders (compared with the General Health Questionnaire) were the primary outcome, while self-reports of patient-centered care, psychosocial interventions and referral were the secondary outcomes.

RESULTS

Six to 8 months postintervention, no changes were observed in terms of rate of recognition across the entire sample. Nurses significantly increased their recognition rates (from 23% to 39%, P=.05), while GPs demonstrated a significant decrease (from 42% to 30%, P=.04). There were significant increases in reports of patient-centered care, but no changes in other secondary outcomes.

CONCLUSIONS

Training professionals in a shared care model was not associated with consistent improvements in the recognition or management of mental health problems. Although instabilities in the local context may have contributed to the lack of effects, wider changes in the system of care may be required to augment training and encourage reliable changes in behavior, and more specific educating models are necessary.

What is the role of consultation-liaison psychiatry in the management of depression in primary care? A systematic review and meta-analysis

OBJECTIVE

To assess the effectiveness of consultation-liaison services, involving mental health professionals working to advise and support primary care professionals in the management of depression.

METHODS

Studies of consultation-liaison for depression in primary care were identified from a systematic search of electronic databases, augmented by identification of papers from reference lists, published reviews and from hand searching. Data on study quality, intervention characteristics and outcomes were extracted by two reviewers, and outcome data were meta-analyzed.

RESULTS

Five studies met the criteria. There was no significant effect of consultation-liaison on antidepressant use (risk ratio 1.23, 95% CI 0.91 to 1.66) or depression outcomes in the short- (standardized mean difference -0.04, 95% CI -0.21 to 0.14) or long-term (standardized mean difference 0.06, 95% CI -0.13 to 0.26).

CONCLUSIONS

Evidence concerning consultation-liaison for depression in primary care remains limited, but the existing studies do not suggest it is more effective than usual care. Further research is required to explore the mechanisms by which consultation-liaison might be made more effective, including the potential role of consultation-liaison in combination with other models of care, and in other patient populations.

On-site mental health workers delivering psychological therapy and psychosocial interventions to patients in primary care: effects on the professional practice of primary care providers

BACKGROUND

Mental health problems are common in primary care and mental health workers (MHWs) are increasingly working in this setting delivering psychological therapy and psychosocial interventions to patients. In addition to treating patients directly, the introduction of on-site MHWs represents an organisational change that may lead to changes in the clinical behaviour of primary care providers (PCPs).

OBJECTIVES

To assess the effects of on-site MHWs delivering psychological therapy and psychosocial interventions in primary care on the clinical behaviour of primary care providers (PCPs).

SEARCH STRATEGY

The following sources were searched in 1998: the Cochrane Effective Practice and Organisation of Care Group Specialised Register, the Cochrane Controlled Trials Register, MEDLINE, EMBASE, PsycINFO, CounselLit, NPCRDC skill-mix in primary care bibliography, and reference lists of articles. Additional searches were conducted in February 2007 using the following sources: MEDLINE, EMBASE, PsycINFO, CINAHL, and Cochrane Central Register of Clinical Trials (CENTRAL) (The Cochrane Library).

SELECTION CRITERIA

Randomised trials, controlled before and after studies, and interrupted time series analyses of MHWs working alongside PCPs in primary care settings. The outcomes included objective measures of PCP behaviours such as consultation rates, prescribing, and referral.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed study quality.

MAIN RESULTS

Forty-two studies were included in the review. There was evidence that MHWs caused significant reductions in PCP consultations (standardised mean difference -0.17, 95% CI -0.30 to -0.05), psychotropic prescribing (relative risk 0.67, 95% CI 0.56 to 0.79), prescribing costs (standardised mean difference -0.22, 95% CI -0.38 to -0.07), and rates of mental health referral (relative risk 0.13, 95% CI 0.09 to 0.20) for the patients they were seeing. In controlled before and after studies, the addition of MHWs to a practice did not affect prescribing behaviour towards the wider practice population and there was no consistent pattern to the impact on referrals in the wider patient population.

AUTHORS' CONCLUSIONS

This review provides some evidence that MHWs working in primary care to deliver psychological therapy and psychosocial interventions cause a significant reduction in PCP behaviours such as consultations, prescribing, and referrals to specialist care. However, the changes are modest in magnitude, inconsistent, do not generalise to the wider patient population, and their clinical or economic significance is unclear.

Validity and applicability of the Mini International Neuropsychiatric Interview administered by family medicine residents in primary health care in Brazil

OBJECTIVE

To evaluate the validity and applicability of the Mini International Neuropsychiatric Interview (MINI) used by family medicine residents in primary health care (PHC) in Brazil.

METHODS

Training for administrating the MINI was given as part of a broad psychiatry education program. Interviews were held with 120 PHC patients who were at least 15 years old. MINI was administered by 25 resident physicians, while the Structured Clinical Interview for Diagnosis (SCID) was administered by a psychiatrist blind to patients' results on the MINI, and the diagnoses on both interviews were compared. The resident physicians answered questions on the applicability of the MINI.

RESULTS

Concordance levels for any mental disorder, the broader current diagnostic categories and the most common specific diagnoses were analyzed. Kappa coefficients ranged between 0.65 and 0.85; sensitivity, between 0.75 and 0.92; specificity, between 0.90 and 0.99; positive predictive values (PPV), between 0.60 and 0.86; negative predictive values (NPV), between 0.92 and 0.99; and accuracy, between 0.88 and 0.98. The resident physicians considered MINI comprehensibility and clinical relevance satisfactory.

CONCLUSIONS

These good psychometric results in a real-world setting may be related to a special training program, which is more frequent, intensive and diversified. In these conditions, the MINI is a useful tool for general practitioners.

Models and patterns of service in child and youth consultation-liaison services

OBJECTIVE

The aim was to examine referral pathways to child and youth consultation-liaison (C-L) services to identify patterns associated with demographic characteristics of patients, referral sources, the presenting problem and models of service.

METHOD

A case record review with a cross-sectional design. Data were extracted from the records of all patients referred to the C-L service for a 3 month period.

RESULTS

Adolescents were more likely to access mental health services through informal liaison services. Medical specialty areas that were inclusive of nursing and allied health, in both the request for service and initial response to the request, had higher frequencies of referral. There was no difference between the disciplines of medicine and social work in the frequency of referrals. However, medicine, social work and nursing differed in the number of staff who initiated the request for consultation, and the types of problems that were presented as reasons for referral.

CONCLUSIONS

Inclusive multidisciplinary models may facilitate the development of service relationships in paediatric hospital settings, due to the stability of staffing arrangements. The wider participation of allied health and nursing staff within paediatric hospitals may extend opportunities for the identification of mental health problems and enhance timely management of referrals.

Redevelopment of a consultation-liaison service at a tertiary paediatric hospital

OBJECTIVE

This paper aims to describe the way a multidisciplinary team set out to redevelop a consultation-liaison (C-L) service at a tertiary paediatric hospital.

METHOD

The activities and processes in which the team members engaged were documented within a continuous quality improvement cycle. These activities included literature review, analysis of referral patterns, consultation with extant services, survey of referral sources and consultation with other tertiary paediatric services.

RESULTS

The outcomes of these initiatives were integrated into a re-formulated multidisciplinary team model dedicated to providing C-L services to the paediatric hospital. Significant challenges identified in the initial process were ongoing issues with caseload management and clarification of boundary demarcations.

CONCLUSION

There has been a gradual acceptance of the new C-L service by medical staff. The structure has resulted in a focused and coordinated C-L team that has contributed to innovations in the C-L process within the hospital.

Use of a routine outcome measure in a consultation-liaison mental health service

OBJECTIVE

The problem severity of patients seen by a psychiatric consultation- liaison service was studied through the use of a routine outcome measure.

METHODS

Ratings on the Health of the Nation Outcome Scales (HoNOS) over nearly 3 years in the emergency department, general hospital, and on admission to the acute psychiatric unit were compared.

RESULTS

Mean HoNOS total scores in the emergency department were not significantly different from those at admission to the acute psychiatric unit, but were significantly higher than those in the general hospital. Mean scores in all three settings were higher than those obtained at case review of psychiatric patients in the community. Despite differences in age, sex, and psychiatric diagnosis between the three hospital settings, differences in mean HoNOS total scores remained substantially unchanged after adjustment for these factors. Most HoNOS assessments were performed by medical staff.

CONCLUSIONS

The suspected high levels of problem severity and comorbidity of patients seen by a psychiatric consultation-liaison service were confirmed through the use of a routine outcome measure.

Primary mental health workers in child and adolescent mental health services

BACKGROUND

The interface between primary care and specialist services is increasingly seen as crucial in the effective management of child and adolescent mental health (CAMH) problems. In the United Kingdom, a new role of primary mental health worker (PMHW), has been established in order to achieve effective collaboration across the interface through the provision of clinical care in primary care settings and by improving the skills and confidence of primary care staff. However, little is known about the development of this innovative role in service contexts. Issues raised during the early stages of implementation may have important implications for the preparation and development of professionals who undertake the role.

AIMS

The aim of this paper is to report on a study that examined key issues in implementation of the PMHW role in six health authorities in England.

METHODS

Case study evaluation was conducted, using thematic analysis of 75 qualitative interviews with key stakeholders from different professions (e.g. PMHWs, general practitioners, health visitors, psychiatrists and service managers) and representing different sectors (primary care, specialist services and community child health services).

FINDINGS

The study identified three models of organization (outreach, primary care-based and teams). Each was associated with different advantages and disadvantages in its effects on referral rates to specialist services and the development of effective working relationships with primary care providers. Problems associated with accommodation and effective integration of PMHWs with specialist services, and tensions caused by the two different roles that PMHWs could undertake (direct clinical care vs. consultation-liaison) were common across all sites.

CONCLUSIONS

The PMHW role is an important development that may go some way towards realizing the potential of primary care services in CAMH. The implementation of new roles and models of working in primary care is complex, but may be facilitated by effective planning with primary care providers, clear goals for staff, and a long-term perspective on service development.

Knowledge dissemination and utilization in gerontology: an organizing framework

PURPOSE

Enabling valuable research findings to be used by the field requires a strategic approach to dissemination and utilization rather than simply making constituencies aware of the information. This article describes a conceptual framework for the dissemination and utilization of information, along with examples of its use by the Boston University Roybal Center for Enhancement of Late Life Function.

DESIGN AND METHODS

The framework identifies dissemination/utilization goals of exposure, experience, expertise, and embedding ("4 E") and relates each goal to strategies targeted for specific users.

RESULTS AND IMPLICATIONS

The Boston University center exposed the field to information through presentations, print- and Web-based information, provided consumers and family members with new findings through motivational videotapes, developed expertise-level training programs, and embedded the new findings within organizations and systems. The 4 E framework can translate critical research outcomes into useful information to assist the field to better care and support available for individuals in late life.