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Kullberg MLJ, Schoorl M, Oprel DAC, Hoeboer CM, Smit F, van der Does W, de Kleine RA, van Minnen A, van den Hout W. Exposure-based treatments for childhood abuse-related post-traumatic stress disorder in adults: a health-economic evaluation. Eur J Psychotraumatol 2023; 14:2171752. [PMID: 37052103 PMCID: PMC9930771 DOI: 10.1080/20008066.2023.2171752] [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: 08/31/2022] [Accepted: 12/17/2022] [Indexed: 02/16/2023] Open
Abstract
Background: Prolonged exposure (PE) is an effective treatment for post-traumatic stress disorder (PTSD).Objective: This study aimed to analyse the cost-effectiveness of three exposure-based treatments in patients with childhood abuse-related PTSD.Method: A net-benefit analysis was conducted alongside a pragmatic randomized controlled trial with participants (N = 149) randomized to three conditions: PE (n = 48), intensified PE (i-PE, n = 51), and phase-based PE [Skills Training in Affective and Interpersonal Regulation (STAIR) + PE, n = 50]. Assessments took place at baseline (T0), post-treatment (T3), 6 month follow-up (T4), and 12 month follow-up (T5). Costs stemming from healthcare utilization and productivity losses were estimated using the Trimbos/iMTA questionnaire for Costs associated with Psychiatric Illness. Quality-adjusted life-years (QALYs) were based on the 5-level EuroQoL 5 Dimensions (EQ-5D-5L) using the Dutch tariff. Missing values of costs and utilities were multiply imputed. To compare i-PE to PE and STAIR + PE to PE, pair-wise unequal-variance t-tests were conducted. Net-benefit analysis was used to relate costs to QALYs and to draw acceptability curves.Results: Intervention costs did not differ across the three treatment conditions. Total medical costs, productivity losses, total societal costs, and EQ-5D-5L-based QALYs did not differ between treatment conditions either (all p > .10). At the relevant €50,000/QALY threshold, the probability of one treatment being more cost-effective than another was 32%, 28%, and 40% for PE, i-PE, and STAIR-PE, respectively.Conclusion: Three equally effective treatments were compared and no differences in cost-effectiveness between treatments were found. Therefore, we advocate the implementation and adoption of any of the treatments and endorse shared decision making.
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Affiliation(s)
| | - Maartje Schoorl
- Department of Clinical Psychology, Leiden University, Leiden, The Netherlands
| | - Danielle A. C. Oprel
- Department of Clinical Psychology, Leiden University, Leiden, The Netherlands
- PsyQ, Parnassiagroep, The Hague, The Netherlands
| | - Chris M. Hoeboer
- Department of Clinical Psychology, Leiden University, Leiden, The Netherlands
- Department of Psychiatry, Amsterdam University Medical Centers Location AMC, Amsterdam Public Health, Amsterdam, The Netherlands
| | - Filip Smit
- Centre of Health Economic Evaluation and Department of Mental Health and Prevention, Trimbos Institute (Netherlands Institute of Mental Health and Addiction), Utrecht, The Netherlands
- Department of Clinical Psychology and Department of Epidemiology and Biostatistics, University Medical Centers Amsterdam, Location VUmc, Amsterdam, The Netherlands
| | - Willem van der Does
- Department of Clinical Psychology, Leiden University, Leiden, The Netherlands
| | - Rianne A. de Kleine
- Department of Clinical Psychology, Leiden University, Leiden, The Netherlands
- PsyQ, Parnassiagroep, The Hague, The Netherlands
| | - Agnes van Minnen
- PSYTREC, Bilthoven, The Netherlands
- Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands
| | - Wilbert van den Hout
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
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Menear M, Girard A, Dugas M, Gervais M, Gilbert M, Gagnon MP. Personalized care planning and shared decision making in collaborative care programs for depression and anxiety disorders: A systematic review. PLoS One 2022; 17:e0268649. [PMID: 35687610 PMCID: PMC9187074 DOI: 10.1371/journal.pone.0268649] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 05/04/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Collaborative care is an evidence-based approach to improving outcomes for common mental disorders in primary care. Efforts are underway to broadly implement the collaborative care model, yet the extent to which this model promotes person-centered mental health care has been little studied. The aim of this study was to describe practices related to two patient and family engagement strategies-personalized care planning and shared decision making-within collaborative care programs for depression and anxiety disorders in primary care. METHODS We conducted an update of a 2012 Cochrane review, which involved searches in Cochrane CCDAN and CINAHL databases, complemented by additional database, trial registry, and cluster searches. We included programs evaluated in a clinical trials targeting adults or youth diagnosed with depressive or anxiety disorders, as well as sibling reports related to these trials. Pairs of reviewers working independently selected the studies and data extraction for engagement strategies was guided by a codebook. We used narrative synthesis to report on findings. RESULTS In total, 150 collaborative care programs were analyzed. The synthesis showed that personalized care planning or shared decision making were practiced in fewer than half of programs. Practices related to personalized care planning, and to a lesser extent shared decision making, involved multiple members of the collaborative care team, with care managers playing a pivotal role in supporting patient and family engagement. Opportunities for quality improvement were identified, including fostering greater patient involvement in collaborative goal setting and integrating training and decision aids to promote shared decision making. CONCLUSION This review suggests that personalized care planning and shared decision making could be more fully integrated within collaborative care programs for depression and anxiety disorders. Their absence in some programs is a missed opportunity to spread person-centered mental health practices in primary care.
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Affiliation(s)
- Matthew Menear
- VITAM Research Centre for Sustainable Health, Quebec, Quebec, Canada
- Department of Family Medicine and Emergency Medicine, Université Laval, Quebec, Quebec, Canada
| | - Ariane Girard
- VITAM Research Centre for Sustainable Health, Quebec, Quebec, Canada
- Department of Family Medicine and Emergency Medicine, Université Laval, Quebec, Quebec, Canada
| | - Michèle Dugas
- VITAM Research Centre for Sustainable Health, Quebec, Quebec, Canada
| | - Michel Gervais
- Centre Intégré Universitaire de Santé et de Services Sociaux de la Capitale-Nationale, Quebec, Quebec, Canada
| | - Michel Gilbert
- Centre National d’Excellence en Santé Mentale, Quebec, Quebec, Canada
| | - Marie-Pierre Gagnon
- VITAM Research Centre for Sustainable Health, Quebec, Quebec, Canada
- Faculty of Nursing, Université Laval, Quebec, Quebec, Canada
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Gallagher E, Alvarez E, Jin L, Guenter D, Hatcher L, Furlan A. Patient contracts for chronic medical conditions: Scoping review. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2022; 68:e169-e177. [PMID: 35552216 PMCID: PMC9097748 DOI: 10.46747/cfp.6805e169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To describe how and why patient contracts are used for the management of chronic medical conditions. DATA SOURCES A scoping review was conducted in the following databases: MEDLINE, Embase, AMED, PsycInfo, Cochrane Library, CINAHL, and Nursing & Allied Health. Literature from 1997 to 2017 was included. STUDY SELECTION Articles were included if they were written in English and described the implementation of a patient contract by a health care provider for the management of a chronic condition. Articles had to present an outcome as a result of using the contract or an intervention that included the contract. SYNTHESIS Of the 7528 articles found in the original search, 76 met the inclusion criteria for the final review. Multiple study types were included. Extensive variety in contract elements, target populations, clinical settings, and cointerventions was found. Purposes for initiating contracts included behaviour change and skill development, including goal development and problem solving; altering beliefs and knowledge, including motivation and perceived self-efficacy; improving interpersonal relationships and role clarification; improving quality and process of chronic care; and altering objective and subjective health indices. How contracts were developed, implemented, and assessed was inconsistently described. CONCLUSION More research is required to determine whether the use of contracts is accomplishing their intended purposes. Questions remain regarding their rationale, development, and implementation.
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Affiliation(s)
- Erin Gallagher
- Assistant Professor in the Department of Family Medicine at McMaster University in Hamilton, Ont.
| | - Elizabeth Alvarez
- Assistant Professor in the Department of Health Research Methods, Evidence and Impact at McMaster University
| | - Lin Jin
- Master of public health candidate at McMaster University
| | - Dale Guenter
- Associate Professor in the Department of Family Medicine and the Department of Health Research Methods, Evidence and Impact at McMaster University
| | - Lydia Hatcher
- Associate Clinical Professor in the Department of Family Medicine at McMaster University
| | - Andrea Furlan
- Associate Professor in the Department of Medicine at the University of Toronto in Ontario
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Effectiveness of a task-sharing collaborative care model for identification and management of depressive symptoms in patients with hypertension attending public sector primary care clinics in South Africa: pragmatic parallel cluster randomised controlled trial. J Affect Disord 2021; 282:112-121. [PMID: 33412490 DOI: 10.1016/j.jad.2020.12.123] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 10/21/2020] [Accepted: 12/24/2020] [Indexed: 01/23/2023]
Abstract
BACKGROUND We tested the real-world effectiveness of a collaborative task-sharing model on depressive symptom reduction in hypertensive Primary Health Care (PHC) patients in South Africa. METHOD A pragmatic parallel cluster randomised trial in 20 clinics in the Dr Kenneth Kaunda district, North West province. PHC clinics were stratified by sub-district and randomised in a 1:1 ratio. Control clinics received care as usual (CAU), involving referral to PHC doctors and/or mental health specialists. Intervention clinics received CAU plus enhanced mental health training and a lay counselling referral service. Participant inclusion criteria were ≥ 18 years old, Patient Health Questionnaire-9 (PHQ-9) score ≥ 9 and receiving hypertension medication. Primary superiority outcome was ≥ 50% reduction in PHQ-9 score at 6 months. Statistical analyses comprised mixed effects regression models and a non-inferiority analysis. TRIAL REGISTRATION NUMBER NCT02425124. RESULTS Between April 2015 and October 2015, 1043 participants were enrolled (504 intervention and 539 control); 82% were women; half were ≥ 55 years. At 6 and 12 months follow-up, 91% and 89% of participants were interviewed respectively. One control group participant committed suicide. There was no significant difference in the primary outcome between intervention (N=256/456) and control (N=232/492) groups (55.9% versus 50.9%; adjusted risk difference = -0.04 ([95% CI = -0.19; 0.11], p = 0.6). The difference in PHQ-9 scores was within the defined equivalence limits at 6 and 12 months for the non-inferiority analysis. LIMITATIONS The trial was limited by low exposure to depression treatment by trial participants and by observed co-intervention in control clinics CONCLUSIONS: Incorporating lay counselling services within collaborative care models does not produce superior nor inferior outcomes to models with specialist only counselling services. FUNDING This work was supported by the UK Department for International Development [201446] as well as the National Institute of Mental Health, United States of America, grant number 1R01MH100470-01. Graham Thornicroft is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South London at King's College London and King's College Hospital NHS Foundation Trust.
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Goorden M, van der Feltz-Cornelis CM, van Steenbergen-Weijenburg KM, Horn EK, Beekman AT, Hakkaart-van Roijen L. Cost-utility of collaborative care for the treatment of comorbid major depressive disorder in outpatients with chronic physical conditions. A randomized controlled trial in the general hospital setting (CC-DIM). Neuropsychiatr Dis Treat 2017; 13:1881-1893. [PMID: 28765710 PMCID: PMC5525903 DOI: 10.2147/ndt.s134008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE Major depressive disorder (MDD) is highly prevalent in patients with a chronic physical condition, and this comorbidity has a negative influence on quality of life, health care costs, self-care, morbidity, and mortality. Research has shown that collaborative care (CC) may be a cost-effective treatment. However, its cost-effectiveness in this patient group has not yet been established. Therefore, the aim of this study was to evaluate the cost-utility of CC for the treatment of comorbid MDD in chronically ill patients in the outpatient general hospital setting. The study was conducted from a health care and societal perspective. PATIENTS AND METHODS In this randomized controlled trial, 81 patients with moderate-to-severe MDD were included; 42 were randomly assigned to the CC group and 39 to the care as usual (CAU) group. We applied the TiC-P, short-form Health-Related Quality of Life questionnaire, and EuroQol EQ-5D 3 level version, measuring the use of health care, informal care, and household work, respectively, at baseline and at 3, 6, 9, and 12 months follow-up. RESULTS The mean annual direct medical costs in the CC group were €6,718 (95% confidence interval [CI]: 3,541 to 10,680) compared to €4,582 (95% CI: 2,782 to 6,740) in the CAU group. The average quality-adjusted life years (QALYs) gained were 0.07 higher in the CC group, indicating that CC is more costly but also more effective than CAU. From a societal perspective, the incremental cost-effectiveness ratio was €24,690/QALY. CONCLUSION This first cost-utility analysis in chronically ill patients with comorbid MDD shows that CC may be a cost-effective treatment depending on willingness-to-pay levels. Nevertheless, the low utility scores emphasize the need for further research to improve the cost-effectiveness of CC in this highly prevalent and costly group of patients.
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Affiliation(s)
- Maartje Goorden
- Institute of Health Policy and Management (iBMG)/Institute for Medical Technology Assessment (iMTA), Erasmus University Rotterdam, Rotterdam
| | | | | | - Eva K Horn
- Viersprong Institute for Studies on Personality Disorders, Halsteren
| | - Aartjan Tf Beekman
- Department of Psychiatry.,EMGO+ Research Institute VUmc, VU University Medical Centre, Amsterdam, the Netherlands
| | - Leona Hakkaart-van Roijen
- Institute of Health Policy and Management (iBMG)/Institute for Medical Technology Assessment (iMTA), Erasmus University Rotterdam, Rotterdam
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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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Steel JL, Geller DA, Kim KH, Butterfield LH, Spring M, Grady J, Sun W, Marsh W, Antoni M, Dew MA, Helgeson V, Schulz R, Tsung A. Web-based collaborative care intervention to manage cancer-related symptoms in the palliative care setting. Cancer 2016; 122:1270-82. [PMID: 26970434 PMCID: PMC4828258 DOI: 10.1002/cncr.29906] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Revised: 11/23/2015] [Accepted: 12/28/2015] [Indexed: 01/02/2023]
Abstract
BACKGROUND The aim of this study was to examine the efficacy of a collaborative care intervention in reducing depression, pain, and fatigue and improve quality of life. METHODS A total of 261 patients with advanced cancer and 179 family caregivers were randomized to a web-based collaborative care intervention or enhanced usual care. The intervention included the following: 1) a web site with written and audiovisual self-management strategies, a bulletin board, and other resources; 2) visits with a care coordinator during a physician's appointment every 2 months; and 3) telephone follow-up every 2 weeks. Primary patient outcomes included measures of depression, pain, fatigue, and health-related quality of life. Secondary outcomes included Interleukin (IL)-1α, IL-1β, IL-6, and IL-8 levels, Natural Killer (NK) cell numbers, and caregiver stress and depression. RESULTS At the baseline, 51% of the patients reported 1 or more symptoms in the clinical range. For patients who presented with clinical levels of symptoms and were randomized to the intervention, reductions in depression (Cohen's d = 0.71), pain (Cohen's d = 0.62), and fatigue (Cohen's d = 0.26) and improvements in quality of life (Cohen's d = 0.99) were observed when compared to those in the enhanced usual car arm at 6 months. Reductions in IL-6 (φ = 0.18), IL-1β (φ = 0.35), IL-1α (φ = 0.19), and IL-8 (φ = 0.15) and increases in NK cell numbers (φ = 0.23) were observed in comparison with enhanced usual care arm at 6 months. Reductions in caregiver stress (Cohen's d = 0.75) and depression (Cohen's d = 0.37) were observed at 6 months for caregivers whose loved ones were randomized to the intervention arm. CONCLUSIONS The integration of screening and symptom management into cancer care is recommended.
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Affiliation(s)
- Jennifer L Steel
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Psychology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David A Geller
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Kevin H Kim
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lisa H Butterfield
- Departments of Medicine, Surgery and Immunology, Hillman Cancer Center, University of Pittsburgh Cancer Institute, Pittsburgh, Pennsylvania
| | - Michael Spring
- School of Information Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Jonathan Grady
- School of Information Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Weiing Sun
- Cancer Institute, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Wallis Marsh
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michael Antoni
- Department of Psychology, University of Miami, Sylvester Comprehensive Cancer Center, Miami, Florida
| | - Mary Amanda Dew
- Departments of Psychiatry, Psychology, Epidemiology, Biostatistics, and Clinical and Translational Science, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Vicki Helgeson
- Department of Psychology, Carnegie Mellon University, Pittsburgh, Pennsylvania
| | - Richard Schulz
- Department of Psychology, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Allan Tsung
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
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8
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Goorden M, Huijbregts KML, van Marwijk HWJ, Beekman ATF, van der Feltz-Cornelis CM, Hakkaart-van Roijen L. Cost-utility of collaborative care for major depressive disorder in primary care in the Netherlands. J Psychosom Res 2015; 79:316-23. [PMID: 26255095 DOI: 10.1016/j.jpsychores.2015.06.006] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2014] [Revised: 06/19/2015] [Accepted: 06/20/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Major depression is a great burden on society, as it is associated with high disability/costs. The aim of this study was to evaluate the cost-utility of Collaborative Care (CC) for major depressive disorder compared to Care As Usual (CAU) in a primary health care setting from a societal perspective. METHODS A cluster randomized controlled trial was conducted, including 93 patients that were identified by screening (45-CC, 48-CAU). Another 57 patients were identified by the GP (56-CC, 1-CAU). The outcome measures were TiC-P, SF-HQL and EQ-5D, respectively measuring health care utilization, production losses and general health related quality of life at baseline three, six, nine and twelve months. A cost-utility analysis was performed for patients included by screening and a sensitivity analysis was done by also including patients identified by the GP. RESULTS The average annual total costs was €1131 (95% C.I., €-3158 to €750) lower for CC compared to CAU. The average quality of life years (QALYs) gained was 0.02 (95% C.I., -0.004 to 0.04) higher for CC, so CC was dominant from a societal perspective. Taking a health care perspective, CC was less cost-effective due to higher costs, €1173 (95% C.I., €-216 to €2726), of CC compared to CAU which led to an ICER of 53,717 Euro/QALY. The sensitivity analysis showed dominance of CC. CONCLUSION The cost-utility analysis from a societal perspective showed that CC was dominant to CAU. CC may be a promising treatment for depression in the primary care setting. Further research should explore the cost-effectiveness of long-term CC. TRIAL REGISTRATION Netherlands Trial Register ISRCTN15266438.
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Affiliation(s)
- Maartje Goorden
- Institute for Medical Technology Assessment, Institute of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.
| | - Klaas M L Huijbregts
- GGZinGeest, partner VU University Medical Center, Amsterdam, The Netherlands; Department of Psychiatry and the EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Harm W J van Marwijk
- Department of General Practice and the EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Aartjan T F Beekman
- GGZinGeest, partner VU University Medical Center, Amsterdam, The Netherlands; Department of Psychiatry and the EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - Christina M van der Feltz-Cornelis
- Department of Tranzo, University of Tilburg, Tilburg, The Netherlands; Topclinical Center for Body, Mind and Health Academic Psychiatry Department, GGZBreburg, Tilburg, The Netherlands
| | - Leona Hakkaart-van Roijen
- Institute for Medical Technology Assessment, Institute of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
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Wernher I, Bjerregaard F, Tinsel I, Bleich C, Boczor S, Kloppe T, Scherer M, Härter M, Niebling W, König HH, Hüll M. Collaborative treatment of late-life depression in primary care (GermanIMPACT): study protocol of a cluster-randomized controlled trial. Trials 2014; 15:351. [PMID: 25195020 PMCID: PMC4247596 DOI: 10.1186/1745-6215-15-351] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Accepted: 08/04/2014] [Indexed: 01/18/2023] Open
Abstract
Background Depression is not a normal side effect of aging, however it is one of the most prevalent mental health issues in later life, imposing a tremendous burden on patients, their families, and the healthcare system. We describe the experimental implementation of a collaborative, stepped-care model for the treatment of late-life depression (GermanIMPACT trial) in the German primary care context. GermanIMPACT was developed as an adaptation of a successful and widely used American model. The aim of the study is to evaluate the model’s applicability to the German primary care setting and its cost-effectiveness. Methods/Design The study will be conducted as a cluster-randomized controlled trial comparing the development of depressive symptoms in primary care patients who either receive treatment as usual (control arm) or treatment according to the GermanIMPACT model (intervention arm). In two German cities (Freiburg and Hamburg), a total of 60 general practice offices will be selected and randomized. Each general practice office will be asked to enroll five patients into the trial who are 60 years of age or older and who show moderate depressive symptoms in the scope of a diagnosed depressive episode, recurrent depressive disorder, or dysthymia. General practices in the control arm will provide treatment as usual; general practices in the intervention arm will work closely with a specially trained care manager and a supervising mental health specialist. Evidence-based elements of the treatment plan manual include patient education, identification and integration of positive activities into the daily routine, relapse prevention, and training of problem-solving techniques as needed. The intervention period per patient will be one year. Data will be collected at baseline, 6, and 12 months. Primary outcome is the patient-reported change of depressive symptoms (Patient Health Questionnaire, PHQ-9). Secondary outcomes include measures of quality of life, anxiety, depression-related behavior, problem-solving skills, resilience, and an overall economic evaluation of the program. Discussion The GermanIMPACT trial will provide evidence about the effectiveness, feasibility, and cost-effectiveness of collaborative stepped care in treating late-life depression in German primary care. Positive results will be a first step toward integrating specialized depression care managers into the primary care setting. Trial registration German Clinical Trials Register: DRKS00003589 (September 2012).
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Affiliation(s)
| | - Frederike Bjerregaard
- Division of Psychiatry and Psychotherapy, Psychotherapy and Health Services Research, University Medical Center Freiburg, Hauptstr, 5, 79104 Freiburg, Germany.
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Lee HS. The impact of emergency room utilization by depression patients on medical treatment expense in Korea. Osong Public Health Res Perspect 2013; 4:240-5. [PMID: 24298439 PMCID: PMC3845249 DOI: 10.1016/j.phrp.2013.09.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 09/02/2013] [Accepted: 09/03/2013] [Indexed: 11/24/2022] Open
Abstract
Objectives To investigate the determinants of total medical expense for depression patients admitted through the emergency room (ER). Methods Data were selected from the Korean National Health Insurance sample data for 2009. SPSS version 18 was used for the statistical analysis such as descriptive analysis, correlation analysis, and multiple regression analysis. Data included 1203 cases admitted through the ER with ICD-10 codes (F31–F39). Results In the multiple regression analysis, significant variables affecting total payment were gender (p < 0.001), age (p < 0.001), main illness (p < 0.001), course of admission to the ER (p < 0.05), and length of stay (p < 0.001). Conclusion It is necessary to build a long-term program and system for high-risk depression groups.
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Affiliation(s)
- Hyun Sook Lee
- Department of Health Administration, Yonsei University, Wonju, Korea
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11
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de Heer EW, Dekker J, van Eck van der Sluijs JF, Beekman ATF, van Marwijk HWJ, Holwerda TJ, Bet PM, Roth J, Hakkaart-Van Roijen L, Ringoir L, Kat F, van der Feltz-Cornelis CM. Effectiveness and cost-effectiveness of transmural collaborative care with consultation letter (TCCCL) and duloxetine for major depressive disorder (MDD) and (sub)chronic pain in collaboration with primary care: design of a randomized placebo-controlled multi-Centre trial: TCC:PAINDIP. BMC Psychiatry 2013; 13:147. [PMID: 23705849 PMCID: PMC3698098 DOI: 10.1186/1471-244x-13-147] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Accepted: 05/11/2013] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND The comorbidity of pain and depression is associated with high disease burden for patients in terms of disability, wellbeing, and use of medical care. Patients with major and minor depression often present themselves with pain to a general practitioner and recognition of depression in such cases is low, but evolving. Also, physical symptoms, including pain, in major depressive disorder, predict a poorer response to treatment. A multi-faceted, patient-tailored treatment programme, like collaborative care, is promising. However, treatment of chronic pain conditions in depressive patients has, so far, received limited attention in research. Cost effectiveness of an integrated approach of pain in depressed patients has not been studied. METHODS/DESIGN This study is a placebo controlled double blind, three armed randomized multi centre trial. Patients with (sub)chronic pain and a depressive disorder are randomized to either a) collaborative care with duloxetine, b) collaborative care with placebo or c) duloxetine alone. 189 completers are needed to attain sufficient power to show a clinically significant effect of 0.6 SD on the primary outcome measures (PHQ-9 score). Data on depression, anxiety, mental and physical health, medication adherence, medication tolerability, quality of life, patient-doctor relationship, coping, health resource use and productivity will be collected at baseline and after three, six, nine and twelve months. DISCUSSION This study enables us to show the value of a closely monitored integrated treatment model above usual pharmacological treatment. Furthermore, a comparison with a placebo arm enables us to evaluate effectiveness of duloxetine in this population in a real life setting. Also, this study will provide evidence-based treatments and tools for their implementation in practice. This will facilitate generalization and implementation of results of this study. Moreover, patients included in this study are screened for pain symptoms, differentiating between nociceptive and neuropathic pain. Therefore, pain relief can be thoroughly evaluated. TRIAL REGISTRATION NTR1089.
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Affiliation(s)
- Eric W de Heer
- Netherlands Institute of Mental Health and Addiction (Trimbos-institute), Utrecht, The Netherlands
- Tilburg School of Behavioral and Social Sciences, Tranzo Department, University of Tilburg, Tilburg, The Netherlands
- TopClinical Centre for Body, Mind and Health, GGz Breburg, Tilburg, The Netherlands
| | - Jack Dekker
- Arkin, Mental Health Institute, Amsterdam, The Netherlands
- Department of Clinical Psychology, VU University, Amsterdam, The Netherlands
| | - Jonna F van Eck van der Sluijs
- Tilburg School of Behavioral and Social Sciences, Tranzo Department, University of Tilburg, Tilburg, The Netherlands
- TopClinical Centre for Body, Mind and Health, GGz Breburg, Tilburg, The Netherlands
| | - Aartjan TF Beekman
- The EMGO Institute for health and care research (EMGO+), Amsterdam, The Netherlands
- Department of Psychiatry, VU University Medical Centre, Amsterdam, The Netherlands
- GGz inGeest, Mental Health Institute, Amsterdam, The Netherlands
| | - Harm WJ van Marwijk
- The EMGO Institute for health and care research (EMGO+), Amsterdam, The Netherlands
- Department of General Practice, VU University Medical Centre, Amsterdam, The Netherlands
| | | | - Pierre M Bet
- Department of Clinical Pharmacology and Pharmacy, VU University Medical Centre, Amsterdam, The Netherlands
| | - Joost Roth
- GGz inGeest, Mental Health Institute, Amsterdam, The Netherlands
| | | | - Lianne Ringoir
- Tilburg School of Behavioral and Social Sciences, Department of Medical Psychology, Tilburg University, Tilburg, The Netherlands
| | - Fiona Kat
- Arkin, Mental Health Institute, Amsterdam, The Netherlands
| | - Christina M van der Feltz-Cornelis
- Netherlands Institute of Mental Health and Addiction (Trimbos-institute), Utrecht, The Netherlands
- Tilburg School of Behavioral and Social Sciences, Tranzo Department, University of Tilburg, Tilburg, The Netherlands
- TopClinical Centre for Body, Mind and Health, GGz Breburg, Tilburg, The Netherlands
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12
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de Bont PAJM, van den Berg DPG, van der Vleugel BM, de Roos C, Mulder CL, Becker ES, de Jongh A, van der Gaag M, van Minnen A. A multi-site single blind clinical study to compare the effects of prolonged exposure, eye movement desensitization and reprocessing and waiting list on patients with a current diagnosis of psychosis and co morbid post traumatic stress disorder: study protocol for the randomized controlled trial Treating Trauma in Psychosis. Trials 2013; 14:151. [PMID: 23702050 PMCID: PMC3667059 DOI: 10.1186/1745-6215-14-151] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2012] [Accepted: 04/30/2013] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Trauma contributes to psychosis and in psychotic disorders post-traumatic stress disorder (PTSD) is often a comorbid disorder. A problem is that PTSD is underdiagnosed and undertreated in people with psychotic disorders. This study's primary goal is to examine the efficacy and safety of prolonged exposure and eye movement desensitization and reprocessing (EMDR) for PTSD in patients with both psychotic disorders and PTSD, as compared to a waiting list. Secondly, the effects of both treatments are determined on (a) symptoms of psychosis, in particular verbal hallucinations, (b) depression and social performance, and (c) economic costs. Thirdly, goals concern links between trauma exposure and psychotic symptomatology and the prevalence of exposure to traumatic events, and of PTSD. Fourthly predictors, moderators, and mediators for treatment success will be explored. These include cognitions and experiences concerning treatment harm, credibility and burden in both participants and therapists. METHODS/DESIGN A short PTSD-screener assesses the possible presence of PTSD in adult patients (21- to 65- years old) with psychotic disorders, while the Clinician Administered PTSD Scale interview will be used for the diagnosis of current PTSD. The M.I.N.I. Plus interview will be used for diagnosing lifetime psychotic disorders and mood disorders with psychotic features. The purpose is to include consenting participants (N = 240) in a multi-site single blind randomized clinical trial. Patients will be allocated to one of three treatment conditions (N = 80 each): prolonged exposure or EMDR (both consisting of eight weekly sessions of 90 minutes each) or a six-month waiting list. All participants are subjected to blind assessments at pre-treatment, two months post treatment, and six months post treatment. In addition, participants in the experimental conditions will have assessments at mid treatment and at 12 months follow-up. DISCUSSION The results from the post treatment measurement can be considered strong empirical indicators of the safety and effectiveness of prolonged exposure and EMDR. The six-month and twelve-month follow-up data have the potential of reliably providing documentation of the long-term effects of both treatments on the various outcome variables. Data from pre-treatment and midtreatment can be used to reveal possible pathways of change. TRIAL REGISTRATION Trial registration: ISRCTN79584912.
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Affiliation(s)
- Paul AJM de Bont
- Mental Health Organization (MHO) GGZ Oost Brabant Land van Cuijk en Noord Limburg, Bilderbeekstraat 44, Boxmeer, 5831 CX, The Netherlands
- Behavioural Science Institute, NijCare, Radboud University, Montessorilaan 3, P.O. Box 9104, Nijmegen, 6525 HR, The Netherlands
| | - David PG van den Berg
- Parnassia Psychiatric Institute, Prinsegracht 63, Den Haag, 2512 EX, The Netherlands
- Department of Clinical Psychology, VU University Amsterdam and EMGO Institute for Health and Care Research, Van der Boechorststraat 1, Amsterdam, 1081 BT, the Netherlands
| | - Berber M van der Vleugel
- Department of Clinical Psychology, VU University Amsterdam and EMGO Institute for Health and Care Research, Van der Boechorststraat 1, Amsterdam, 1081 BT, the Netherlands
- MHO GGZ Noord-Holland Noord, Oude Hoeverweg 10, Alkmaar, 1816 BT, The Netherlands
| | - Carlijn de Roos
- MHO Rivierduinen, Schuttersveld 9, P.O. Box 2211, Leiden, 2316 XG, the Netherlands
| | - Cornelis L Mulder
- Department of Psychiatry, and BavoEuropoort, University Medical Center Rotterdam, Dr. Molewaterplein 50, Rotterdam, 3015 GE, The Netherlands
| | - Eni S Becker
- Behavioural Science Institute, NijCare, Radboud University, Montessorilaan 3, P.O. Box 9104, Nijmegen, 6525 HR, The Netherlands
| | - Ad de Jongh
- Department of Behavioral Sciences, Academic Centre for Dentistry Amsterdam (ACTA), Gustav Mahler Laan 3004, Amsterdam, 1081 LA, The Netherlands
- Department of Behavioral Sciences, Academic Centre for Dentistry Amsterdam (ACTA), VU University Amsterdam, Gustav Mahler Laan 3004, Amsterdam, 1081 LA, The Netherlands
- School of Health Sciences, Salford University, The Crescent, Salford, M5 4WT, United Kingdom
| | - Mark van der Gaag
- Parnassia Psychiatric Institute, Prinsegracht 63, Den Haag, 2512 EX, The Netherlands
- Department of Clinical Psychology, VU University Amsterdam and EMGO Institute for Health and Care Research, Van der Boechorststraat 1, Amsterdam, 1081 BT, the Netherlands
| | - Agnes van Minnen
- Behavioural Science Institute, NijCare, Radboud University, Montessorilaan 3, P.O. Box 9104, Nijmegen, 6525 HR, The Netherlands
- MHO ‘Pro Persona’, Centre for Anxiety Disorders Overwaal, Pastoor van Laakstraat 48, 6663 CB, Lent, The Netherlands
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13
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van Emmerik–van Oortmerssen K, Vedel E, Koeter MW, de Bruijn K, Dekker JJM, van den Brink W, Schoevers RA. Investigating the efficacy of integrated cognitive behavioral therapy for adult treatment seeking substance use disorder patients with comorbid ADHD: study protocol of a randomized controlled trial. BMC Psychiatry 2013; 13:132. [PMID: 23663651 PMCID: PMC3659028 DOI: 10.1186/1471-244x-13-132] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Accepted: 04/24/2013] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Attention deficit hyperactivity disorder (ADHD) frequently co-occurs with substance use disorders (SUD). The combination of ADHD and SUD is associated with a negative prognosis of both SUD and ADHD. Pharmacological treatments of comorbid ADHD in adult patients with SUD have not been very successful. Recent studies show positive effects of cognitive behavioral therapy (CBT) in ADHD patients without SUD, but CBT has not been studied in ADHD patients with comorbid SUD. METHODS/DESIGN This paper presents the protocol of a randomized controlled trial to test the efficacy of an integrated CBT protocol aimed at reducing SUD as well as ADHD symptoms in SUD patients with a comorbid diagnosis of ADHD. The experimental group receives 15 CBT sessions directed at symptom reduction of SUD as well as ADHD. The control group receives treatment as usual, i.e. 10 CBT sessions directed at symptom reduction of SUD only. The primary outcome is the level of self-reported ADHD symptoms. Secondary outcomes include measures of substance use, depression and anxiety, quality of life, health care consumption and neuropsychological functions. DISCUSSION This is the first randomized controlled trial to test the efficacy of an integrated CBT protocol for adult SUD patients with a comorbid diagnosis of ADHD. The rationale for the trial, the design, and the strengths and limitations of the study are discussed.
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Affiliation(s)
- Katelijne van Emmerik–van Oortmerssen
- Arkin Mental Health Care and Addiction Treatment Center, Amsterdam, The Netherlands,Jellinek Substance Abuse Treatment Center, Amsterdam, The Netherlands,Amsterdam Institute for Addiction Research, Department of Psychiatry, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands,Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ellen Vedel
- Arkin Mental Health Care and Addiction Treatment Center, Amsterdam, The Netherlands,Jellinek Substance Abuse Treatment Center, Amsterdam, The Netherlands
| | - Maarten W Koeter
- Amsterdam Institute for Addiction Research, Department of Psychiatry, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Kim de Bruijn
- Arkin Mental Health Care and Addiction Treatment Center, Amsterdam, The Netherlands,Jellinek Substance Abuse Treatment Center, Amsterdam, The Netherlands
| | - Jack J M Dekker
- Arkin Mental Health Care and Addiction Treatment Center, Amsterdam, The Netherlands
| | - Wim van den Brink
- Amsterdam Institute for Addiction Research, Department of Psychiatry, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Robert A Schoevers
- Department of Psychiatry, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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14
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Arean PA. Personalizing behavioral interventions: the case of late-life depression. ACTA ACUST UNITED AC 2013; 2:135-145. [PMID: 23646065 DOI: 10.2217/npy.12.15] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
This article reviews the potential utility of behavioral interventions in personalized depression treatment. The paper begins with a definition of personalized treatment, moves to current thinking regarding the various causes of depression, and proposes how those causes can be used to inform the selection of behavioral interventions. Two examples from the late-life depression field will illustrate how a team of researchers at Cornell University (NY, USA) and University of California, San Francisco (CA, USA) created a research partnership to select and study behavioral interventions for older adults with risk factors associated with poor response to selective serotonin reuptake inhibitor medications. The paper ends with a discussion of how the process used by the Cornell University-University of California, San Francisco team can be applied to the selection and development of behavioral interventions for other psychiatric disorders.
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Affiliation(s)
- Patricia A Arean
- University of California, San Francisco, 401 Parnassus Avenue, San Francisco, CA 94143, USA
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15
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A target-driven collaborative care model for Major Depressive Disorder is effective in primary care in the Netherlands. A randomized clinical trial from the depression initiative. J Affect Disord 2013; 146:328-37. [PMID: 23068021 DOI: 10.1016/j.jad.2012.09.015] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2012] [Revised: 09/12/2012] [Accepted: 09/15/2012] [Indexed: 11/22/2022]
Abstract
BACKGROUND Practice variation in the primary care treatment of depression may be considerable in the Netherlands, due to relatively small and unregulated practices. We adapted the collaborative care model for the treatment of Major Depressive Disorder (MDD) to accommodate existing practice variation and tested whether this had added value over Care as Usual (CAU). METHODS A cluster randomized controlled trial was conducted to compare an adapted target driven collaborative care model with Care as Usual (CAU). Randomization was at the level of 18 (sub)urban primary care centers. The care manager and GP were supported by a web-based tracking and decision aid system that advised targeted treatment actions to achieve rapid response and if possible remission, and that warned the consultant psychiatrist if such treatment advice was not followed up. Eligible patients had a score of 10 or higher on the PHQ9, and met diagnostic criteria for major depression at the subsequent MINI Neuropsychiatric interview. A total of 93 patients were identified by screening. They received either collaborative care (CC) or CAU. Another 56 patients received collaborative care after identification by the GP. The outcome measures were response to treatment (50% or greater reduction of the PHQ9-total score from baseline) at three, six, nine and twelve months, and remission (a score of 0-4 on the PHQ9 at follow-up). RESULTS Treatment response and remission in CAU were low. Collaborative care was more effective on achieving treatment response than CAU at three months for the total group of patients who received collaborative care [OR 5.2 ((1.41-16.09), NNT 2] and at nine months [OR 5.6 ((1.40-22.58)), NNT 3]. The effect was not statistically significant at 6 and 12 months. LIMITATIONS A relatively high percentage of patients (36.5%) did not return one or more follow-up questionnaires. There was no evidence for selective non response. CONCLUSIONS Our adapted target driven CC was considerably more effective than CAU for MDD in primary care in the Netherlands. The Numbers Needed To Treat (NNT) to achieve response in one additional patient were low (2-3), which suggest that introducing CC at a larger scale may be beneficial. The relatively large effects may be due to our focus on reducing practice variation through the introduction of easy to use web based tracking and decision aids. The findings are highly relevant for the application of the model in areas where practices tend to be small and for mixed healthcare systems such as in many countries in Europe. TRIAL REGISTRATION Dutch trial register ISRCTN15266438 (http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=820).
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16
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Huijbregts KML, de Jong FJ, van Marwijk HWJ, Beekman ATF, Adèr HJ, van der Feltz-Cornelis CM. A high physical symptom count reduces the effectiveness of treatment for depression, independently of chronic medical conditions. J Psychosom Res 2013; 74:179-85. [PMID: 23438706 DOI: 10.1016/j.jpsychores.2013.01.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2012] [Revised: 01/09/2013] [Accepted: 01/10/2013] [Indexed: 11/30/2022]
Abstract
AIM To assess to what extent a high physical symptom count influences the effect of treatment for major depressive disorder (MDD), and whether or not actual comorbid medical conditions explain this relationship. METHOD Secondary data-analysis on a cluster-randomized trial in primary care, comparing the effectiveness of collaborative care with care as usual (CAU). MDD was measured using the PHQ-9. The Physical Symptoms Questionnaire (PSQ) was filled out at baseline by 115 patients (77.2% of those who entered the trial). Multilevel logistic regression models were used to test whether a high physical symptom count predicted lack of response to treatment, adding interaction terms to test differential effects on collaborative care versus CAU. RESULTS A high physical symptom count negatively influenced the effect of both collaborative care and care as usual (no interaction). Specifically, a high physical symptom count predicted lack of response in both conditions at 3 (odds ratio=6.8), 6 (OR=4.1), and 9 months follow-up (OR=6.4). This was not explained by chronic physical illness. CONCLUSION In this RCT, patients with MDD accompanied by a high physical symptom count benefited less from treatment for MDD in primary care, regardless of the type of treatment (either collaborative care or CAU). This was not explained by the presence of comorbid medical conditions. Further research is needed to improve treatment for MDD accompanied by a high physical symptom count, although collaborative care for depression is still more effective than CAU for this group of patients. TRIAL REGISTRATION Dutch trial register ISRCTN15266438.
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Affiliation(s)
- Klaas M L Huijbregts
- Netherlands Institute of Mental Health and Addiction (Trimbos Institute), Utrecht, The Netherlands.
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17
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Archer J, Bower P, Gilbody S, Lovell K, Richards D, Gask L, Dickens C, Coventry P. Collaborative care for depression and anxiety problems. Cochrane Database Syst Rev 2012; 10:CD006525. [PMID: 23076925 DOI: 10.1002/14651858.cd006525.pub2] [Citation(s) in RCA: 465] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Common mental health problems, such as depression and anxiety, are estimated to affect up to 15% of the UK population at any one time, and health care systems worldwide need to implement interventions to reduce the impact and burden of these conditions. Collaborative care is a complex intervention based on chronic disease management models that may be effective in the management of these common mental health problems. OBJECTIVES To assess the effectiveness of collaborative care for patients with depression or anxiety. SEARCH METHODS We searched the following databases to February 2012: The Cochrane Collaboration Depression, Anxiety and Neurosis Group (CCDAN) trials registers (CCDANCTR-References and CCDANCTR-Studies) which include relevant randomised controlled trials (RCTs) from MEDLINE (1950 to present), EMBASE (1974 to present), PsycINFO (1967 to present) and the Cochrane Central Register of Controlled Trials (CENTRAL, all years); the World Health Organization (WHO) trials portal (ICTRP); ClinicalTrials.gov; and CINAHL (to November 2010 only). We screened the reference lists of reports of all included studies and published systematic reviews for reports of additional studies. SELECTION CRITERIA Randomised controlled trials (RCTs) of collaborative care for participants of all ages with depression or anxiety. DATA COLLECTION AND ANALYSIS Two independent researchers extracted data using a standardised data extraction sheet. Two independent researchers made 'Risk of bias' assessments using criteria from The Cochrane Collaboration. We combined continuous measures of outcome using standardised mean differences (SMDs) with 95% confidence intervals (CIs). We combined dichotomous measures using risk ratios (RRs) with 95% CIs. Sensitivity analyses tested the robustness of the results. MAIN RESULTS We included seventy-nine RCTs (including 90 relevant comparisons) involving 24,308 participants in the review. Studies varied in terms of risk of bias.The results of primary analyses demonstrated significantly greater improvement in depression outcomes for adults with depression treated with the collaborative care model in the short-term (SMD -0.34, 95% CI -0.41 to -0.27; RR 1.32, 95% CI 1.22 to 1.43), medium-term (SMD -0.28, 95% CI -0.41 to -0.15; RR 1.31, 95% CI 1.17 to 1.48), and long-term (SMD -0.35, 95% CI -0.46 to -0.24; RR 1.29, 95% CI 1.18 to 1.41). However, these significant benefits were not demonstrated into the very long-term (RR 1.12, 95% CI 0.98 to 1.27).The results also demonstrated significantly greater improvement in anxiety outcomes for adults with anxiety treated with the collaborative care model in the short-term (SMD -0.30, 95% CI -0.44 to -0.17; RR 1.50, 95% CI 1.21 to 1.87), medium-term (SMD -0.33, 95% CI -0.47 to -0.19; RR 1.41, 95% CI 1.18 to 1.69), and long-term (SMD -0.20, 95% CI -0.34 to -0.06; RR 1.26, 95% CI 1.11 to 1.42). No comparisons examined the effects of the intervention on anxiety outcomes in the very long-term.There was evidence of benefit in secondary outcomes including medication use, mental health quality of life, and patient satisfaction, although there was less evidence of benefit in physical quality of life. AUTHORS' CONCLUSIONS Collaborative care is associated with significant improvement in depression and anxiety outcomes compared with usual care, and represents a useful addition to clinical pathways for adult patients with depression and anxiety.
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Affiliation(s)
- Janine Archer
- School of Nursing, Midwifery and Social Work, The University of Manchester, Manchester, UK.
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18
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van der Lem R, van der Wee NJA, van Veen T, Zitman FG. Efficacy versus effectiveness: a direct comparison of the outcome of treatment for mild to moderate depression in randomized controlled trials and daily practice. PSYCHOTHERAPY AND PSYCHOSOMATICS 2012; 81:226-34. [PMID: 22584117 DOI: 10.1159/000330890] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Accepted: 07/17/2011] [Indexed: 11/19/2022]
Abstract
BACKGROUND Results from randomized controlled trials (RCTs) are considered to give the most reliable information on treatment outcome (efficacy). Yet, the generalizability of efficacy results to daily practice (effectiveness) might be diminished by the design of RCTs. The STAR*D trial approached daily practice as much as possible, but still has some properties of an RCT. In this study, we compare results from treatment of major depressive disorder (MDD) in routine clinical practice to those of RCTs and STAR*D. METHODS Effectiveness in routine clinical practice was compared with efficacy results from 15 meta-analyses on antidepressant, psychotherapeutic and combination treatment and results from STAR*D. Data on daily practice patients and treatments were derived from a routine outcome monitoring (ROM) system. Treatment outcome was defined as proportion of remitters (MADRS ≤10) and within-group effect size. RESULTS From ROM, 598 patients suffering from a MDD episode according to the MINI-plus were included. Remission percentages were lower in routine practice than in meta-analyses for all treatment modalities (32 vs.40-74%). Differences were less explicit for antidepressants (21 vs. 34-47%) than for individual psychotherapy (27 vs. 34-58%; effect size 0.85 vs. 1.71) and combination therapy (21 vs. 45-63%), since only 60% of the meta-analyses for antidepressants showed significant differences with ROM, while for psychotherapy and combination treatment almost all meta-analyses showed significant differences. No differences in effectiveness were found between routine practice and STAR*D (antidepressants 27 vs. 28%; individual psychotherapy 27 vs. 25%; combination treatment 21 vs. 23%, respectively). CONCLUSIONS Effectiveness of treatment for mild-to-moderate MDD in daily practice is similar to STAR*D and significantly lower than efficacy results from RCTs.
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Affiliation(s)
- Rosalind van der Lem
- Department of Psychiatry, Leiden University Medical Center/Rivierduinen, Leiden, The Netherlands.
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Berghöfer A, Hartwich A, Bauer M, Unützer J, Willich SN, Pfennig A. Efficacy of a systematic depression management program in high utilizers of primary care: a randomized trial. BMC Health Serv Res 2012; 12:298. [PMID: 22943609 PMCID: PMC3489593 DOI: 10.1186/1472-6963-12-298] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2012] [Accepted: 08/22/2012] [Indexed: 12/14/2022] Open
Abstract
Background Approximately 25% of so-called high utilizers of medical care are estimated to suffer from depression. A large proportion of these individuals remain undiagnosed and untreated. This study aims to examine the effects of a systematic screening and collaborative treatment program on depression severity in small primary care practices of the German outpatient health care system. Method High utilizers of primary care who screened positive for depressive symptoms on the Brief Psychiatric Health Questionnaire (B-PHQ) were further diagnosed using the DIA-X, a standardized diagnostic interview, performed by trained and supervised interviewers. Patients with major depression were randomized (cluster randomization by practice) to (a) a six-month treatment program of pharmacotherapy, standardized patient and provider education, and physician and patient counseling or (b) six months of usual medical care. All subjects were followed for a 12-month observation period using the 17-item Hamilton Depression Rating scale (HAMD-17) rated by the treating physicians and the B-PHQ-9 rated by the patients. Results A total of 63 high utilizer patients were included in the trial (17 male, 46 female), 19 randomized to intervention, 44 to usual care. The mean age was 49.7 (SD 13.8). Most patients had one or more somatic co-morbidities. There was no significant difference in response (defined as a decrease in the HAMD-17 sum score of at least 50%) after six months of treatment (50% vs. 42%, p = 0.961, all analyses adjusted for age) and after 12 months of treatment (83% vs. 54%, p = 0.282) between groups. Using patient self-rating assessments with the B-PHQ-9 questionnaire the intervention was superior to treatment as usual at six months (83% vs. 16%, p = 0.000). There was no significant difference in HAMD-17 depression severity at six months between the groups (10.5 (SD 7.6) vs. 12.3 (SD 7.8), p = 0.718), but a trend at 12 months (4.7 (SD 8.0) vs. 11.2 (SD 7.4), p = 0.083). Again, using B-PHQ-9 sum scores depression severity was significantly lower in the intervention group than in the treatment as usual group after six months (6.4 (SD 5.2) vs. 11.5 (SD 5.8), p = 0.020), but not at 12 months (7.9 (SD 8.7) vs. 9.0 (SD 5.2), p = 0.858). Conclusion A systematic collaborating treatment program for depression in high utilizers in primary care showed superiority to treatment as usual only in terms of patients´ self-assessment but not according to physicians´ assessment. The advance of the intervention group at 6 months was lost after 12 months of follow-up. Overall, positive results from similar trials in the US health care systems could not be confirmed in a German primary care setting.
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Affiliation(s)
- Anne Berghöfer
- Institute for Social Medicine, Epidemiology and Health Economics, Charité University Medical Center, Berlin, Germany.
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20
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van der Feltz-Cornelis CM, Sarchiapone M, Postuvan V, Volker D, Roskar S, Grum AT, Carli V, McDaid D, O'Connor R, Maxwell M, Ibelshäuser A, Van Audenhove C, Scheerder G, Sisask M, Gusmão R, Hegerl U. Best practice elements of multilevel suicide prevention strategies: a review of systematic reviews. CRISIS 2012; 32:319-33. [PMID: 21945840 PMCID: PMC3306243 DOI: 10.1027/0227-5910/a000109] [Citation(s) in RCA: 175] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background: Evidence-based best practices for incorporation
into an optimal multilevel intervention for suicide prevention should be
identifiable in the literature. Aims: To identify effective
interventions for the prevention of suicidal behavior. Methods:
Review of systematic reviews found in the Pubmed, Cochrane, and DARE databases.
Steps include risk-of-bias assessment, data extraction, summarization of best
practices, and identification of synergistic potentials of such practices in
multilevel approaches. Results: Six relevant systematic reviews
were found. Best practices identified as effective were as follows: training
general practitioners (GPs) to recognize and treat depression and suicidality,
improving accessibility of care for at-risk people, and restricting access to
means of suicide. Although no outcomes were reported for multilevel
interventions or for synergistic effects of multiple interventions applied
together, indirect support was found for possible synergies in particular
combinations of interventions within multilevel strategies.
Conclusions: A number of evidence-based best practices for
the prevention of suicide and suicide attempts were identified. Research is
needed on the nature and extent of potential synergistic effects of various
preventive activities within multilevel interventions.
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Aragonès E, Caballero A, Piñol JL, López-Cortacans G, Badia W, Hernández JM, Casaus P, Folch S, Basora J, Labad A. A randomized, controlled trial of disease management modules, including telepsychiatric care, for depression in rural primary care. BMC Public Health 2011; 7:253. [PMID: 17883845 PMCID: PMC2094706 DOI: 10.1186/1471-2458-7-253] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2007] [Accepted: 09/20/2007] [Indexed: 12/16/2022] Open
Abstract
Background Most depressed patients are attended at primary care. However, there are significant shortcomings in the diagnosis, management and outcomes of these patients. The aim of this study is to determine whether the implementation of a structured programme for managing depression will provide better health outcomes than usual management. Methods/Design Design: A cluster-randomized controlled trial involving two groups, one of which is the control group consisting of patients who are treated for depression in the usual way and the other is the intervention group consisting of patients on a structured programme for treating depression. Setting: 20 primary care centres in the province of Tarragona (Spain) Sample: 400 patients over 18 years of age who have experienced an episode of major depression (DSM-IV) and who need to initiate antidepressant treatment Intervention: A multi-component programme with clinical, educational and organisational procedures that includes training for the health care provider and evidence-based clinical guidelines. It also includes primary care nurses working as care-managers who provide educational and emotional support for the patients and who are responsible for active and systematic clinical monitoring. The programme aims to improve the primary care/specialized level interface. Measurements: The patients will be monitored by telephone interviews. The interviewer will not know which group the patient belongs to (blind trial). These interviews will be given at 0, 3, 6 and 12 months. Main variables: Severity of the depressive symptoms, response rate and remission rate. Analysis: Outcomes will be analyzed on an intent-to-treat basis and the unit of analysis will be the individual patient. This analysis will take into account the effect of study design on potential lack of independence between observations within the same cluster. Discussion The effectiveness of caring for depression in primary care can be improved by various strategies. The most effective models involve organisational changes and a greater role of nurses. However, these models are almost exclusively from the USA, and this randomized clinical trial will determine if this approach could be effective to improve the outcomes of depression in primary care in the Spanish health care system. Trial registration ISRCTN16384353
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Affiliation(s)
- Enric Aragonès
- Tarragona-Reus Primary Care Area, Catalan Health Institute, Spain
- Centre d'Atenció Primària de Constantí; Carrer dels Horts, 6. 43120 Constantí (Tarragona), Spain
| | | | - Josep Ll Piñol
- Tarragona-Reus Primary Care Area, Catalan Health Institute, Spain
| | | | - Waleska Badia
- Tarragona-Reus Primary Care Area, Catalan Health Institute, Spain
| | | | - Pilar Casaus
- University Psychiatric Hospital "Institut Pere Mata", Reus, Spain
| | - Sílvia Folch
- Tarragona-Reus Primary Care Area, Catalan Health Institute, Spain
| | - Josep Basora
- Tarragona-Reus Primary Care Area, Catalan Health Institute, Spain
| | - Antonio Labad
- University Psychiatric Hospital "Institut Pere Mata", Reus, Spain
- Unit of Psychiatry, Rovira i Virgili University, Reus, Spain
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van der Lem R, van der Wee NJA, van Veen T, Zitman FG. The generalizability of antidepressant efficacy trials to routine psychiatric out-patient practice. Psychol Med 2011; 41:1353-1363. [PMID: 21078225 DOI: 10.1017/s0033291710002175] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Generalizability of antidepressant efficacy trials (AETs) to daily practice is questioned because of their very stringent patient selection. This study aims to determine eligibility for AETs of out-patients suffering from major depression in a routine out-patient setting and investigates influence of eligibility on treatment outcome. METHOD Data collection (n = 1653) was performed through routine outcome monitoring by independent trained research nurses. The Mini-International Neuropsychiatric Interview Plus and the Dimensional Assessment of Personality Pathology, short Dutch version were used for diagnostic assessment and personality pathology screening. The Montgomery-Asberg Depression Rating Scale (MADRS) was used for assessment of baseline severity and treatment outcome. Eligibility was assessed by stepwise application of commonly used exclusion criteria. Influence of eligibility on treatment outcome was investigated in a subsample of the 1653 patients who had at least one follow-up assessment (n = 626). Eligible and non-eligible patients were compared on proportion of response (50% reduction) and remission on MADRS (MADRS ≤ 10). RESULTS Altogether, 17-25% of the patients were eligible for AETs. The most common reasons for exclusion would be 'not meeting minimum baseline severity' and 'presence of co-morbid Axis I disorder'. Eligible and non-eligible patients did not differ in treatment outcome. Only 'meeting the minimum baseline severity' is associated with remission. CONCLUSIONS The majority of 'real life' out-patients are not eligible for AETs. However, the influence of eligibility on treatment outcome seems to be small. This suggests that stringent patient selection by eligibility criteria is not the major reason for lack of generalizability of AETs. Exclusion of less severely depressed patients from the analyses resulted in better treatment outcome. Milder depression is highly prevalent in daily practice and more research into treatment effectiveness in milder depression is warranted.
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Affiliation(s)
- R van der Lem
- Leiden University Medical Center/Rivierduinen, Department of Psychiatry, Leiden, The Netherlands.
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Stringer B, van Meijel B, Koekkoek B, Kerkhof A, Beekman A. Collaborative Care for patients with severe borderline and NOS personality disorders: a comparative multiple case study on processes and outcomes. BMC Psychiatry 2011; 11:102. [PMID: 21699740 PMCID: PMC3135521 DOI: 10.1186/1471-244x-11-102] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2011] [Accepted: 06/24/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Structured psychotherapy is recommended as the preferred treatment of personality disorders. A substantial group of patients, however, has no access to these therapies or does not benefit. For those patients who have no (longer) access to psychotherapy a Collaborative Care Program (CCP) is developed. Collaborative Care originated in somatic health care to increase shared decision making and to enhance self management skills of chronic patients. Nurses have a prominent position in CCP's as they are responsible for optimal continuity and coordination of care. The aim of the CCP is to improve quality of life and self management skills, and reduce destructive behaviour and other manifestations of the personality disorder. METHODS/DESIGN Quantitative and qualitative data are combined in a comparative multiple case study. This makes it possible to test the feasibility of the CCP, and also provides insight into the preliminary outcomes of CCP. Two treatment conditions will be compared, one in which the CCP is provided, the other in which Care as Usual is offered. In both conditions 16 patients will be included. The perspectives of patients, their informal carers and nurses are integrated in this study. Data (questionnaires, documents, and interviews) will be collected among these three groups of participants. The process of treatment and care within both research conditions is described with qualitative research methods. Additional quantitative data provide insight in the preliminary results of the CCP compared to CAU. With a stepped analysis plan the 'black box' of the application of the program will be revealed in order to understand which characteristics and influencing factors are indicative for positive or negative outcomes. DISCUSSION The present study is, as to the best of our knowledge, the first to examine Collaborative Care for patients with severe personality disorders receiving outpatient mental health care. With the chosen design we want to examine how and which elements of the CC Program could contribute to a better quality of life for the patients. TRIAL REGISTRATION Netherlands Trial Register (NTR): NTR2763.
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Affiliation(s)
- Barbara Stringer
- Department of Psychiatry and EMGO institute, VU University Medical Center/GGZ inGeest, Amsterdam, the Netherlands
- Research Group Mental Health Nursing, Inholland University for Applied Sciences, Amsterdam, the Netherlands
| | - Berno van Meijel
- Research Group Mental Health Nursing, Inholland University for Applied Sciences, Amsterdam, the Netherlands
| | - Bauke Koekkoek
- Propersona, Centre for Education and Science, ProPersona, Wolfheze, the Netherlands
- Research Group Social Psychiatry & Mental Health Nursing, HAN University of Applied Science, Nijmegen, the Netherlands
| | - Ad Kerkhof
- Department of Clinical Psychology and EMGO institute, VU University Medical Center, Amsterdam, the Netherlands
| | - Aartjan Beekman
- Department of Psychiatry and EMGO institute, VU University Medical Center/GGZ inGeest, Amsterdam, the Netherlands
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Abstract
Background and problem statement Integrated care for mental disorders aims to encompass forms of collaboration between different health care settings for the treatment of mental disorders. To this end, it requires integration at several levels, i.e. integration of psychiatry in medicine, of the psychiatric discourse in the medical discourse; of localization of mental health care and general health care facilities; and of reimbursement systems. Description of policy practice Steps have been taken in the last decade to meet these requirements, enabling psychiatry to move on towards integrated treatment of mental disorder as such, by development of a collaborative care model that includes structural psychiatric consultation that was found to be applicable and effective in several Dutch health care settings. This collaborative care model is a feasible and effective model for integrated care in several health care settings. The Bio Psycho Social System has been developed as a feasible instrument for assessment in integrated care as well. Discussion The discipline of psychiatry has moved from anti-psychiatry in the last century, towards an emancipated medical discipline. This enabled big advances towards integrated care for mental disorder, in collaboration with other medical disciplines, in the last decade. Conclusion Now is the time to further expand this concept of care towards other mental disorders, and towards integrated care for medical and mental co-morbidity. Integrated care for mental disorder should be readily available to the patient, according to his/her preference, taking somatic co-morbidity into account, and with a focus on rehabilitation of the patient in his or her social roles.
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Richards DA, Suckling R. Improving access to psychological therapies: Phase IV prospective cohort study. BRITISH JOURNAL OF CLINICAL PSYCHOLOGY 2010; 48:377-96. [DOI: 10.1348/014466509x405178] [Citation(s) in RCA: 109] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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26
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Hetlevik Ø, Gjesdal S. Norwegian GPs' participation in multidisciplinary meetings: a register-based study from 2007. BMC Health Serv Res 2010; 10:309. [PMID: 21078187 PMCID: PMC2999607 DOI: 10.1186/1472-6963-10-309] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Accepted: 11/15/2010] [Indexed: 11/12/2022] Open
Abstract
Background An increasing number of patients with chronic disorders and a more complex health service demand greater interdisciplinary collaboration in Primary Health Care. The aim of this study was therefore to identify factors related to general practitioners (GPs), their list populations and practice municipalities associated with a high rate of GP participation in multidisciplinary meetings (MDMs). Methods A national cross-sectional register-based study of Norwegian general practice was conducted, including data on all GPs in the Regular GP Scheme in 2007 (N = 3179). GPs were grouped into quartiles based on the annual number of MDMs per patient on their list, and the groups were compared using one-way analysis of variance. Binary logistic regression was used to analyse associations between high rates of participation and characteristics of the GP, their list population and practice municipality. Results On average, GPs attended 30 MDMs per year. The majority of the meetings concerned patients in the age groups 20-59 years. Psychological disorders were the motivation for 53% of the meetings. In a multivariate logistic regression model, the following characteristics predicted a high rate of MDM attendance: younger age of the GP, with an OR of 1.6 (95% CI 1.2-2.1) for GPs < 45 years, a short patient list, with an OR of 4.9 (3.2-7.5) for list sizes below 800 compared to lists ≥ 1600, higher proportion of psychological diagnosis in consultations (OR3.4 (2.6-4.4)) and a high MDM proportion with elderly patients (OR 4.1 (3.3-5.4)). Practising in municipalities with less than 10,000 inhabitants (OR 3.7 (2.8-4.9)) and a high proportion of disability pensioners (OR 1.6 (1.2-2.2)) or patients receiving social assistance (OR 2.2 (1.7-2.8)) also predicted high rates of meetings. Conclusions Psychological problems including substance addiction gave grounds for the majority of MDMs. GPs with a high proportion of consultations with such problems also participated more frequently in MDMs. List size was negatively associated with the rate of MDMs, while a more disadvantaged list population was positively associated. Working in smaller organisational units seemed to facilitate cooperation between different professionals. There may be a generation shift towards more frequent participation in interdisciplinary work among younger GPs.
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Affiliation(s)
- Øystein Hetlevik
- Department of Public Health and Primary Health Care, University of Bergen, Kalfarveien 31, N-5018 Bergen, Norway.
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Gunn JM, Palmer VJ, Dowrick CF, Herrman HE, Griffiths FE, Kokanovic R, Blashki GA, Hegarty KL, Johnson CL, Potiriadis M, May CR. Embedding effective depression care: using theory for primary care organisational and systems change. Implement Sci 2010; 5:62. [PMID: 20687962 PMCID: PMC2925331 DOI: 10.1186/1748-5908-5-62] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Accepted: 08/06/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Depression and related disorders represent a significant part of general practitioners (GPs) daily work. Implementing the evidence about what works for depression care into routine practice presents a challenge for researchers and service designers. The emerging consensus is that the transfer of efficacious interventions into routine practice is strongly linked to how well the interventions are based upon theory and take into account the contextual factors of the setting into which they are to be transferred. We set out to develop a conceptual framework to guide change and the implementation of best practice depression care in the primary care setting. METHODS We used a mixed method, observational approach to gather data about routine depression care in a range of primary care settings via: audit of electronic health records; observation of routine clinical care; and structured, facilitated whole of organisation meetings. Audit data were summarised using simple descriptive statistics. Observational data were collected using field notes. Organisational meetings were audio taped and transcribed. All the data sets were grouped, by organisation, and considered as a whole case. Normalisation Process Theory (NPT) was identified as an analytical theory to guide the conceptual framework development. RESULTS Five privately owned primary care organisations (general practices) and one community health centre took part over the course of 18 months. We successfully developed a conceptual framework for implementing an effective model of depression care based on the four constructs of NPT: coherence, which proposes that depression work requires the conceptualisation of boundaries of who is depressed and who is not depressed and techniques for dealing with diffuseness; cognitive participation, which proposes that depression work requires engagement with a shared set of techniques that deal with depression as a health problem; collective action, which proposes that agreement is reached about how care is organised; and reflexive monitoring, which proposes that depression work requires agreement about how depression work will be monitored at the patient and practice level. We describe how these constructs can be used to guide the design and implementation of effective depression care in a way that can take account of contextual differences. CONCLUSIONS Ideas about what is required for an effective model and system of depression care in primary care need to be accompanied by theoretically informed frameworks that consider how these can be implemented. The conceptual framework we have presented can be used to guide organisational and system change to develop common language around each construct between policy makers, service users, professionals, and researchers. This shared understanding across groups is fundamental to the effective implementation of change in primary care for depression.
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Affiliation(s)
- Jane M Gunn
- Primary Care Research Unit, The Department of General Practice, School of Medicine, The University of Melbourne, Australia
| | - Victoria J Palmer
- Primary Care Research Unit, The Department of General Practice, School of Medicine, The University of Melbourne, Australia
| | - Christopher F Dowrick
- Department of Primary Care, School of Population, Community and Behavioural Sciences, University of Liverpool, Liverpool, UK
| | - Helen E Herrman
- Centre for Youth Mental Health, The University of Melbourne, Australia
| | - Frances E Griffiths
- Centre for Primary Health Care Studies, Warwick Medical School, University of Warwick, UK
| | - Renata Kokanovic
- Department of Sociology, School of Political and Social Enquiry, Monash University, Australia
| | - Grant A Blashki
- Nossal Institute for Global Health, The University of Melbourne, Australia
| | - Kelsey L Hegarty
- Primary Care Research Unit, The Department of General Practice, School of Medicine, The University of Melbourne, Australia
| | - Caroline L Johnson
- Primary Care Research Unit, The Department of General Practice, School of Medicine, The University of Melbourne, Australia
| | - Maria Potiriadis
- Primary Care Research Unit, The Department of General Practice, School of Medicine, The University of Melbourne, Australia
| | - Carl R May
- Institute of Health and Society, Newcastle University, UK
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Richards DA, Hughes-Morley A, Hayes RA, Araya R, Barkham M, Bland JM, Bower P, Cape J, Chew-Graham CA, Gask L, Gilbody S, Green C, Kessler D, Lewis G, Lovell K, Manning C, Pilling S. Collaborative Depression Trial (CADET): multi-centre randomised controlled trial of collaborative care for depression--study protocol. BMC Health Serv Res 2009; 9:188. [PMID: 19832996 PMCID: PMC2770465 DOI: 10.1186/1472-6963-9-188] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2009] [Accepted: 10/16/2009] [Indexed: 01/17/2023] Open
Abstract
Background Comprising of both organisational and patient level components, collaborative care is a potentially powerful intervention for improving depression treatment in UK primary Care. However, as previous models have been developed and evaluated in the United States, it is necessary to establish the effect of collaborative care in the UK in order to determine whether this innovative treatment model can replicate benefits for patients outside the US. This Phase III trial was preceded by a Phase II patient level RCT, following the MRC Complex Intervention Framework. Methods/Design A multi-centre controlled trial with cluster-randomised allocation of GP practices. GP practices will be randomised to usual care control or to "collaborative care" - a combination of case manager coordinated support and brief psychological treatment, enhanced specialist and GP communication. The primary outcome will be symptoms of depression as assessed by the PHQ-9. Discussion If collaborative care is demonstrated to be effective we will have evidence to enable the NHS to substantially improve the organisation of depressed patients in primary care, and to assist primary care providers to deliver a model of enhanced depression care which is both effective and acceptable to patients. Trial Registration Number ISRCTN32829227
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Affiliation(s)
- David A Richards
- Mood Disorders Centre, School of Psychology, University of Exeter, EX4 4QG, UK.
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The TrueBlue study: is practice nurse-led collaborative care effective in the management of depression for patients with heart disease or diabetes? BMC FAMILY PRACTICE 2009; 10:46. [PMID: 19545446 PMCID: PMC2714499 DOI: 10.1186/1471-2296-10-46] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/25/2009] [Accepted: 06/23/2009] [Indexed: 11/10/2022]
Abstract
Background In the presence of type 2 diabetes (T2DM) or coronary heart disease (CHD), depression is under diagnosed and under treated despite being associated with worse clinical outcomes. Our earlier pilot study demonstrated that it was feasible, acceptable and affordable for practice nurses to extend their role to include screening for and monitoring of depression alongside biological and lifestyle risk factors. The current study will compare the clinical outcomes of our model of practice nurse-led collaborative care with usual care for patients with depression and T2DM or CHD. Methods This is a cluster-randomised intervention trial. Eighteen general practices from regional and metropolitan areas agreed to join this study, and were allocated randomly to an intervention or control group. We aim to recruit 50 patients with co-morbid depression and diabetes or heart disease from each of these practices. In the intervention group, practice nurses (PNs) will be trained for their enhanced roles in this nurse-led collaborative care study. Patients will be invited to attend a practice nurse consultation every 3 months prior to seeing their usual general practitioner. The PN will assess psychological, physiological and lifestyle parameters then work with the patient to set management goals. The outcome of this assessment will form the basis of a GP Management Plan document. In the control group, the patients will continue to receive their usual care for the first six months of the study before the PNs undergo the training and switch to the intervention protocol. The primary clinical outcome will be a reduction in the depression score. The study will also measure the impact on physiological measures, quality of life and on patient attitude to health care delivered by practice nurses. Conclusion The strength of this programme is that it provides a sustainable model of chronic disease management with monitoring and self-management assistance for physiological, lifestyle and psychological risk factors for high-risk patients with co-morbid depression, diabetes or heart disease. The study will demonstrate whether nurse-led collaborative care achieves better outcomes than usual care.
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The Depression Initiative. Description of a collaborative care model for depression and of the factors influencing its implementation in the primary care setting in the Netherlands. Int J Integr Care 2009; 9:e81. [PMID: 19590761 PMCID: PMC2707588 DOI: 10.5334/ijic.313] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2008] [Revised: 02/06/2009] [Accepted: 02/19/2009] [Indexed: 12/04/2022] Open
Abstract
Background In the Depression Initiative, a promising collaborative care model for depression that was developed in the US was adapted for implementation in the Netherlands. Aim Description of a collaborative care model for major depressive disorder (MDD) and of the factors influencing its implementation in the primary care setting in the Netherlands. Data sources Data collected during the preparation phase of the CC:DIP trial of the Depression Initiative, literature, policy documents, information sheets from professional associations. Results Factors facilitating the implementation of the collaborative care model are continuous supervision of the care managers by the consultant psychiatrist and the trainers, a supportive web-based tracking system and the new reimbursement system that allows for introduction of a mental health care-practice nurse (MHC-PN) in the general practices and coverage of the treatment costs. Impeding factors might be the relatively high percentage of solo-primary care practices, the small percentage of professionals that are located in the same building, unfamiliarity with the concept of collaboration as required for collaborative care, the reimbursement system that demands regular negotiations between each health care provider and the insurance companies and the reluctance general practitioners might feel to expand their responsibility for their depressed patients. Conclusion Implementation of the collaborative care model in the Netherlands requires extensive training and supervision on micro level, facilitation of reimbursement on meso- and macro level and structural effort to change the treatment culture for chronic mental disorders in the primary care setting.
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Treatment of mental disorder in the primary care setting in the Netherlands in the light of the new reimbursement system: a challenge? Int J Integr Care 2008; 8:e56. [PMID: 18695748 PMCID: PMC2504701 DOI: 10.5334/ijic.249] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2007] [Revised: 03/24/2008] [Accepted: 04/28/2008] [Indexed: 11/20/2022] Open
Abstract
Introduction Different professionals provide health care for mental disorder in the primary care setting. In view of the changing reimbursement system in the Netherlands, information is needed on their specific expertise. Method This study attempts to describe this by literature study, by assessment of expert opinions, and by consulting Associations of the relevant professions. Results There is no clear differentiation of expertise and tasks amongst these professionals in primary care. Notably, distinction between different psychotherapeutic treatment modes provided by psychologists is unclear. Discussion Research is needed to assess actual treatment modules in correlation with patient diagnostic classification for the different professions in primary care. An alternative way of classifying patients, that takes into account not only mental disorder or problems but especially the level of functioning, is proposed to discern which patients can be treated in primary care, and which patients should not. Integrated care models are promising, because many professionals can be involved in treatment of mental disorder in the primary care setting; especially for collaborative care models, evidence favours the treatment of common mental disorders in this setting. Conclusion Integrated care models, such as collaborative care, provide a basis for multidisciplinary care for mental disorder in the primary care setting. Professional responsibilities should be clearly differentiated in order to facilitate integrated care. The level of functioning of patients with mental disorder can be used as indication criterion for treatment in the primary care setting or in Mental Health Institutions. Research to establish the feasibility of this model is needed.
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Vlasveld MC, Anema JR, Beekman ATF, van Mechelen W, Hoedeman R, van Marwijk HWJ, Rutten FF, Roijen LHV, Feltz-Cornelis CMVD. Multidisciplinary collaborative care for depressive disorder in the occupational health setting: design of a randomised controlled trial and cost-effectiveness study. BMC Health Serv Res 2008; 8:99. [PMID: 18457589 PMCID: PMC2390533 DOI: 10.1186/1472-6963-8-99] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2008] [Accepted: 05/05/2008] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Major depressive disorder (MDD) has major consequences for both patients and society, particularly in terms of needlessly long sick leave and reduced functioning. Although evidence-based treatments for MDD are available, they show disappointing results when implemented in daily practice. A focus on work is also lacking in the treatment of depressive disorder as well as communication of general practitioners (GPs) and other health care professionals with occupational physicians (OPs). The OP may play a more important role in the recovery of patients with MDD. Purpose of the present study is to tackle these obstacles by applying a collaborative care model, which has proven to be effective in the USA, with a focus on return to work (RTW). From a societal perspective, the (cost)effectiveness of this collaborative care treatment, as a way of transmural care, will be evaluated in depressed patients on sick leave in the occupational health setting. METHODS/DESIGN A randomised controlled trial in which the treatment of MDD in the occupational health setting will be evaluated in the Netherlands. A transmural collaborative care model, including Problem Solving Treatment (PST), a workplace intervention, antidepressant medication and manual guided self-help will be compared with care as usual (CAU). 126 Patients with MDD on sick leave between 4 and 12 weeks will be included in the study. Care in the intervention group will be provided by a multidisciplinary team of a trained OP-care manager and a consultant psychiatrist. The treatment is separated from the sickness certification. Data will be collected by means of questionnaires at baseline and at 3, 6, 9 and 12 months after baseline. Primary outcome measure is reduction of depressive symptoms, secondary outcome measure is time to RTW, tertiary outcome measure is the cost effectiveness. DISCUSSION The high burden of MDD and the high level of sickness absence among people with MDD contribute to the relevance of this study. The intervention is an innovative approach, with trained OPs in a new role as care managers in the treatment of MDD. If this intervention proves to be cost-effective, implementation will be very relevant for individual patients as well as for society. TRIAL REGISTRATION ISRCTN78462860.
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Affiliation(s)
- Moniek C Vlasveld
- Netherlands Institute of Mental Health and Addiction (Trimbos-institute), Utrecht, The Netherlands
- EMGO Institute, VU University Medical Centre, Amsterdam, The Netherlands
- Department of Public and Occupational Health, VU University Medical Centre, The Netherlands
| | - Johannes R Anema
- EMGO Institute, VU University Medical Centre, Amsterdam, The Netherlands
- Department of Public and Occupational Health, VU University Medical Centre, The Netherlands
- Body@Work, Research Centre Physical Activity, Work and Health, TNO-VU, Amsterdam, The Netherlands
- Research Centre for Insurance Medicine AMC-UWV-VU University Medical Centre, Amsterdam, The Netherlands
| | - Aartjan TF Beekman
- EMGO Institute, VU University Medical Centre, Amsterdam, The Netherlands
- Department of Psychiatry, VU University Medical Centre, Amsterdam, The Netherlands
| | - Willem van Mechelen
- EMGO Institute, VU University Medical Centre, Amsterdam, The Netherlands
- Department of Public and Occupational Health, VU University Medical Centre, The Netherlands
- Body@Work, Research Centre Physical Activity, Work and Health, TNO-VU, Amsterdam, The Netherlands
- Research Centre for Insurance Medicine AMC-UWV-VU University Medical Centre, Amsterdam, The Netherlands
| | - Rob Hoedeman
- ArboNed Utrecht, The Netherlands
- University Medical Centre Groningen, University of Groningen, The Netherlands
| | - Harm WJ van Marwijk
- EMGO Institute, VU University Medical Centre, Amsterdam, The Netherlands
- Department of General Practice, VU University Medical Centre, Amsterdam, The Netherlands
| | - Frans F Rutten
- institute for Medical Technology Assessment, Erasmus University, Rotterdam, The Netherlands
| | | | - Christina M van der Feltz-Cornelis
- Netherlands Institute of Mental Health and Addiction (Trimbos-institute), Utrecht, The Netherlands
- EMGO Institute, VU University Medical Centre, Amsterdam, The Netherlands
- Department of Psychiatry, VU University Medical Centre, Amsterdam, The Netherlands
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