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Sylvia LG, Tovey RE, Katz D, Boccagno C, Stromberg AR, Peters AT, Temes CM, Gold AK, Mow J, Puvanich N, Albury EA, Stephan NJ, Faria CM, Nierenberg AA, Kamali MP. A New Treatment Program: Focused Integrated Team-based Treatment Program for Bipolar Disorder (FITT-BD). J Psychiatr Pract 2023; 29:176-188. [PMID: 37185884 DOI: 10.1097/pra.0000000000000703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
OBJECTIVE Bipolar disorder (BD) is complicated by a dynamic, chronic course along with multiple comorbid psychiatric and medical conditions, making it challenging for clinicians to treat and patients to thrive. To efficiently manage the complexity of BD and help patients recover, we developed a Focused Integrated Team-based Treatment Program for Bipolar Disorder (FITT-BD). The purpose of this paper is to describe how we developed this clinic and the lessons we learned. METHODS We developed FITT-BD by integrating strategies from stepped care, collaborative care, and learning health care systems. We describe the rationale, details, and lessons learned in developing FITT-BD. RESULTS By integrating stepped care, collaborative care, and a learning health care system approach, FITT-BD aims to reduce barriers to care, leverage the expertise of a multidisciplinary treatment team, ensure patient-centeredness, and use assessments to inform and continuously improve outcomes in real time. We learned that there are challenges in the creation of a web-based application that tracks the treatment of patients within a network of hospitals. CONCLUSIONS The success of FITT-BD will be determined by the degree to which it can increase treatment access, improve treatment adherence, and help individuals with BD achieve their treatment goals. We expect that FITT-BD will improve outcomes in the context of ongoing clinical care. PUBLIC HEALTH SIGNIFICANCE The treatment of BD is challenging and complex. We propose a new treatment model for BD: FITT-BD. We expect that this program will be a patient-centered approach that improves outcomes in the context of ongoing clinical care for patients with BD.
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Berger M, Fernando S, Churchill A, Cornish P, Henderson J, Shah J, Tee K, Salmon A. Scoping review of stepped care interventions for mental health and substance use service delivery to youth and young adults. Early Interv Psychiatry 2022; 16:327-341. [PMID: 34018335 PMCID: PMC9292436 DOI: 10.1111/eip.13180] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 04/21/2021] [Accepted: 05/05/2021] [Indexed: 11/28/2022]
Abstract
AIMS Many young people with mental health and/or substance use concerns do not have access to timely, appropriate, and effective services. Within this context, stepped care models (SCMs) have emerged as a guiding framework for care delivery, inspiring service innovations across the globe. However, substantial gaps remain in the evidence for SCMs as a strategy to address the current systemic challenges in delivering services for young people. This scoping review aims to identify where these gaps in evidence exist, and the next steps for addressing them. METHODS A scoping review was conducted involving both peer-reviewed and grey literature. Eligible studies explored SCMs implemented in the various health care settings accessed by young people aged 12-24 seeking treatment for mental health and substance use challenges. After screening titles and abstracts, two reviewers examined full-text articles and extracted data to create a descriptive summary of the models. RESULTS Of the 656 studies that were retrieved, 51 studies were included and grouped by study team for a final yield of 43 studies. Almost half of the studies were focused on the adult population (i.e., 18 and over), and most did not specify interventions for young people. Among the SCMs, substantial variability was found in almost every aspect of the models. CONCLUSIONS Considering the current body of evidence, there is an urgent need for a consensus position on the definition, implementation, and outcome measures required for rigorously assessing the utility of SCMs for young people.
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Affiliation(s)
- Mai Berger
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - Saranee Fernando
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - AnnMarie Churchill
- Student Wellness and Counseling Centre, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Peter Cornish
- Director of Counseling and Psychological Services, University of California, Berkeley, Berkeley, California, USA.,Honorary Research Professor, Memorial University of Newfoundland, St. John's, Newfoundland and Labrador, Canada
| | - Joanna Henderson
- Margaret and Wallace McCain Centre for Child, Youth and Family Mental Health, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.,Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Jai Shah
- Prevention and Early Intervention Program for Psychosis (PEPP-Montreal), Douglas Mental Health University Institute, Montreal, Quebec, Canada.,ACCESS Open Minds, Douglas Mental Health University Institute, Montreal, Quebec, Canada.,Department of Psychiatry, McGill University, Montreal, Quebec, Canada
| | - Karen Tee
- Foundry, Vancouver, British Columbia, Canada
| | - Amy Salmon
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada.,School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
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Sam JM, Ismail SIF, Tan KA, Sidik SM, Osman ZJ. Evaluating the Change Process of a Brief Cognitive Behavior Therapy Workshop for Psychological Distress Among Primary Care Self-Referrals in Selangor, Malaysia. Front Psychiatry 2022; 13:848094. [PMID: 35757226 PMCID: PMC9231521 DOI: 10.3389/fpsyt.2022.848094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 03/29/2022] [Indexed: 11/13/2022] Open
Abstract
Despite the high prevalence of psychological distress in primary care, only a limited number of individuals can benefit from early and evidenced-based psychological approach. Barriers to help-seeking attributable to stigma, lack of proper care pathway to evidence-based psychological interventions, and a high volume of primary care attendees are among the factors that contribute to the inadequate psychological treatments. This study examined the implementation of a change process using a brief cognitive behavioral therapy (b-CBT) workshop as a potential approach in managing psychological distress among 73 primary care self-referrals using purposive sampling. One-way repeated-measures multivariate analysis of variance (ANOVA) was used to analyze changes in psychological distress within a non-randomized quasi-experimental study. Results revealed significant differences in psychological distress using Depression, Anxiety, and Stress Scale-21 items at three time points (pre-intervention, post-intervention, and 1-month follow-up). Implementation of the b-CBT workshop showed positive changes for psychological distress, suggesting the possibility of integrating brief, non-stigmatized, and evidence-based psychological approach at the primary care level. However, the self-referral characteristics of the attendees remain unknown. Factors such as potential feasibility, participant's usability and satisfaction, and implementation of b-CBT workshop to improve psychological distress are discussed in this study.
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Affiliation(s)
- Jeng Mun Sam
- Department of Psychiatry, Faculty of Medical and Health Sciences, Universiti Putra Malaysia, Seri Kembangan, Malaysia
| | - Siti Irma Fadhilah Ismail
- Department of Psychiatry, Faculty of Medical and Health Sciences, Universiti Putra Malaysia, Seri Kembangan, Malaysia
| | - Kit-Aun Tan
- Department of Psychiatry, Faculty of Medical and Health Sciences, Universiti Putra Malaysia, Seri Kembangan, Malaysia
| | - Sherina Mohd Sidik
- Department of Psychiatry, Faculty of Medical and Health Sciences, Universiti Putra Malaysia, Seri Kembangan, Malaysia
| | - Zubaidah Jamil Osman
- Department of Medicine, International Medical School, Universiti Putra Malaysia, Seri Kembangan, Malaysia
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Trombka M, Creedon TB, Demarzo M, Cuoco LT, Smith L, Oxnard AC, Rozembaque AT, Hirayama MS, Moreno NB, Comeau A, Gawande R, Griswold T, Cook BL, Rocha NS, Schuman-Olivier Z. Mindfulness Training for Primary Care for Portuguese-Speaking Immigrants: A Pilot Study. Front Psychiatry 2021; 12:664381. [PMID: 34566708 PMCID: PMC8458702 DOI: 10.3389/fpsyt.2021.664381] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 08/04/2021] [Indexed: 11/24/2022] Open
Abstract
Background: Portuguese-speaking immigrants are a growing underserved population in the Unites States who experience high levels of psychological distress and increased vulnerability to mental health disorders such as depression and anxiety. Current evidence shows that mindfulness-based interventions (MBIs) are effective to promote physical and mental health among educated English speakers; nonetheless, the lack of diversity in the mindfulness literature is a considerable limitation. To our knowledge, the feasibility and acceptability of MBIs among Portuguese-speaking immigrants have not yet been investigated. Methods: This single-arm pilot study (N = 30) explored the feasibility, acceptability, and cultural aspects of Mindfulness Training for Primary Care (MTPC)-Portuguese among Portuguese-speaking immigrants in the Boston area. MTPC is an 8-week, primary care-adapted, referral-based, insurance-reimbursable, trauma-informed MBI that is fully integrated into a healthcare system. The study also examined intervention preliminary effectiveness on mental health outcomes (depression and anxiety symptoms) and self-regulation (emotional regulation, mindfulness, self-compassion, interoceptive awareness), and initiation of health behavior was explored. Results: Primary care providers referred 129 patients from 2018 to 2020. Main DSM-5 primary diagnoses were depression (76.3%) and anxiety disorders (6.7%). Participants (N = 30) attended a mean of 6.1 (SD 1.92) sessions and reported a mean of 213.7 (SD = 124.3) min of practice per week. All survey finishers would recommend the program to a friend, found the program helpful, and rated the overall program as "very good" or "excellent," and 93% would participate again, with satisfaction mean scores between 4.6 and 5 (Likert scale 0-5). Participants and group leaders provided feedback to refine MTPC-Portuguese culturally responsiveness regarding materials language, settings, time, food, and community building. Patients exhibited reductions in depression (d = 0.67; p < 0.001) and anxiety (d = 0.48; p = 0.011) symptoms, as well as enhanced emotional regulation (d = 0.45; p = 0.009), and among survey finishers, 50% initiated health behavior change through action plan initiation. Conclusion: This pilot study suggests that MTPC-Portuguese is feasible, acceptable, and culturally appropriate among Portuguese-speaking patients in the Boston area. Furthermore, the intervention might potentially decrease depression and anxiety symptoms, facilitate health behavior change, and improve emotional regulation. MTPC-Portuguese investigation with larger samples in controlled studies is warranted to support its dissemination and implementation in the healthcare system. Clinical Trial Registration: Identifier: NCT04268355.
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Affiliation(s)
- Marcelo Trombka
- Postgraduate Program in Psychiatry and Behavioral Sciences, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Department of Psychiatry–Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Innovations and Interventions for Quality of Life Research Group, Porto Alegre, Brazil
- Clinical Research Center–Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Cambridge Health Alliance, Center for Mindfulness and Compassion, Cambridge, MA, United States
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Timothy B. Creedon
- Cambridge Health Alliance, Health Equity Research Lab, Cambridge, MA, United States
| | - Marcelo Demarzo
- Department of Preventive Medicine, Mente Aberta–Brazilian Center for Mindfulness and Health Promotion, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Letícia T. Cuoco
- Cambridge Health Alliance, Center for Mindfulness and Compassion, Cambridge, MA, United States
| | - Lydia Smith
- Cambridge Health Alliance, Center for Mindfulness and Compassion, Cambridge, MA, United States
| | - Alexandra C. Oxnard
- Cambridge Health Alliance, Center for Mindfulness and Compassion, Cambridge, MA, United States
| | - Alana T. Rozembaque
- Cambridge Health Alliance, Center for Mindfulness and Compassion, Cambridge, MA, United States
| | - Marcio S. Hirayama
- Mente Aberta—Brazilian Center for Mindfulness and Health Promotion, Federal University of São Paulo (UNIFESP), São Paulo, Brazil
| | - Natalia B. Moreno
- Cambridge Health Alliance, Center for Mindfulness and Compassion, Cambridge, MA, United States
| | - Alexandra Comeau
- Cambridge Health Alliance, Center for Mindfulness and Compassion, Cambridge, MA, United States
| | - Richa Gawande
- Cambridge Health Alliance, Center for Mindfulness and Compassion, Cambridge, MA, United States
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Todd Griswold
- Cambridge Health Alliance, Center for Mindfulness and Compassion, Cambridge, MA, United States
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Benjamin L. Cook
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States
- Cambridge Health Alliance, Health Equity Research Lab, Cambridge, MA, United States
| | - Neusa S. Rocha
- Postgraduate Program in Psychiatry and Behavioral Sciences, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
- Department of Psychiatry–Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
- Innovations and Interventions for Quality of Life Research Group, Porto Alegre, Brazil
- Clinical Research Center–Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
| | - Zev Schuman-Olivier
- Cambridge Health Alliance, Center for Mindfulness and Compassion, Cambridge, MA, United States
- Department of Psychiatry, Harvard Medical School, Boston, MA, United States
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Huxley E, Lewis KL, Coates AD, Borg WM, Miller CE, Townsend ML, Grenyer BFS. Evaluation of a brief intervention within a stepped care whole of service model for personality disorder. BMC Psychiatry 2019; 19:341. [PMID: 31694681 PMCID: PMC6836372 DOI: 10.1186/s12888-019-2308-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 09/30/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although there is growing evidence that stepped models of care are useful for providing appropriate, person centered care, there are very few studies applied to personality disorders. A brief, four session, psychological treatment intervention for personality disorder within a whole of service stepped care model was evaluated. The intervention stepped between acute emergency crisis mental health services and longer-term outpatient treatments. METHODS Study 1 used service utilization data from 191 individuals referred to the brief intervention at a single community health site in a metropolitan health service. Proportions of individuals retained across the intervention and the referral pathways accessed following the intervention were examined. Study 2 examined 67 individuals referred to the brief intervention across 4 different sites in metropolitan health services. A range of measures of symptoms and quality of life were administered at the first and last session of the intervention. Effect sizes were calculated to examine mean changes across the course of the intervention. RESULTS Study 1 found that 84.29% of individuals referred to the intervention attended at least 1 session, 60.21% attended 2 sessions or more and 41.89% attended 3 or more sessions. 13.61% of the sample required their care to be "stepped up" within the service, whereas 29.31% were referred to other treatment providers following referral to the intervention. Study 2 found a significant reduction in borderline personality disorder symptom severity and distress following the intervention, and an increase in quality of life. The largest reduction was found for suicidal ideation (d = 1.01). CONCLUSIONS Brief psychological intervention was a useful step between acute services and longer-term treatments in this stepped model of care for personality disorder. Suicide risk and symptom severity reduced and quality of life improved, with only a small proportion of individuals requiring ongoing support from the health service following the intervention.
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Affiliation(s)
- Elizabeth Huxley
- School of Psychology and Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, NSW, 2522, Australia
| | - Kate L Lewis
- School of Psychology and Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, NSW, 2522, Australia
| | - Adam D Coates
- South East Sydney Local Health District, Sydney, Australia
| | - Wayne M Borg
- South East Sydney Local Health District, Sydney, Australia
| | - Caitlin E Miller
- School of Psychology and Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, NSW, 2522, Australia
| | - Michelle L Townsend
- School of Psychology and Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, NSW, 2522, Australia
| | - Brin F S Grenyer
- School of Psychology and Illawarra Health and Medical Research Institute, University of Wollongong, Wollongong, NSW, 2522, Australia.
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Prevalence and Associated Factors of Mental Distress among Caregivers of Patients with Epilepsy in Ethiopia: A Cross-Sectional Study Design. PSYCHIATRY JOURNAL 2018; 2018:2819643. [PMID: 30363640 PMCID: PMC6180922 DOI: 10.1155/2018/2819643] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2018] [Accepted: 09/06/2018] [Indexed: 11/24/2022]
Abstract
Background Caregiving to individuals with mental illness is a broad responsibility, including not only practical help and care but also emotional support. Cross-sectional studies in different localities suggested a significant burden of mental distress among caregivers of patients with epilepsy, but we are not aware about the condition in Ethiopia. Therefore, the aim of the current study is to assess the prevalence and associated factors of mental distress among caregivers of patients with epilepsy in Ethiopia. Methods An institutional based cross-sectional study was conducted in Neuropsychiatric Department of Amanuel Mental Specialized Hospital, Addis Ababa, Ethiopia. Using systematic random sampling technique, 409 caregivers participated in the study. Data was collected by face to face interview using standardized and validated Kessler Psychological Distress Scale (K-10) to assess mental distress. Descriptive, bivariate, and multivariate logistic regression models were used for analysis. Adjusted Odd Ratio (AOR) with 95% Confidence Interval (CI) was used to show the odds, and P-value < 0.05 was considered as statistically significant. Results The mean age of respondents was 43.3 years with standard deviation of ±11.4 years. Two hundred eighteen (53.3%) of the respondents were male. The prevalence of mental distress was found to be 27.1% with 95% CI [22.6-31.1]. Relationship with patient of being mother [AOR: 5.67, 95% CI: (1.68-13.70)], father [AOR: 4.42, 95% CI: (1.25-12.58)], wife/husband [AOR: 10.59, 95% CI: (2.43-14.19)], and child [AOR: 5.37, 95% CI: (1.27-12.69)]; caring for young person below 20 years of age [AOR: 4.00, 95% CI: (1.43-11.21)]; poor social support [AOR: 7.26, 95% CI: (3.60-14.65)]); and experienced stigma [AOR: 3.03, 95% CI: (1.63-5.66)] were statistically and significantly associated factors of mental distress among caregivers of patients with epilepsy. Conclusion and Recommendation We found a lower prevalence of mental distress among caregivers of patients with epilepsy compared to other low- and middle-income settings. Being caring for young patients, being parents to the patient, poor social support, and stigma were statistically significant associated factors of mental distress among caregivers. Therefore, appropriate psychosocial interventions are warranted to be designed and implemented emphasizing the aforementioned associated factors.
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Smith SM, Cousins G, Clyne B, Allwright S, O'Dowd T. Shared care across the interface between primary and specialty care in management of long term conditions. Cochrane Database Syst Rev 2017; 2:CD004910. [PMID: 28230899 PMCID: PMC6473196 DOI: 10.1002/14651858.cd004910.pub3] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
BACKGROUND Shared care has been used in the management of many chronic conditions with the assumption that it delivers better care than primary or specialty care alone; however, little is known about the effectiveness of shared care. OBJECTIVES To determine the effectiveness of shared care health service interventions designed to improve the management of chronic disease across the primary/specialty care interface. This is an update of a previously published review.Secondary questions include the following:1. Which shared care interventions or portions of shared care interventions are most effective?2. What do the most effective systems have in common? SEARCH METHODS We searched MEDLINE, Embase and the Cochrane Library to 12 October 2015. SELECTION CRITERIA One review author performed the initial abstract screen; then two review authors independently screened and selected studies for inclusion. We considered randomised controlled trials (RCTs), non-randomised controlled trials (NRCTs), controlled before-after studies (CBAs) and interrupted time series analyses (ITS) evaluating the effectiveness of shared care interventions for people with chronic conditions in primary care and community settings. The intervention was compared with usual care in that setting. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data from the included studies, evaluated study quality and judged the certainty of the evidence using the GRADE approach. We conducted a meta-analysis of results when possible and carried out a narrative synthesis of the remainder of the results. We presented the results in a 'Summary of findings' table, using a tabular format to show effect sizes for all outcome types. MAIN RESULTS We identified 42 studies of shared care interventions for chronic disease management (N = 18,859), 39 of which were RCTs, two CBAs and one an NRCT. Of these 42 studies, 41 examined complex multi-faceted interventions and lasted from six to 24 months. Overall, our confidence in results regarding the effectiveness of interventions ranged from moderate to high certainty. Results showed probably few or no differences in clinical outcomes overall with a tendency towards improved blood pressure management in the small number of studies on shared care for hypertension, chronic kidney disease and stroke (mean difference (MD) 3.47, 95% confidence interval (CI) 1.68 to 5.25)(based on moderate-certainty evidence). Mental health outcomes improved, particularly in response to depression treatment (risk ratio (RR) 1.40, 95% confidence interval (CI) 1.22 to 1.62; six studies, N = 1708) and recovery from depression (RR 2.59, 95% CI 1.57 to 4.26; 10 studies, N = 4482) in studies examining the 'stepped care' design of shared care interventions (based on high-certainty evidence). Investigators noted modest effects on mean depression scores (standardised mean difference (SMD) -0.29, 95% CI -0.37 to -0.20; six studies, N = 3250). Differences in patient-reported outcome measures (PROMs), processes of care and participation and default rates in shared care services were probably limited (based on moderate-certainty evidence). Studies probably showed little or no difference in hospital admissions, service utilisation and patient health behaviours (with evidence of moderate certainty). AUTHORS' CONCLUSIONS This review suggests that shared care improves depression outcomes and probably has mixed or limited effects on other outcomes. Methodological shortcomings, particularly inadequate length of follow-up, may account in part for these limited effects. Review findings support the growing evidence base for shared care in the management of depression, particularly stepped care models of shared care. Shared care interventions for other conditions should be developed within research settings, with account taken of the complexity of such interventions and awareness of the need to carry out longer studies to test effectiveness and sustainability over time.
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Affiliation(s)
- Susan M Smith
- RCSI Medical SchoolHRB Centre for Primary Care Research, Department of General Practice123 St Stephens GreenDublinIreland
| | - Gráinne Cousins
- Royal College of Surgeons in IrelandSchool of Pharmacy123 St. Stephens GreenDublinIrelandDublin 2
| | - Barbara Clyne
- RCSI Medical SchoolHRB Centre for Primary Care Research, Department of General Practice123 St Stephens GreenDublin 2Ireland
| | - Shane Allwright
- Trinity College Centre for Health SciencesDepartment of Public Health and Primary CareDublinIreland
| | - Tom O'Dowd
- Trinity College Centre for Health SciencesDepartment of Public Health and Primary CareDublinIreland
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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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Nordgreen T, Haug T, Öst LG, Andersson G, Carlbring P, Kvale G, Tangen T, Heiervang E, Havik OE. Stepped Care Versus Direct Face-to-Face Cognitive Behavior Therapy for Social Anxiety Disorder and Panic Disorder: A Randomized Effectiveness Trial. Behav Ther 2016; 47:166-83. [PMID: 26956650 DOI: 10.1016/j.beth.2015.10.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2015] [Revised: 10/07/2015] [Accepted: 10/08/2015] [Indexed: 11/15/2022]
Abstract
The aim of this study was to assess the effectiveness of a cognitive behavioral therapy (CBT) stepped care model (psychoeducation, guided Internet treatment, and face-to-face CBT) compared with direct face-to-face (FtF) CBT. Patients with panic disorder or social anxiety disorder were randomized to either stepped care (n=85) or direct FtF CBT (n=88). Recovery was defined as meeting two of the following three criteria: loss of diagnosis, below cut-off for self-reported symptoms, and functional improvement. No significant differences in intention-to-treat recovery rates were identified between stepped care (40.0%) and direct FtF CBT (43.2%). The majority of the patients who recovered in the stepped care did so at the less therapist-demanding steps (26/34, 76.5%). Moderate to large within-groups effect sizes were identified at posttreatment and 1-year follow-up. The attrition rates were high: 41.2% in the stepped care condition and 27.3% in the direct FtF CBT condition. These findings indicate that the outcome of a stepped care model for anxiety disorders is comparable to that of direct FtF CBT. The rates of improvement at the two less therapist-demanding steps indicate that stepped care models might be useful for increasing patients' access to evidence-based psychological treatments for anxiety disorders. However, attrition in the stepped care condition was high, and research regarding the factors that can improve adherence should be prioritized.
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Affiliation(s)
- Tine Nordgreen
- Anxiety Disorders Research Network, Haukeland University Hospital; University of Bergen.
| | - Thomas Haug
- Anxiety Disorders Research Network, Haukeland University Hospital
| | - Lars-Göran Öst
- Anxiety Disorders Research Network, Haukeland University Hospital; University of Bergen; Stockholm University; Karolinska Institutet
| | | | | | - Gerd Kvale
- Anxiety Disorders Research Network, Haukeland University Hospital; University of Bergen
| | - Tone Tangen
- Anxiety Disorders Research Network, Haukeland University Hospital; University of Bergen
| | - Einar Heiervang
- Anxiety Disorders Research Network, Haukeland University Hospital; Institute of Clinical Medicine, University of Oslo
| | - Odd E Havik
- Anxiety Disorders Research Network, Haukeland University Hospital; University of Bergen
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Delaney KR. Improving Mental Health Care: What Nurses Can Do. JOURNAL OF CHILD AND ADOLESCENT PSYCHIATRIC NURSING 2016; 28:155-6. [DOI: 10.1111/jcap.12128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Kathleen R. Delaney
- Community and Mental Health Nursing; Rush College of Nursing; Chicago IL USA
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Malakouti SK, Nojomi M, Poshtmashadi M, Hakim Shooshtari M, Mansouri Moghadam F, Rahimi-Movaghar A, Afghah S, Bolhari J, Bazargan-Hejazi S. Integrating a suicide prevention program into the primary health care network: a field trial study in Iran. BIOMED RESEARCH INTERNATIONAL 2015; 2015:193729. [PMID: 25648221 PMCID: PMC4306260 DOI: 10.1155/2015/193729] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2014] [Revised: 12/10/2014] [Accepted: 12/15/2014] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To describe and evaluate the feasibility of integrating a suicide prevention program with Primary Health Care services and evaluate if such system can improve screening and identification of depressive disorder, reduce number of suicide attempters, and lower rate of suicide completion. METHODOLOGY This was a quasi-experimental trial in which one community was exposed to the intervention versus the control community with no such exposure. The study sites were two counties in Western Iran. The intervention protocol called for primary care and suicide prevention collaboration at different levels of care. The outcome variables were the number of suicides committed, the number of documented suicide attempts, and the number of identified depressed cases. RESULTS We identified a higher prevalence of depressive disorders in the intervention site versus the control site (χ (2) = 14.8, P < 0.001). We also found a reduction in the rate of suicide completion in the intervention region compared to the control, but a higher prevalence of suicide attempts in both the intervention and the control sites. CONCLUSION Integrating a suicide prevention program with the Primary Health Care network enhanced depression and suicide surveillance capacity and subsequently reduced the number of suicides, especially in rural areas.
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Affiliation(s)
- Seyed Kazem Malakouti
- Mental Health Research Center, Tehran Institute of Psychiatry, School of Behavioral Sciences and Mental Health, Iran University of Medical Sciences, Tehran, Iran
| | - Marzieh Nojomi
- Department of Community Medicine, School of Medicine, Iran University of Medical Sciences, P.O. Box 14155-5988, Iran
| | - Marjan Poshtmashadi
- Department of Clinical Psychology, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Mitra Hakim Shooshtari
- Mental Health Research Center, Tehran Institute of Psychiatry, School of Behavioral Sciences and Mental Health, Iran University of Medical Sciences, Tehran, Iran
| | | | - Afarin Rahimi-Movaghar
- Iranian National Center for Addiction Studies (INCAS), Iranian Institute for Reduction of High-Risk Behaviors, Tehran University of Medical Sciences, Tehran, Iran
| | - Susan Afghah
- Department of Psychiatry, University of Social Welfare and Rehabilitation Sciences, Tehran, Iran
| | - Jafar Bolhari
- Mental Health Research Center, Tehran Institute of Psychiatry, School of Behavioral Sciences and Mental Health, Iran University of Medical Sciences, Tehran, Iran
| | - Shahrzad Bazargan-Hejazi
- Department of Psychiatry, Charles R. Drew University of Medicine and Science, 1731 East 120th Street, Los Angeles, CA 90059, USA
- David Geffen School of Medicine at UCLA, CA, USA
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McDermott BM, Cobham VE. A stepped-care model of post-disaster child and adolescent mental health service provision. Eur J Psychotraumatol 2014; 5:24294. [PMID: 25045422 PMCID: PMC4095762 DOI: 10.3402/ejpt.v5.24294] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 06/06/2014] [Accepted: 06/10/2014] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND From a global perspective, natural disasters are common events. Published research highlights that a significant minority of exposed children and adolescents develop disaster-related mental health syndromes and associated functional impairment. Consistent with the considerable unmet need of children and adolescents with regard to psychopathology, there is strong evidence that many children and adolescents with post-disaster mental health presentations are not receiving adequate interventions. OBJECTIVE To critique existing child and adolescent mental health services (CAMHS) models of care and the capacity of such models to deal with any post-disaster surge in clinical demand. Further, to detail an innovative service response; a child and adolescent stepped-care service provision model. METHOD A narrative review of traditional CAMHS is presented. Important elements of a disaster response - individual versus community recovery, public health approaches, capacity for promotion and prevention and service reach are discussed and compared with the CAMHS approach. RESULTS Difficulties with traditional models of care are highlighted across all levels of intervention; from the ability to provide preventative initiatives to the capacity to provide intense specialised posttraumatic stress disorder interventions. In response, our over-arching stepped-care model is advocated. The general response is discussed and details of the three tiers of the model are provided: Tier 1 communication strategy, Tier 2 parent effectiveness and teacher training, and Tier 3 screening linked to trauma-focused cognitive behavioural therapy. CONCLUSION In this paper, we argue that traditional CAMHS are not an appropriate model of care to meet the clinical needs of this group in the post-disaster setting. We conclude with suggestions how improved post-disaster child and adolescent mental health outcomes can be achieved by applying an innovative service approach.
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Affiliation(s)
- Brett M. McDermott
- Kids in Mind Research, Mater Research, University of Queensland, Brisbane, Australia
| | - Vanessa E. Cobham
- Kids in Mind Research, Mater Research, University of Queensland, Brisbane, Australia
- Department of Psychology, University of Queensland, Brisbane, Australia
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Fleury MJ. La réforme des soins primaires de santé mentale au Québec et le rôle et les stratégies de coordination des omnipraticiens. SANTE MENTALE AU QUEBEC 2014. [DOI: 10.7202/1025905ar] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Les systèmes sociosanitaire et de santé mentale au Québec ont été substantiellement transformés dans les dernières années. Au coeur des restructurations, les réformes ont visé la consolidation des soins primaires et une meilleure intégration du dispositif de soins, tendances centrales des réformes sur le plan international. Cet article résume les principaux axes de transformation des réformes du système sociosanitaire et de la santé mentale au Québec. Il présente aussi le rôle clé des omnipraticiens dans la prise en charge des troubles mentaux et les stratégies de coordination déployées. Les réformes visent principalement l’intensification du travail en réseau des omnipraticiens avec les intervenants psychosociaux et les psychiatres. L’article conclut sur l’importance d’optimiser le déploiement de réseaux intégrés de soins et de bonnes pratiques en santé mentale. Par ailleurs, les réformes devraient toujours être accompagnées de mesures et de stratégies d’implantation à juste titre aussi ambitieuses que les changements planifiés !
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Affiliation(s)
- Marie-Josée Fleury
- Professeure agrégée, Département de psychiatrie, Université McGill
- Directrice scientifique, Centre de réadaptation en dépendance de Montréal – Institut universitaire (CRDM-IU)
- Chercheure, Douglas, Institut universitaire en santé mentale
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Nover CH. Implementing a mental health and primary care partnership program in Placer County, California. SOCIAL WORK IN HEALTH CARE 2014; 53:156-182. [PMID: 24483334 DOI: 10.1080/00981389.2013.864378] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Individuals with serious mental illness are at an increased risk for developing co-morbid chronic physical illnesses, such as diabetes and cardiovascular disease. This article is a descriptive piece about an intervention to decrease physical health risks in this population through a partnership effort between a primary care clinic and mental health agency in rural Placer County, California. The project was conducted as a part of the CalMEND Pilot Collaborative to Integrate Primary Care and Mental Health Services, which took place in five California counties in 2010-2011. A description of the program elements, conceptual models, key measures, and the process of program implementation is provided. Benefits were observed in areas of quality assurance, intra- and inter-agency teamwork, and access to adequate primary care for this population.
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Affiliation(s)
- Cynthia Helen Nover
- a School of Social Work , Eastern Washington University , Cheney , Washington , USA
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Fleury MJ, Acef S. [Mental healthcare system transformation: international tendencies and Québec-France perspectives]. SANTE MENTALE AU QUEBEC 2013; 38:17-41. [PMID: 24336988 DOI: 10.7202/1019184ar] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
This article is an overview of international tendencies on current mental healthcare transformation. It describes best practices based models and strategies aimed at improving efficiency of mental healthcare systems. To illustrate reforms in Quebec and France, the article reviews current literature and ongoing research on mental health care and service organization. During the last decade, primary care reinforcement, including best-practices and service integration, has been at the core of the mental healthcare system transformation. However, challenges regarding implementation appear to undermine the transformation's success. This article discusses mental healthcare services planning in order to improve their efficiency and allow the transfer of knowledge acquired through these reforms.
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Affiliation(s)
- Marie-Josée Fleury
- Université McGill; Centre de recherche du Douglas Institut universitaire en santé mentale; FRQ-S, Centre de réadaptation en dépendance de Montréal - Institut universitaire
| | - Saïd Acef
- Aura 77; Mission nationale d'appui en santé mentale
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Mayo-Wilson E, Montgomery P. Media-delivered cognitive behavioural therapy and behavioural therapy (self-help) for anxiety disorders in adults. Cochrane Database Syst Rev 2013:CD005330. [PMID: 24018460 DOI: 10.1002/14651858.cd005330.pub4] [Citation(s) in RCA: 62] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Anxiety disorders are the most common mental health problems. They are chronic and unremitting. Effective treatments are available, but access to services is limited. Media-delivered behavioural and cognitive behavioural interventions (self-help) aim to deliver treatment with less input from professionals compared with traditional therapies. OBJECTIVES To assess the effects of media-delivered behavioural and cognitive behavioural therapies for anxiety disorders in adults. SEARCH METHODS Published and unpublished studies were considered without restriction by language or date. The Cochrane Depression, Anxiety and Neurosis Review Group's Specialized Register (CCDANCTR) was searched all years to 1 January 2013. The CCDANCTR includes relevant randomised controlled trials from the following bibliographic databases: The Cochrane Library (all years), EMBASE (1974 to date), MEDLINE (1950 to date) and PsycINFO (1967 to date). Complementary searches were carried out on Ovid MEDLINE (1950 to 23 February 2013) and PsycINFO (1987 to February, Week 2, 2013), together with International trial registries (the trials portal of the World Health Organization (ICTRP) and ClinicalTrials.gov). Reference lists from previous meta-analyses and reports of randomised controlled trials were checked, and authors were contacted for unpublished data. SELECTION CRITERIA Randomised controlled trials of media-delivered behavioural or cognitive behavioural therapy in adults with anxiety disorders (other than post-traumatic stress disorder) compared with no intervention (including attention/relaxation controls) or compared with face-to-face therapy. DATA COLLECTION AND ANALYSIS Both review authors independently screened titles and abstracts. Study characteristics and outcomes were extracted in duplicate. Outcomes were combined using random-effects models, and tests for heterogeneity and for small study bias were conducted. We examined subgroup differences by type of disorder, type of intervention provided, type of media, and recruitment methods used. MAIN RESULTS One hundred and one studies with 8403 participants were included; 92 studies were included in the quantitative synthesis. These trials compared several types of media-delivered interventions (with varying levels of support) with no treatment and with face-to-face interventions. Inconsistency and risk of bias reduced our confidence in the overall results. For the primary outcome of symptoms of anxiety, moderate-quality evidence showed medium effects compared with no intervention (standardised mean difference (SMD) 0.67, 95% confidence interval (CI) 0.55 to 0.80; 72 studies, 4537 participants), and low-quality evidence of small effects favoured face-to-face therapy (SMD -0.23, 95% CI -0.36 to -0.09; 24 studies, 1360 participants). The intervention was associated with greater response than was seen with no treatment (risk ratio (RR) 2.34, 95% CI 1.81 to 3.03; 21 studies, 1547 participants) and was not significantly inferior to face-to-face therapy in these studies (RR 0.78, 95 % CI 0.56 to 1.09; 10 studies, 575 participants), but the latter comparison included versions of therapies that were not as comprehensive as those provided in routine clinical practice. Evidence suggested benefit for secondary outcome measures (depression, mental-health related disability, quality of life and dropout), but this evidence was of low to moderate quality. Evidence regarding harm was lacking. AUTHORS' CONCLUSIONS Self-help may be useful for people who are not able or are not willing to use other services for people with anxiety disorders; for people who can access it, face-to-face cognitive behavioural therapy is probably clinically superior. Economic analyses were beyond the scope of this review.Important heterogeneity was noted across trials. Recent interventions for specific problems that incorporate clinician support may be more effective than transdiagnostic interventions (i.e. interventions for multiple disorders) provided with no guidance, but these issues are confounded in the available trials.Although many small trials have been conducted, the generalisability of their findings is limited. Most interventions tested are not available to consumers. Self-help has been recommended as the first step in the treatment of some anxiety disorders, but the short-term and long-term effectiveness of media-delivered interventions has not been established. Large, pragmatic trials are needed to evaluate and to maximise the benefits of self-help interventions.
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Affiliation(s)
- Evan Mayo-Wilson
- Research Department of Clinical, Educational and Health Psychology, University College London, 1-19 Torrington Place, London, UK, WC1E 7HB
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Health reform and the Affordable Care Act: the importance of mental health treatment to achieving the triple aim. J Psychosom Res 2013; 74:533-7. [PMID: 23731753 PMCID: PMC3816931 DOI: 10.1016/j.jpsychores.2013.04.005] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Revised: 04/16/2013] [Accepted: 04/18/2013] [Indexed: 12/21/2022]
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Bramesfeld A, Moock J, Kopke K, Büchtemann D, Kästner D, Radisch J, Rössler W. Effectiveness and efficiency of assertive outreach for Schizophrenia in Germany: study protocol on a pragmatic quasi-experimental controlled trial. BMC Psychiatry 2013; 13:56. [PMID: 23414234 PMCID: PMC3618001 DOI: 10.1186/1471-244x-13-56] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2011] [Accepted: 02/06/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A model of assertive outreach (AO) in which office-based psychiatrists collaborate with ambulatory nursing services for providing intensive home-treatment is currently being implemented in rural areas of Lower Saxony, Germany. The costs of the model are reimbursed by some of the statutory health insurance companies active in Lower Saxony. Effectiveness and efficiency of this model for patients suffering from schizophrenia is evaluated in a pragmatic and prospective trial. METHODS Quasi-experimental controlled trial: patients receiving the intervention are all those receiving AO; controls are patients not eligible for AO based on their health insurance affiliation. ELIGIBILITY CRITERIA clinical diagnosis of schizophrenia (ICD-10 F.20), aged at least 18 years and being moderately to severely impaired in global functioning. PRIMARY OUTCOME admission and days spent in psychiatric inpatient care; secondary outcomes: clinical and functional status; patient satisfaction with chronic care; health care costs. Follow-up time: 6 and 12 months. DISCUSSION The study faces many challenges typical to pragmatic trials such as the rejection of randomisation by service providers, the quality of treatment as usual (TAU) to which the intervention will be compared, and the impairment of the study subjects. Solutions of how to deal with these challenges are presented and discussed in detail. TRIAL REGISTRATION International Standard Randomised Controlled Trial Number: http://ISRCTN34900108, German Clinical Trial Register: http://DRKS00003351.
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Affiliation(s)
- Anke Bramesfeld
- Innovation Incubator, Leuphana University Luneburg, Luneburg, Germany,Institute Epidemiology, Social Medicine and Health System Research, Hanover Medical School, Hanover, Germany
| | - Jörn Moock
- Innovation Incubator, Leuphana University Luneburg, Luneburg, Germany
| | - Kirsten Kopke
- Innovation Incubator, Leuphana University Luneburg, Luneburg, Germany
| | | | - Denise Kästner
- Innovation Incubator, Leuphana University Luneburg, Luneburg, Germany
| | - Jeanett Radisch
- Innovation Incubator, Leuphana University Luneburg, Luneburg, Germany
| | - Wulf Rössler
- Innovation Incubator, Leuphana University Luneburg, Luneburg, Germany,Clinic for Social and General Psychiatry, University of Zurich, Zurich, Switzerland
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The Autonomic Nervous System Questionnaire and the Brief Patient Health Questionnaire as screening instruments for panic disorder in Finnish primary care. Eur Psychiatry 2013; 28:442-7. [PMID: 23273422 DOI: 10.1016/j.eurpsy.2012.03.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Revised: 03/11/2012] [Accepted: 03/12/2012] [Indexed: 11/20/2022] Open
Abstract
PURPOSE As panic disorder often remains unrecognized in the health care system, some screening methods have been developed to enhance its recognition. The aim of this study was to test and compare the Autonomic Nervous System Questionnaire (ANS) and the Brief Patient Health Questionnaire (BPHQ) in primary care. SUBJECTS AND METHODS A total sample of 211 primary care outpatients was studied. The Structured Clinical Interview for DSM-IV was the criterion standard for the presence of panic disorder. Indices of diagnostic utility for both screening methods were calculated and compared. RESULTS The AUC (area under the ROC curve) was 0.885 for the ANS and 0.877 for the BPHQ. At the optimal cut-off level, the ANS had the sensitivity of 0.88 and specificity of 0.77; the BPHQ had the sensitivity of 0.79 and the specificity of 0.87. There was not any statistically significant difference between the screens. CONCLUSIONS Both screening methods can be recommended both for clinical practice and research use. In busy primary care practice, the BPHQ may be more useful, as it can be used together with the depression module of the BPHQ.
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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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Ali Afzali HH, Karnon J, Gray J, Beilby J. Evaluation of collaborative models of care in the management of patients with depression: protocol and progress. MENTAL HEALTH IN FAMILY MEDICINE 2012; 9:91-7. [PMID: 23730333 PMCID: PMC3513701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Introduction Depression is highly prevalent and has a considerable impact on the quality of life of affected individuals, and on healthcare resources. Evidence indicates that collaborative care models can improve patient outcomes within a primary care setting. The Primary Care Services Improvement Project (PCSIP) aims to investigate the costs and outcomes of different models of care for the management of patients with depression. These models have been defined based on the level of involvement of practice nurses in management processes within the primary care setting in Australia. This paper describes our study protocol and its progress. Methods PCSIP is an observational study that will link retrospective data from a range of sources to estimate costs and intermediate outcomes (such as relapse rate) over a 3-year time horizon. The main sources of primary data include the medical records of patients held at participating practices and Medicare Australia. Initial report We recruited 15 practices from a metropolitan area and allocated them to three models of care. Two hundred and sixty-one patients agreed to participate. Appropriate regression-based analyses will be used to evaluate the association between different models of care and patient-level outcomes while controlling for several covariates such as age and gender. Discussion/conclusions This project will generate the knowledge required to promote investment in the most cost-effective initiatives, and to ensure that waste of resources due to the implementation of comparatively inefficient interventions is minimised. Given the scarcity of resources, the increasing costs of providing healthcare and the increasing prevalence of chronic diseases, such research is essential.
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Fleury MJ, Imboua A, Aubé D, Farand L. Collaboration between general practitioners (GPs) and mental healthcare professionals within the context of reforms in Quebec. MENTAL HEALTH IN FAMILY MEDICINE 2012; 9:77-90. [PMID: 23730332 PMCID: PMC3513700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
Background In the context of the high prevalence and impact of mental disorders worldwide, and less than optimal utilisation of services and adequacy of care, strengthening primary mental healthcare should be a leading priority. This article assesses the state of collaboration among general practitioners (GPs), psychiatrists and psychosocial mental healthcare professionals, factors that enable and hinder shared care, and GPs' perceptions of best practices in the management of mental disorders. A collaboration model is also developed. Methods The study employs a mixed-method approach, with emphasis on qualitative investigation. Drawing from a previous survey representative of the Quebec GP population, 60 GPs were selected for further investigation. Results Globally, GPs managed mental healthcare patients in solo practice in parallel or sequential follow-up with mental healthcare professionals. GPs cited psychologists and psychiatrists as their main partners. Numerous hindering factors associated with shared care were found: lack of resources (either professionals or services); long waiting times; lack of training, time and incentives for collaboration; and inappropriate GP payment modes. The ideal practice model includes GPs working in multidisciplinary group practice in their own settings. GPs recommended expanding psychosocial services and shared care to increase overall access and quality of care for these patients. Conclusion As increasing attention is devoted worldwide to the development of optimal integrated primary care, this article contributes to the discussion on mental healthcare service planning. A culture of collaboration has to be encouraged as comprehensive services and continuity of care are key recovery factors of patients with mental disorders.
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Affiliation(s)
- Marie-Josée Fleury
- Associate Professor, Department of Psychiatry, McGill University, Douglas Mental Health University Institute Research Centre, Montreal, Canada
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Meuldijk D, Carlier IVE, van Vliet IM, van den Akker-Marle ME, Zitman FG. A randomized controlled trial of the efficacy and cost-effectiveness of a brief intensified cognitive behavioral therapy and/or pharmacotherapy for mood and anxiety disorders: design and methods. Contemp Clin Trials 2012; 33:983-92. [PMID: 22588010 DOI: 10.1016/j.cct.2012.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Revised: 03/30/2012] [Accepted: 05/01/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Anxiety and mood disorders involve a high disease burden and are associated with high economic costs. A stepped-care approach intervention and abbreviated diagnostic method are assumed to increase effectiveness and efficiency of the mental healthcare and are expected to reduce economic costs. METHODS Presented are the rationale, design, and methods of a two-armed randomized controlled trial comparing 'treatment as usual' (TAU) with a brief intensified cognitive behavioral therapy (CBT) and/or pharmacotherapy. Eligible participants (N=500) of five Dutch outpatient Mental Healthcare Centers are randomly assigned to either TAU or to the experimental condition (brief CBT and/or pharmacotherapy). Data on patients' progress and clinical effectiveness of treatment are assessed at baseline, post-treatment (3 months after baseline), and at 6 and 12 months post-treatment by Routine Outcome Monitoring (ROM). Cost analysis is performed on the obtained data. DISCUSSION Since few studies have investigated both the clinical and cost effectiveness of a stepped-care approach intervention and a shortened diagnostic ROM method in both anxiety and/or mood disorders within secondary mental health care, the results of this study might contribute to the improvement of (cost)-effective treatment options and diagnostic methods for these disorders.
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Affiliation(s)
- Denise Meuldijk
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands.
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Coull G, Morris PG. The clinical effectiveness of CBT-based guided self-help interventions for anxiety and depressive disorders: a systematic review. Psychol Med 2011; 41:2239-2252. [PMID: 21672297 DOI: 10.1017/s0033291711000900] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Cognitive-behavioural therapy (CBT)-based guided self-help (GSH) has been suggested to be an effective intervention for mild to moderate anxiety and depression, yet the evidence seems inconclusive, with some studies reporting that GSH is effective and others finding that GSH is ineffective. GSH differs in important respects from other levels of self-help, yet the literature regarding exclusively guided self-help interventions for anxiety and depression has not been reviewed systematically. METHOD A literature search for randomized controlled trials (RCTs) examining CBT-based GSH interventions for anxiety and depressive disorders was conducted. Multiple electronic databases were searched; several journals spanning key disciplines were hand-searched; reference lists of included review articles were scanned and relevant first authors were contacted. RESULTS Thirteen studies met the inclusion criteria. Meta-analysis indicated the effectiveness of GSH at post-treatment, although GSH was found to have limited effectiveness at follow-up or among more clinically representative samples. Studies that reported greater effectiveness of GSH tended to be of lower methodological quality and generally involved participants who were self-selected rather than recruited through clinical referrals. CONCLUSIONS Although there is support for the effectiveness of CBT-based GSH among media-recruited individuals, the finding that the reviewed RCTs had limited effectiveness within routine clinical practice demonstrates that the evidence is not conclusive. Further rigorous evidence based on clinical populations that examines longer-term outcomes is required before CBT-based GSH interventions can be deemed effective for adults accessing primary care services for treatment of anxiety and depression.
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Affiliation(s)
- G Coull
- Clinical and Health Psychology, University of Edinburgh, UK.
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Seekles W, van Straten A, Beekman A, van Marwijk H, Cuijpers P. Stepped care treatment for depression and anxiety in primary care. a randomized controlled trial. Trials 2011; 12:171. [PMID: 21736720 PMCID: PMC3152524 DOI: 10.1186/1745-6215-12-171] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Accepted: 07/07/2011] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Depressive and anxiety disorders are common in general practice but not always treated adequately. Introducing stepped care might improve this. In this randomized trial we examined the effectiveness of such a stepped care model. METHODS The study population consisted of primary care attendees aged 18-65 years with minor or major DSM-IV depressive and/or anxiety disorders, recruited through screening. We randomized 120 patients to either stepped care or care as usual. The stepped care program consisted of (1) watchful waiting, (2) guided self-help, (3) short face-to-face problem solving treatment and (4) pharmacotherapy and/or specialized mental health care. Patients were assessed at baseline and after 8, 16 and 24 weeks. RESULTS Symptoms of depression and anxiety decreased significantly over time for both groups. However, there was no statistically significant difference between the two groups (IDS: P = 0.35 and HADS: P = 0.64). The largest, but not significant, effect (d = -0.21) was found for anxiety on T3. In both groups approximately 48% of the patients were recovered from their DSM-IV diagnosis at the final 6 months assessment. CONCLUSIONS In summary we could not demonstrate that stepped care for depression and anxiety in general practice was more effective than care as usual. Possible reasons are discussed. TRIAL REGISTRATION Current Controlled Trails: ISRCTN17831610.
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Affiliation(s)
- Wike Seekles
- Department of Clinical Psychology, VU University, Amsterdam, The Netherlands.
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Verhaak P, Kamsma J, van der Niet A. Wie heeft baat bij eerstelijnspsychologische behandeling? ACTA ACUST UNITED AC 2011. [DOI: 10.1007/s41480-011-0048-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Cuijpers P, Donker T, Johansson R, Mohr DC, van Straten A, Andersson G. Self-guided psychological treatment for depressive symptoms: a meta-analysis. PLoS One 2011; 6:e21274. [PMID: 21712998 PMCID: PMC3119687 DOI: 10.1371/journal.pone.0021274] [Citation(s) in RCA: 181] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2010] [Accepted: 05/24/2011] [Indexed: 11/23/2022] Open
Abstract
Background A number of trials have examined the effects of self-guided psychological intervention, without any contact between the participants and a therapist or coach. The results and sizes of these trials have been mixed. This is the first quantitative meta-analysis, aimed at organizing and evaluating the literature, and estimating effect size. Method We conducted systematic literature searches in PubMed, PsycINFO and Embase up to January 2010, and identified additional studies through earlier meta-analyses, and the references of included studies. We identified seven randomized controlled trials that met our inclusion criteria, with a total of 1,362 respondents. The overall quality of the studies was high. A post-hoc power calculation showed that the studies had sufficient statistical power to detect an effect size of d = 0.19. Results The overall mean effect size indicating the difference between self-guided psychological treatment and control groups at post-test was d = 0.28 (p<0.001), which corresponds to a NNT of 6.41. At 4 to 12 months follow-up the effect size was d = 0.23. There was no indication for significant publication bias. Conclusions We found evidence that self-guided psychological treatment has a small but significant effect on participants with increased levels of depressive symptomatology.
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Affiliation(s)
- Pim Cuijpers
- Department of Clinical Psychology, VU University Amsterdam, Amsterdam, The Netherlands.
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Seekles W, van Straten A, Beekman A, van Marwijk H, Cuijpers P. Effectiveness of guided self-help for depression and anxiety disorders in primary care: a pragmatic randomized controlled trial. Psychiatry Res 2011; 187:113-20. [PMID: 21145112 DOI: 10.1016/j.psychres.2010.11.015] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2010] [Revised: 11/02/2010] [Accepted: 11/11/2010] [Indexed: 11/16/2022]
Abstract
The objective of this study is to evaluate the effectiveness of (guided) self-help in primary care for patients diagnosed with a minor or major mood and/or anxiety disorder. The study population consists of 120 (screened) primary care patients aged 18-65 years with at least one mood and/or anxiety disorder. The primary focus is the reduction of depressive and anxiety symptoms. The self-help courses (Problem Solving Treatment and exposure) took 6 weeks to complete. The self-help group reported slightly better outcomes than the care-as-usual group but these results were not significant: d=-0.18 (95% CI=-2.29 to 7.31) for symptoms of depression and d=-0.20 (95% CI=-0.74 to 2.29) for symptoms of anxiety. For patients with an anxiety disorder only, the anxiety symptoms decreased significantly compared to the care-as-usual group (d=-0.68; 95% CI=0.25 to 4.77). Self-help seems only slightly superior to care-as-usual and therefore might not be an effective tool in general practice. But the lack of results could also be due to our selection of patients or to our selection of GPs (with interest in psychiatric disorders). Nonetheless the promising signals with respect to anxiety disorders warrant further research.
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Affiliation(s)
- Wike Seekles
- Department of Clinical Psychology, VU University, Amsterdam, The Netherlands.
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van Straten A, Seekles W, van 't Veer-Tazelaar NJ, Beekman ATF, Cuijpers P. Stepped care for depression in primary care: what should be offered and how? Med J Aust 2010; 192:S36-9. [PMID: 20528706 DOI: 10.5694/j.1326-5377.2010.tb03691.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2009] [Accepted: 01/19/2010] [Indexed: 11/17/2022]
Abstract
Stepped-care approaches may offer a solution to delivering accessible, effective and efficient services for individuals with depression. In stepped care, all patients commence with a low-intensity, low-cost treatment. Treatment results are monitored systematically, and patients move to a higher-intensity treatment only if necessary. We deliver a stepped-care model targeting patients with depression. The first step consists of "watchful waiting", as half of all patients with a depressive episode recover spontaneously within 3 months. The second step, guided self-help, is the key element of the stepped-care model. Guided self-help, especially when offered through the internet, is effective and cost-efficient. The third step consists of brief face-to-face psychotherapy. Finally, in the fourth step, longer-term face-to-face psychotherapy and antidepressant medication might be considered. Patients are monitored by one person, a care manager, who is responsible for the decision to step up to the next treatment and for continuity of care. The different treatments within the stepped-care model are evidence-based. Data on cost-effectiveness of the full model are still scarce, but we recently demonstrated that the incidence of new cases of depression and anxiety could be halved by introducing stepped care. Effects of web-based guided self-help could be enhanced by incorporating them in a stepped-care model.
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Affiliation(s)
- Annemieke van Straten
- Department of Clinical Psychology, VU University Amsterdam, Amsterdam, The Netherlands.
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