Cost-effectiveness of referral for generic care or problem-solving treatment from community mental health nurses, compared with usual general practitioner care for common mental disorders: Randomised controlled trial

The research gap in evaluating community-based mental health interventions in Korea: A comparative analysis with the United Kingdom

South Korea has historically relied on inpatient psychiatric care. Although the 1995 Mental Health Act aimed to promote community mental health services, progress in developing community-based interventions has been limited. This review aims to provide a concise analysis of the current state of research on evaluating community mental health care in Korea, employing a comparative perspective with the United Kingdom (UK), where community-based mental health approaches have been more extensively studied and implemented. On November 19, 2024, a literature search was conducted using PubMed. The search strategy combined keywords related to mental illness and community intervention with the terms "Korea" or "United Kingdom." The review focused on randomized controlled trials from both countries that assessed patient-level outcomes of community-based mental health interventions. The findings reveal a striking contrast: in Korea, only one randomized pilot trial focused on depression in older adults was found. In contrast, 69 studies were identified in the UK, including 13 pilot/feasibility studies and 56 main studies, with 38 of these addressing severe mental illness. This clear difference underscores the limited research and evaluation of community-based mental health interventions in Korea. The results indicate a pressing need for research to assess these interventions. Such research could guide policy reforms toward deinstitutionalization and help Korea strengthen its community-based mental health system in line with global trends.

Randomized controlled trials of mental health nurse-delivered interventions: A systematic review

WHAT IS KNOWN ON THE SUBJECT?: Well conducted randomized controlled trials provide the highest level of evidence of effectiveness of healthcare interventions, including those delivered by mental health nurses. Trials have been conducted over the years but there has not been a comprehensive review since 2005, and never one including studies conducted outside the UK. WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE?: The paper provides a comprehensive overview of results from randomized controlled trials of mental health nurse-delivered interventions conducted in the UK, Ireland, US, Australia, New Zealand, or Canada and reported 2005 to 2020. It highlights that the trial evidence is limited and offers only partial evidence for interventions that are central to mental health nursing practice. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Much mental health nursing practice is not supported by the highest level trial evidence. Mental health nurses need to carefully select evidence on which to base their practice both from the mental health nursing literature and beyond. Mental health nurses and other stakeholders should demand greater investment in trials to strengthen the evidence base.

ABSTRACT

INTRODUCTION: Nurses are the largest professional disciplinary group working in mental health services and have been involved in numerous trials of nursing-specific and multidisciplinary interventions. Systematic appraisal of relevant research findings is rare.

AIM

To review trials from the core Anglosphere (UK, US, Canada, Ireland, Australia, New Zealand) published from 2005 to 2020.

METHOD

A systematic review reported in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses. Comprehensive electronic database searches were conducted. Eligible studies were randomized controlled trials of mental health nurse-delivered interventions conducted in relevant countries. The risk of bias was independently assessed. Synthesis involved integration of descriptive statistics of standardized metrics and study bias.

RESULTS

Outcomes from 348 between-group comparisons were extracted from K = 51 studies (N = 11,266 participants), Standardized effect sizes for 68 (39 very small/small, 29 moderate/large) statistically significant outcomes from 30 studies were calculable. All moderate/large effect sizes were at risk of bias.

DISCUSSION

Trial evidence of effective mental health nurse-delivered interventions is limited. Many studies produced few or no measurable benefits; none demonstrated improvements related to personal recovery.

IMPLICATIONS FOR PRACTICE

Mental health nurses should look beyond gold standard RCT evidence, and to evidence-based interventions that have not been trialled with mental health nurse delivery.

Evaluating the Change Process of a Brief Cognitive Behavior Therapy Workshop for Psychological Distress Among Primary Care Self-Referrals in Selangor, Malaysia

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.

Retrospectively Collected EQ-5D-5L Data as Valid Proxies for Imputing Missing Information in Longitudinal Studies

OBJECTIVES

Studies face challenges with missing 5-level EQ-5D (EQ-5D-5L) data, often because of the need for longitudinal EQ-5D-5L data collection. There is a dearth of validated methodologies for dealing with missing EQ-5D-5L data in the literature. This study, for the first time, examined the possibility of using retrospectively collected EQ-5D-5L data as proxies for the missing data.

METHODS

Participants who had prospectively completed a 3rd month postdischarge EQ-5D-5L instrument (in-the-moment collection) were randomly interviewed to respond to a 2nd "retrospective collection" of their 3rd month EQ-5D-5L at 6th, 9th, or 12th month after hospital discharge. A longitudinal single imputation was also used to assess the relative performance of retrospective collection compared with the longitudinal single imputation. Concordances between the in-the-moment, retrospective, and imputed measures were assessed using intraclass correlation coefficients and weighted kappa statistics.

RESULTS

Considerable agreement was observed on the basis of weighted kappa (range 0.72-0.95) between the mobility, self-care, and usual activities dimensions of EQ-5D-5L collected in-the-moment and retrospectively. Concordance based on intraclass correlation coefficients was good to excellent (range 0.79-0.81) for utility indices computed, and excellent (range 0.93-0.96) for quality-adjusted life-years computed using in-the-moment compared with retrospective EQ-5D-5L. The longitudinal single imputation did not perform as well as the retrospective collection method.

CONCLUSIONS

This study demonstrates that retrospective collection of EQ-5D-5L has high concordance with "in-the-moment" EQ-5D-5L and could be a valid and attractive alternative for data imputation when longitudinally collected EQ-5D-5L data are missing. Future studies examining this method for other disease areas and populations are required to provide more generalizable evidence.

Glucose and cholesterol stabilization in patients with type 2 diabetes mellitus with depressive and anxiety symptoms by problem-solving therapy in primary care centers in Mexico City

Aim The aim of this study was to determine if the problem-solving therapy (PST) helps control metabolic variables in patients with type 2 diabetes mellitus (T2DM) who show depressive and anxiety symptoms.

BACKGROUND

T2DM is a chronic-degenerative multifactorial disease. It is considered one of the main public health problems in the world, and it represents an important social and economic burden. It is frequently associated with major depression and anxiety disorders, which are related with high glycated hemoglobin (HbA1c) concentrations and poor metabolic control.

METHOD

We initially included 123 patients diagnosed with T2DM from five primary care centers (PCC) in Mexico City. HbA1c, central glucose, and lipid profile were measured in each patient. In addition, the Kessler psychological distress scale (K-10), the Beck Depression Inventory, and the Beck Anxiety Inventory were applied at the beginning and, to those who continued, at the end of the PST, as well as four months later. Findings In total, 36 patients completed the PST and the follow-up. There was a significant decrease in depressive and anxiety symptoms (P<0.001), as well as in total cholesterol (P=0.002), HbA1c (P=0.05), and low-density lipoprotein (LDL) (P=0.022). The PST helps reduce depressive and anxiety symptoms and may help stabilize glucose and cholesterol up to four months. Further studies on this area are recommended. If our findings are confirmed, the PST could help improve the quality of life of thousands of individuals with psychiatric-metabolic co-morbidity who only visit PCC.

The oncology nurse coordinator: role perceptions of staff members and nurse coordinators

BACKGROUND

There is extensive evidence that the role of nurse coordinators is beneficial for patients. Nurse coordinators are more available to patients compared to general registered nurses, know better to control symptoms and work as team players with multiple care providers. Despite its significance, there is a dearth of literature on the subject in Israel and a lack of clarity regarding the definitions of the role in terms of responsibilities and authorities. The aim of the study is to: To examine how the role of nurse oncology coordinator is implemented in various fields of oncology and to describe the actual performance of different kinds of oncology nurse coordinators and staff perceptions regarding this role in one tertiary hospital in Jerusalem.

METHODS

A phenomenological approach was used to explore the participants' experiences and views of nurse coordinators' performance. We conducted a qualitative study using in-depth semi-structured interviews. Interviewees included 30 employees from different levels of the hospitals, and leading figures associated with oncology medicine outside of the hospital: Nurses and physicians of the Sharett Oncology Institute of Hadassah Ein Kerem Hospital in Jerusalem, the administrative staff of Hadassah Ein Kerem Hospital, head nurses of the Israel Cancer Association, the chairperson of the Non-Profit Organization of Oncology Nurses, nurse directors at the Ministry of Health Nursing Division, and seven nurse coordinators at Hadassah Ein Kerem Hospital in diverse fields of oncology.

RESULTS

The nurse coordinator is perceived as an important staff member providing care to cancer patients. Several key elements were found to be common features in the work of all nurse coordinators: emotional support, guidance to patients, and coordination of patients' care.

CONCLUSIONS

The nurse coordinator plays a noteworthy role in the health care system. In view of the variety of roles that the nurse coordinator assumes in different units, performance standards must be adapted to the performance areas for each unit, as well as nurses' professional development requirements. Changes in a service organization and careful attention to the continuum of care highlight the need to develop and to strengthen the role of a nurse who coordinates treatment over the entire continuum of care, both in the hospital and in the community.

Exploring the value of mental health nurses working in primary care in England: A qualitative study

WHAT IS KNOWN ON THE SUBJECT?: Primary care and, in particular, general practice (GP) are often first point of access to health care. International evidence suggests that healthcare systems oriented towards primary care may produce better outcomes, at lower costs and with higher user satisfaction. Despite this, there are noted deficiencies and variations in the quality of care in primary care for patients with mental health problems. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Emerging models of providing mental health services in primary care are poorly understood. This paper evaluates a mental health nurse-led Primary Care Liaison Service (PCLS), developed in 2011 in inner London. The findings suggest that this type of service can improve the quality of care for people presenting with mental health problems within primary care, specifically due to improved integration, clinical effectiveness, patient-centred care, access and efficiency. The study also highlighted challenges such as staff retention within this new role and setting appropriate referral criteria. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: This is a relatively new service, and the cost-effectiveness is not yet fully understood; however, commissioners may want to consider the potential benefits of a similar service in their area. The extent to which the findings are transferable will depend on service configuration and local demographics which can vary. Further research within this area could give more detail on the impact of such teams on health outcomes, recovery rates, secondary care referrals and accident and emergency attendances, and its cost-effectiveness.

ABSTRACT

Aims/Question General practice is typically the first point of access to healthcare. This study explores what value a Primary Care Liaison Nurse (PCLN) service, established in 2011, can bring to people with mental health problems in primary care. Method Semi-structured interviews were used to elicit participants' experiences and perspectives on the value of a PCLN service. Participants included ten interviews with seven general practitioners and three senior practitioners working in primary care mental health services. Thematic analysis, based on a 6-phase approach, was used to describe and explore the data collected. Results Five main themes were derived from the thematic analysis of the interviews relating to: integration; clinical effectiveness; patient centred care; access; and efficiency. Discussion The study suggests that the PCLN service can improve the quality of care and is generally highly valued by its stakeholders. The study identifies particularly valued elements of the service, including having a duty worker, as well as aspects which could be improved, such as patient criteria. Implications for practice This is a relatively new service and the cost-effectiveness is not yet fully understood; however, commissioners may want to consider the potential benefits of a similar service in their area.

Potential for substitution of mental health care towards family practices: an observational study

BACKGROUND

Substitution is the shift of care from specialized health care to less expensive and more accessible primary health care. It seems promising for restraining rising mental health care costs. The goal of this study was to investigate a potential for substitution of patients with psychological or social problems, but without severe psychiatric disorders, from Dutch specialized mental health care to primary care, especially family practices.

METHODS

We extracted anonymized data from two national databases representing primary and specialized care in 2012. We calculated the number of patients with and without psychiatric disorder per 1,000 citizens in three major settings: family practices, primary care psychologists, and specialized care. Family physicians recorded psychopathology using the International Classification of Primary Care, while psychologists and specialists used the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition.

RESULTS

Considerable numbers of patients without a diagnosed DSM-IV psychiatric disorder were treated by primary care psychologists (32.8%) or in specialized care (20.8%). Over half of the patients referred by family physicians to mental health care did not have a psychiatric disorder.

CONCLUSION

A recent reform of Dutch mental health care, including new referral criteria, will likely increase the number of patients with psychological or social problems that family physicians have to treat or support. Enabling and improving diagnostic assessment and treatment in family practices seems essential for substitution of mental health care.

Consultations in general practices with and without mental health nurses: an observational study from 2010 to 2014

OBJECTIVES

To investigate care for patients with psychological or social problems provided by mental health nurses (MHNs), and by general practitioners (GPs) with and without MHNs.

DESIGN

An observational study with consultations recorded by GPs and MHNs.

SETTING

Data were routinely recorded in 161-338 Dutch general practices between 2010 and 2014.

PARTICIPANTS

All patients registered at participating general practices were included: 624 477 patients in 2010 to 1 392 187 patients in 2014.

OUTCOME MEASURES

We used logistic and Poisson multilevel regression models to test whether GPs recorded more patients with at least one consultation for psychological or social problems and to analyse the number of consultations over a 5-year time period. We examined the additional effect of an MHN in a practice, and tested which patient characteristics predicted transferral from GPs to MHNs.

RESULTS

Increasing numbers of patients with psychological or social problems visit general practices. Increasing numbers of GPs collaborate with an MHN. GPs working in practices with an MHN record as many consultations per patient as GPs without an MHN, but they record slightly more patients with psychological or social problems (OR=1.05; 95% CI 1.02 to 1.08). MHNs most often treat adult female patients with common psychological symptoms such as depressive feelings.

CONCLUSIONS

MHNs do not seem to replace GP care, but mainly provide additional long consultations. Future research should study to what extent collaboration with an MHN prevents patients from needing specialised mental healthcare.

Self-referral psychological treatment centre for young adults: a 2-year observational evaluation of routine practice before and after treatment

OBJECTIVES

To examine a self-referral psychological service provided to young adults with regard to effects on anxiety, depression and psychological distress and to explore client factors predicting non-adherence and non-response.

DESIGN

Observational study over a 2-year period.

SETTING

Young Adults Centre providing psychological services by self-referral (preprimary care) to Linköping, Åtvidaberg, and Kinda municipalities (combined population 145,000) in Östergötland county, Sweden.

PARTICIPANTS

607 young adults (16-25 years of age); 71% females (n=429).

INTERVENTION

Individually scheduled cognitive behavioural therapy delivered in up to six 45 min sessions structured according to an assessment of the client's mental health problems: anxiety, depression, anxiety and depression combined, or decreased distress without specific anxiety or depression.

PRIMARY OUTCOME MEASURES

Pre-post intervention changes in psychological distress (General Health Questionnaire-12, GHQ-12), Hospital Anxiety and Depression Scale Anxiety/Depression (HADS-A/D).

RESULTS

192 clients (32.5%) discontinued the intervention on their own initiative and 39 clients (6.6%) were referred to a psychiatric clinic during the course of the intervention. Intention-to-treat analyses including all clients showed a medium treatment effect size (d=0.64) with regard to psychological distress, and small effect sizes were observed with regard to anxiety (d=0.58) and depression (d=0.57). Restricting the analyses to clients who adhered to the agreed programme, a large effect size (d=1.26) was observed with regard to psychological distress, and medium effect sizes were observed with regard to anxiety (d=1.18) and depression (d=1.19). Lower age and a high initial HADS-A score were the strongest risk factors for non-adherence, and inability to concentrate and thinking of oneself as a worthless person increased the risk for discontinuation.

CONCLUSIONS

We conclude that provision of psychological services to young people through a self-referral centre has potential to improve long-term mental health in communities, but management of non-adherence remains a central challenge.

Multiple imputation to deal with missing EQ-5D-3L data: Should we impute individual domains or the actual index?

PURPOSE

Missing data are a well-known and widely documented problem in cost-effectiveness analyses alongside clinical trials using individual patient-level data. Current methodological research recommends multiple imputation (MI) to deal with missing health outcome data, but there is little guidance on whether MI for multi-attribute questionnaires, such as the EQ-5D-3L, should be carried out at domain or at summary score level. In this paper, we evaluated the impact of imputing individual domains versus imputing index values to deal with missing EQ-5D-3L data using a simulation study and developed recommendations for future practice.

METHODS

We simulated missing data in a patient-level dataset with complete EQ-5D-3L data at one point in time from a large multinational clinical trial (n = 1,814). Different proportions of missing data were generated using a missing at random (MAR) mechanism and three different scenarios were studied. The performance of using each method was evaluated using root mean squared error and mean absolute error of the actual versus predicted EQ-5D-3L indices.

RESULTS

In large sample sizes (n > 500) and a missing data pattern that follows mainly unit non-response, imputing domains or the index produced similar results. However, domain imputation became more accurate than index imputation with pattern of missingness following an item non-response. For smaller sample sizes (n < 100), index imputation was more accurate. When MI models were misspecified, both domain and index imputations were inaccurate for any proportion of missing data.

CONCLUSIONS

The decision between imputing the domains or the EQ-5D-3L index scores depends on the observed missing data pattern and the sample size available for analysis. Analysts conducting this type of exercises should also evaluate the sensitivity of the analysis to the MAR assumption and whether the imputation model is correctly specified.

An interprofessional nurse-led mental health promotion intervention for older home care clients with depressive symptoms

Background

Depressive symptoms in older home care clients are common but poorly recognized and treated, resulting in adverse health outcomes, premature institutionalization, and costly use of health services. The objectives of this study were to examine the feasibility and acceptability of a new six-month interprofessional (IP) nurse-led mental health promotion intervention, and to explore its effects on reducing depressive symptoms in older home care clients (≥ 70 years) using personal support services.

Methods

A prospective one-group pre-test/post-test study design was used. The intervention was a six-month evidence-based depression care management strategy led by a registered nurse that used an IP approach. Of 142 eligible consenting participants, 98 (69%) completed the six-month and 87 (61%) completed the one-year follow-up. Outcomes included depressive symptoms, anxiety, health-related quality of life (HRQoL), and the costs of use of all types of health services at baseline and six-month and one-year follow-up. An interpretive descriptive design was used to explore clients’, nurses’, and personal support workers’ perceptions about the intervention’s appropriateness, benefits, and barriers and facilitators to implementation.

Results

Of the 142 participants, 56% had clinically significant depressive symptoms, with 38% having moderate to severe symptoms. The intervention was feasible and acceptable to older home care clients with depressive symptoms. It was effective in reducing depressive symptoms and improving HRQoL at six-month follow-up, with small additional improvements six months after the intervention. The intervention also reduced anxiety at one year follow-up. Significant reductions were observed in the use of hospitalization, ambulance services, and emergency room visits over the study period.

Conclusions

Our findings provide initial evidence for the feasibility, acceptability, and sustained effects of the nurse-led mental health promotion intervention in improving client outcomes, reducing use of expensive health services, and improving clinical practice behaviours of home care providers. Future research should evaluate its efficacy using a randomized clinical trial design, in different settings, with an adequate sample of older home care recipients with depressive symptoms.

Trial registration

Clinicaltrials.gov identifier: NCT01407926.

An analysis of 100 referrals for depression from primary care to an adult mental health service

OBJECTIVES

Improving the interface between primary care and mental health services is a key target in current healthcare policy in Ireland. This study examines the content of referrals from primary care to a community mental health service for apparent depression.

METHOD

We retrospectively reviewed the clinical records of 100 patients with depression who consecutively attended a specialist mental health service in Ireland's midwest region. Records were reviewed for demographic and clinical information provided by the doctor at the time of referral, subsequent service engagement, diagnosis and treatment initiated.

RESULTS

There was considerable variation in the content and presentation of information contained in referral letters. Eleven per cent used structured HSE mental health referral forms. Seventy-six per cent of referrals contained clear information regarding name, address, symptoms and treatment previously initiated. Specifically, low mood, biological symptoms of depression and illness severity were documented in 43%, 34% and 27%, respectively. Suicide risk was documented in 20%. More detail was significantly associated with more severe illness. At initial specialist assessment, 71% had commenced antidepressant treatment, with 11% having received an adequate trial of a first antidepressant and 3% an adequate trial of two antidepressants. Two-thirds were diagnosed with mild/moderate depression. Initiation of antidepressant treatment was linked to subsequent diagnosis of depressive illness by mental health services (p < 0.001).

CONCLUSIONS

Our findings indicate variable referral practices from general practice to mental health in our region. Most referrals were for mild to moderate depression. Poor access to psychological services locally may be a key factor in this phenomenon.

Dissemination of behavioural activation for depression to mental health nurses: training evaluation and benchmarked clinical outcomes

Depression causes significant distress, disability and cost within the UK. Behavioural activation (BA) is an effective single-strand psychological approach which may lend itself to brief training programmes for a wide range of clinical staff. No previous research has directly examined outcomes of such dissemination. A 5-day training course for 10 primary care mental health workers aiming to increase knowledge and clinical skills in BA was evaluated using the Training Acceptability Rating Scale. Depression symptom level data collected in a randomized controlled trial using trainees were then compared to results from meta-analysis of studies using experienced therapists. BA training was highly acceptable to trainees (94.4%, SD 6%). The combined effect size of BA was unchanged by the addition of the results of this evaluation to those of studies using specialist therapists. BA offers a promising psychological intervention for depression that appears suitable for delivery by mental health nurses following brief training.

Cost-effectiveness of problem-solving treatment in comparison with usual care for primary care patients with mental health problems: a randomized trial

BACKGROUND

Mental health problems are common and are associated with increased disability and health care costs. Problem-Solving Treatment (PST) delivered to these patients by nurses in primary care might be efficient. The aim of this study was to evaluate the cost-effectiveness of PST by mental health nurses compared with usual care (UC) by the general practitioner for primary care patients with mental health problems.

METHODS

An economic evaluation from a societal perspective was performed alongside a randomized clinical trial. Patients with a positive General Health Questionnaire score (score ≥ 4) and who visited their general practitioner at least three times during the past 6 months were eligible. Outcome measures were improvement on the Hospital Anxiety and Depression Scale and QALYs based on the EQ-5D. Resource use was measured using a validated questionnaire. Missing cost and effect data were imputed using multiple imputation techniques. Bootstrapping was used to analyze costs and cost-effectiveness of PST compared with UC.

RESULTS

There were no statistically significant differences in clinical outcomes at 9 months. Mean total costs were €4795 in the PST group and €6857 in the UC group. Costs were not statistically significantly different between the two groups (95% CI -4698;359). The cost-effectiveness analysis showed that PST was cost-effective in comparison with UC. Sensitivity analyses confirmed these findings.

CONCLUSIONS

PST delivered by nurses seems cost-effective in comparison with UC. However, these results should be interpreted with caution, since the difference in total costs was mainly caused by 3 outliers with extremely high indirect costs in the UC group.

TRIAL REGISTRATION

Nederlands Trial Register ISRCTN51021015.

Cost utility of behavioural activation delivered by the non-specialist

Behavioural activation by non-specialists appears effective in the treatment of depression. We examined incremental cost-effectiveness of behavioural activation (n = 24) v. treatment as usual (n = 23) in a randomised controlled trial. Intention-to-treat analyses indicated a quality-adjusted life-year (QALY) difference in favour of behavioural activation of 0.20 (95% CI 0.01-0.39, P = 0.042), incremental cost-effectiveness ratio of £5756 per QALY and a 97% probability that behavioural activation is more cost-effective at a threshold value of £20,000. Results are promising for dissemination of behavioural activation but require replication in a larger study.

Counselling for mental health and psychosocial problems in primary care

BACKGROUND

The prevalence of mental health and psychosocial problems in primary care is high. Counselling is a potential treatment for these patients, but there is a lack of consensus over the effectiveness of this treatment in primary care.

OBJECTIVES

To assess the effectiveness and cost effectiveness of counselling for patients with mental health and psychosocial problems in primary care.

SEARCH STRATEGY

To update the review, the following electronic databases were searched: the Cochrane Collaboration Depression, Anxiety and Neurosis (CCDAN) trials registers (to December 2010), MEDLINE, EMBASE, PsycINFO and the Cochrane Central Register of Controlled Trials (to May 2011).

SELECTION CRITERIA

Randomised controlled trials of counselling for mental health and psychosocial problems in primary care.

DATA COLLECTION AND ANALYSIS

Data were extracted using a standardised data extraction sheet by two reviewers. Trials were rated for quality by two reviewers using Cochrane risk of bias criteria, to assess the extent to which their design and conduct were likely to have prevented systematic error. Continuous measures of outcome were combined using standardised mean differences. An overall effect size was calculated for each outcome with 95% confidence intervals (CI). Continuous data from different measuring instruments were transformed into a standard effect size by dividing mean values by standard deviations. Sensitivity analyses were undertaken to test the robustness of the results. Economic analyses were summarised in narrative form. There was no assessment of adverse events.

MAIN RESULTS

Nine trials were included in the review, involving 1384 randomised participants. Studies varied in risk of bias, although two studies were identified as being at high risk of selection bias because of problems with concealment of allocation. All studies were from primary care in the United Kingdom and thus comparability was high. The analysis found significantly greater clinical effectiveness in the counselling group compared with usual care in terms of mental health outcomes in the short-term (standardised mean difference -0.28, 95% CI -0.43 to -0.13, n = 772, 6 trials) but not in the long-term (standardised mean difference -0.09, 95% CI -0.27 to 0.10, n = 475, 4 trials), nor on measures of social function (standardised mean difference -0.09, 95% CI -0.29 to 0.11, n = 386, 3 trials). Levels of satisfaction with counselling were high. There was some evidence that the overall costs of counselling and usual care were similar. There were limited comparisons between counselling and other psychological therapies, medication, or other psychosocial interventions.

AUTHORS' CONCLUSIONS

Counselling is associated with significantly greater clinical effectiveness in short-term mental health outcomes compared to usual care, but provides no additional advantages in the long-term. Participants were satisfied with counselling. Although some types of health care utilisation may be reduced, counselling does not seem to reduce overall healthcare costs. The generalisability of these findings to settings outside the United Kingdom is unclear.

Reducing depression in older home care clients: design of a prospective study of a nurse-led interprofessional mental health promotion intervention

BACKGROUND

Very little research has been conducted in the area of depression among older home care clients using personal support services. These older adults are particularly vulnerable to depression because of decreased cognition, comorbid chronic conditions, functional limitations, lack of social support, and reduced access to health services. To date, research has focused on collaborative, nurse-led depression care programs among older adults in primary care settings. Optimal management of depression among older home care clients is not currently known. The objective of this study is to evaluate the feasibility, acceptability and effectiveness of a 6-month nurse-led, interprofessional mental health promotion intervention aimed at older home care clients with depressive symptoms using personal support services.

METHODS/DESIGN

This one-group pre-test post-test study aims to recruit a total of 250 long-stay (> 60 days) home care clients, 70 years or older, with depressive symptoms who are receiving personal support services through a home care program in Ontario, Canada. The nurse-led intervention is a multi-faceted 6-month program led by a Registered Nurse that involves regular home visits, monthly case conferences, and evidence-based assessment and management of depression using an interprofessional approach. The primary outcome is the change in severity of depressive symptoms from baseline to 6 months using the Centre for Epidemiological Studies in Depression Scale. Secondary outcomes include changes in the prevalence of depressive symptoms and anxiety, health-related quality of life, cognitive function, and the rate and appropriateness of depression treatment from baseline to 12 months. Changes in the costs of use of health services will be assessed from a societal perspective. Descriptive and qualitative data will be collected to examine the feasibility and acceptability of the intervention and identify barriers and facilitators to implementation.

DISCUSSION

Data collection began in May 2010 and is expected to be completed by July 2012. A collaborative nurse-led strategy may provide a feasible, acceptable and effective means for improving the health of older home care clients by improving the prevention, recognition, and management of depression in this vulnerable population. The challenges involved in designing a practical, transferable and sustainable nurse-led intervention in home care are also discussed.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT01407926.

Do productivity costs matter?: the impact of including productivity costs on the incremental costs of interventions targeted at depressive disorders

BACKGROUND

When guidelines for health economic evaluations prescribe that a societal perspective should be adopted, productivity costs should be included. However, previous research suggests that, in practice, productivity costs are often neglected. This may considerably bias the results of cost-effectiveness studies, particularly those regarding treatments targeted at diseases with a high incidence rate in the working population, such as depressive disorders.

OBJECTIVES

This study aimed to, first, investigate whether economic evaluations of treatments for depressive disorders include productivity costs and, if so, how. Second, to investigate how the inclusion or exclusion of productivity costs affects incremental costs.

METHODS

A systematic literature review was performed. Included articles were reviewed to determine (i) whether productivity costs had been included and (ii) whether the studies adhered to national health economic guidelines about the inclusion or exclusion of these costs. For those studies that did include productivity costs, we calculated what proportion of total costs were productivity costs. Subsequently, the incremental costs, excluding productivity costs, were calculated and compared with the incremental costs presented in the original article, to analyse the impact of productivity costs on final results. Regression analyses were used to investigate the relationship between the level of productivity costs and the type of depressive disorder, the type of treatment and study characteristics such as time horizon used and productivity cost valuation method.

RESULTS

A total of 81 unique economic evaluations of treatments for adults with depressive disorders were identified, 24 of which included productivity costs in the numerator and one in the denominator. Approximately 69% of the economic evaluations ignored productivity costs. Two-thirds of the studies complied with national guidelines regarding the inclusion of productivity costs. For the studies that included productivity costs, these costs reflected an average of 60% of total costs per treatment arm. The inclusion or exclusion of productivity costs substantially affected incremental costs in a number of studies. Regression analyses showed that the level of productivity costs was significantly associated with study characteristics such as average age, the methods of data collection regarding work time lost, the values attached to lost work time, the type of depressive disorder, the type of treatment provided and the level of direct costs.

CONCLUSIONS

Studies that do not include productivity costs may, in many cases, poorly reflect full societal costs (or savings) of an intervention. Furthermore, when comparing total costs reported in studies that include productivity costs, it should be noted that study characteristics such as the methods used to assess productivity costs may affect their level.

Informal stroke caregivers' self-appraised problem-solving abilities as a predictor of well-being and perceived social support

AIM

To describe the relationship between self-appraised problem-solving abilities and psychological distress, burden and perceived social support in informal, family stroke caregivers.

BACKGROUND

Previous research suggests that self-appraised problem-solving abilities play a significant role in the well-being of family caregivers of patients with chronic illness. However, little is known about its role in caregivers of stroke survivors.

DESIGN

Prospective correlational study.

METHODS

One week before discharge, 103 family caregivers of survivors of a first stroke were assessed for their perceived problem-solving abilities, social support, anxiety, depression and physical well-being. At three months postdischarge, 85 of these caregivers (83% retention) were reassessed on the same measures. In addition, their levels of burden and perceived difficulties were also measured.

RESULTS

Using multiple regression, overall self-appraised problem-solving abilities and its subscale 'confidence in problem-solving' at one week before discharge were significant predictors of caregiver perceived social support (R(2) = 29%) and perceived physical well-being (R(2) = 42%) at three months postdischarge. Other relationships were non-significant.

CONCLUSIONS

Caregivers' perceived social support and physical well-being were significantly predicted by confidence in problem-solving.

RELEVANCE TO CLINICAL PRACTICE

This study is timely given the challenges facing health systems in Hong Kong to effectively manage chronic illness through family-centred care. The significant relationships between caregiver self-appraised problem-solving, perceived social support and well-being suggest that interventions maximising caregiver confidence in problem-solving might be valuable in supporting family caregivers of stroke survivors. Nurses working with families caring for stroke survivors both close to discharge and in the early transition stages back at home may be in an ideal position to offer this support.

The future of specialist community teams in the care of those with severe mental illness

Aims – Specialist interventions in community psychiatry for severe mental illness are expanding and their place needs to be re-examined. Methods – Recent literature is reviewed to evaluate the advantages and disadvantages of specialist teams. Results – Good community mental health services reduce drop out from care, prevent suicide and unnatural deaths, and reduce admission to hospital. Most of these features have been also demonstrated by assertive community outreach and crisis resolution teams when good community services are not available. In well established community services assertive community teams do not reduce admission but both practitioners and patients prefer this service to other approaches and it leads to better engagement. Crisis resolution teams appear to be more successful than assertive community teams in preventing admission to hospital, although head- to-head comparisons have not yet been made. All specialist teams have the potential of fragmenting services and thereby reducing continuity of care. Conclusions – The assets of improved engagement and greater satisfaction with assertive, crisis resolution and home treatment teams are clear from recent evidence, but to improve integration of services they are probably best incorporated into community mental health services rather than standing alone.

Declaration of Interest: The author has been the sole consultant in two assertive outreach teams since 1994 and might there- fore be expected to be in favour of this genre of service. He has received grants for evaluation of different services models from the Department of Health (UK) and the Medical Research Council (UK).

Ways of working at the interface between primary and specialist mental healthcare

Ways of working at the interface between primary and specialist care are considered with discussion of the limits of available evidence and the potential for a new role for psychiatrists in providing supervision and consultation in novel models of care.

Brief psychosocial-behavioral intervention with antidepressant reduces poststroke depression significantly more than usual care with antidepressant: living well with stroke: randomized, controlled trial

BACKGROUND AND PURPOSE

Depression after stroke is prevalent, diminishing recovery and quality of life. Brief behavioral intervention, adjunctive to antidepressant therapy, has not been well evaluated for long-term efficacy in those with poststroke depression.

METHODS

One hundred one clinically depressed patients with ischemic stroke within 4 months of index stroke were randomly assigned to an 8-week brief psychosocial-behavioral intervention plus antidepressant or usual care, including antidepressant. The primary end point was reduction in depressive symptom severity at 12 months after entry.

RESULTS

Hamilton Rating Scale for Depression raw score in the intervention group was significantly lower immediately posttreatment (P<0.001) and at 12 months (P=0.05) compared with control subjects. Remission (Hamilton Rating Scale for Depression <10) was significantly greater immediately posttreatment and at 12 months in the intervention group compared with the usual care control. The mean percent decrease (47%+/-26% intervention versus 32%+/-36% control, P=0.02) and the mean absolute decrease (-9.2+/-5.7 intervention versus -6.2+/-6.4 control, P=0.023) in Hamilton Rating Scale for Depression at 12 months were clinically important and statistically significant in the intervention group compared with control.

CONCLUSIONS

A brief psychosocial-behavioral intervention is highly effective in reducing depression in both the short and long term.

Improving access to psychological therapy: Initial evaluation of two UK demonstration sites

Recently the UK Government announced an unprecedented, large-scale initiative for Improving Access to Psychological Therapies (IAPT) for depression and anxiety disorders. Prior to this development, the Department of Health established two pilot projects that aimed to collect valuable information to inform the national roll-out. Doncaster and Newham received additional funds to rapidly increase the availability of CBT-related interventions and to deploy them in new clinical services, operating on stepped-care principles, when appropriate. This article reports an evaluation of the new services (termed ‘demonstration sites’) during their first thirteen months of operation. A session-by-session outcome monitoring system achieved unusually high levels of pre to post-treatment data completeness. Large numbers of patients were treated, with low-intensity interventions (such as guided self-help) being particularly helpful for achieving high throughput. Clinical outcomes were broadly in line with expectation. 55–56% of patients who had attended at least twice (including the assessment interview) were classified as recovered when they left the services and 5% had improved their employment status. Treatment gains were largely maintained at 10 month follow-up. Opening the services to self-referral appeared to facilitate access for some groups that tend to be underrepresented in general practice referrals. Outcomes were comparable for the different ethnic groups who access the services. Issues for the further development of IAPT are discussed.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed study quality.

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Failure to improve appropriateness of referrals to adult community mental health services--lessons from a multi-site cluster randomized controlled trial

BACKGROUND

Non-clinical factors impact on decisions about whether to refer a patient from primary care to specialist mental health services. The aim of this study was to investigate whether introducing a standardized assessment of severity improves agreement on referrals.

METHODS

Multi-site mixed-method cluster randomized controlled trial, investigating GP referrals from 73 practices (408 839 patients) to 11 community mental health teams (CMHTs). Intervention group GPs were asked to complete a Threshold Assessment Grid (TAG) rating of mental health problem severity. CMHTs rated referral appropriateness.

RESULTS

Two hundred and eighty-one GPs made 1061 mental health referrals. The intervention was only partly implemented with 25% of intervention group GPs completing TAGs. No difference was found in appropriateness (OR 1.18, 95% CI 0.91-1.53) or secondary outcomes. Post-referral primary care contact rates were higher for the intervention group (IRR 1.36, 95% CI 1.07-1.73). Qualitative data identified professional and organizational barriers to implementation.

CONCLUSIONS

Asking GPs to complete a TAG when referring to CMHTs did not improve primary-secondary care agreement on referrals. Low implementation means that uncertainty remains about whether introducing a severity-focussed measure into the referral process is beneficial. Introducing local protocols to manage demand at this interface may not be successful and more attention needs to be paid to human and organizational factors in managing interfaces between services.

The analysis of continuous outcomes in multi-centre trials with small centre sizes

The standard analysis of clinical trials stratified by centre is to include centres as fixed effects, but if many centres contribute small numbers of patients, this approach results in a loss of power. Assuming no treatment by centre interaction, we used simulation to examine power and coverage of confidence intervals from three approaches to the analysis of continuous outcome in multi-centre trials: ignoring centres, including centres as fixed effects, and including them as random effects. The simulation incorporated eight sizes of centre effects; randomization in blocks of size 2 or 4; and two sample sizes, namely 100 and 200 patients per treatment arm in a parallel groups design. All simulated data sets included many centres with few subjects. The three different approaches were unbiased and had similar coverage. Fixed effects analysis was less powerful, particularly when centre effects were small. Incorporating block randomization with larger block size increased non-orthogonality in the design, contributing to loss of power. Where centre effects are small and recruitment in many centres is low, the approaches of ignoring centres or incorporating them as random effects have better performance than the traditional fixed effects analysis.

Primary care patients with mental health problems: outcome of a randomised clinical trial

BACKGROUND

The prevalence of patients with mental health problems in general practice is high, and at least one-third of these problems last for 6 months or longer. Patients with these problems take up more time during a consultation and attend more frequently.

AIM

This study investigated the effectiveness of problem-solving treatment for primary care patients with mental health problems. The hypothesis was that patients receiving problem-solving treatment from a nurse would have fewer symptoms after 3 months, or a lower attendance rate, compared with patients receiving the usual care from the GP.

DESIGN OF THE STUDY

Randomised clinical trial.

SETTING

Twelve general practices in Amsterdam and 12 nurses from a mental healthcare institution.

METHOD

A sample of patients aged >or=18 years were screened for mental health problems with the general health questionnaire (GHQ-12) in the waiting room of the general practices, and were randomised. Patients receiving the problem-solving treatment were required to complete four to six treatment sessions, while patients in the control group were treated as usual by the GP.

RESULTS

No significant difference was found between the groups in terms of improved psychopathology or a decrease in attendance rate. Post-hoc analyses showed a sub-group of patients with more severe pathology who may benefit from problem-solving treatment.

CONCLUSION

The main results show that problem-solving treatment provided by a nurse adds little to the usual care from the GP for frequent attenders with mental health problems. Post-hoc analyses show that there may be a sub-group of more severely depressed patients who could benefit from problem-solving treatment.

Can training community mental health nurses to support family carers reduce behavioural problems in dementia? An exploratory pragmatic randomised controlled trial

BACKGROUND

Community mental health nurses (CMHNs) are the backbone of specialist mental health services in the UK. This study evaluated the effects of training CMHNs in a systematic psychosocial intervention (PSI), to help family carers manage behavioural changes in their relative with dementia.

METHOD

One hundred and thirteen family carers received PSI support from a 'trained' (experimental), or a 'usual practice' (control) CMHN. Primary (day-to-day behaviour problems and management) and secondary (carer mood) outcome measures were obtained at baseline, 6, 12 and 18 months. CMHN training and supervision commenced prior to, and continued throughout, the 18-month study.

RESULTS

Patient cognition declined in both groups, but problem behaviour reduced in experimental group families. However this effect was associated with the practice of some, not all, CMHNs. Carer management and mood improved with PSI support. In contrast, by 18 months, families supported by conventional CMHNs reported reduced coping resources, increased problem behaviour and their level of depression worsened. Only two CMHNs adhered to the PSI-protocol.

CONCLUSIONS

Some, but not all, 'trained' CMHNs used the PSI to help family carers reduce behavioural problems. A relatively long but not intensive PSI of 12-18 months was needed to moderate carer mood. Dementia-specific practice arrangements, training and sustained clinical supervision are important for the delivery of effective psychosocial interventions in dementia.

Shifting the focus: sequential methods of analysis with qualitative data

The purpose of this article is to illustrate both the processes of data analysis and the methodological development involved in adopting the sequential use of two data analysis methods applied to the same data set. Understanding of the phenomena of interest was sought through examining both the content and the form of nurses' accounts of practice experiences. Initially, a method of thematic content analysis was applied to understand what the nurses said about their experiences. The core theme of nurses' change agency derived from this analysis was examined further through a method of narrative analysis. In the second analysis, the focus was shifted to how the nurses accounted for their experiences. The innovative use of iterative, sequential methods of analysis revealed greater complexity and depth of understanding of the phenomena than would have been achieved with one method alone.

Process evaluation for complex interventions in primary care: understanding trials using the normalization process model

BACKGROUND

The Normalization Process Model is a conceptual tool intended to assist in understanding the factors that affect implementation processes in clinical trials and other evaluations of complex interventions. It focuses on the ways that the implementation of complex interventions is shaped by problems of workability and integration.

METHOD

In this paper the model is applied to two different complex trials: (i) the delivery of problem solving therapies for psychosocial distress, and (ii) the delivery of nurse-led clinics for heart failure treatment in primary care.

RESULTS

Application of the model shows how process evaluations need to focus on more than the immediate contexts in which trial outcomes are generated. Problems relating to intervention workability and integration also need to be understood. The model may be used effectively to explain the implementation process in trials of complex interventions.

CONCLUSION

The model invites evaluators to attend equally to considering how a complex intervention interacts with existing patterns of service organization, professional practice, and professional-patient interaction. The justification for this may be found in the abundance of reports of clinical effectiveness for interventions that have little hope of being implemented in real healthcare settings.