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Menear M, Girard A, Dugas M, Gervais M, Gilbert M, Gagnon MP. Personalized care planning and shared decision making in collaborative care programs for depression and anxiety disorders: A systematic review. PLoS One 2022; 17:e0268649. [PMID: 35687610 PMCID: PMC9187074 DOI: 10.1371/journal.pone.0268649] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 05/04/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Collaborative care is an evidence-based approach to improving outcomes for common mental disorders in primary care. Efforts are underway to broadly implement the collaborative care model, yet the extent to which this model promotes person-centered mental health care has been little studied. The aim of this study was to describe practices related to two patient and family engagement strategies-personalized care planning and shared decision making-within collaborative care programs for depression and anxiety disorders in primary care. METHODS We conducted an update of a 2012 Cochrane review, which involved searches in Cochrane CCDAN and CINAHL databases, complemented by additional database, trial registry, and cluster searches. We included programs evaluated in a clinical trials targeting adults or youth diagnosed with depressive or anxiety disorders, as well as sibling reports related to these trials. Pairs of reviewers working independently selected the studies and data extraction for engagement strategies was guided by a codebook. We used narrative synthesis to report on findings. RESULTS In total, 150 collaborative care programs were analyzed. The synthesis showed that personalized care planning or shared decision making were practiced in fewer than half of programs. Practices related to personalized care planning, and to a lesser extent shared decision making, involved multiple members of the collaborative care team, with care managers playing a pivotal role in supporting patient and family engagement. Opportunities for quality improvement were identified, including fostering greater patient involvement in collaborative goal setting and integrating training and decision aids to promote shared decision making. CONCLUSION This review suggests that personalized care planning and shared decision making could be more fully integrated within collaborative care programs for depression and anxiety disorders. Their absence in some programs is a missed opportunity to spread person-centered mental health practices in primary care.
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Affiliation(s)
- Matthew Menear
- VITAM Research Centre for Sustainable Health, Quebec, Quebec, Canada
- Department of Family Medicine and Emergency Medicine, Université Laval, Quebec, Quebec, Canada
- * E-mail:
| | - Ariane Girard
- VITAM Research Centre for Sustainable Health, Quebec, Quebec, Canada
- Department of Family Medicine and Emergency Medicine, Université Laval, Quebec, Quebec, Canada
| | - Michèle Dugas
- VITAM Research Centre for Sustainable Health, Quebec, Quebec, Canada
| | - Michel Gervais
- Centre Intégré Universitaire de Santé et de Services Sociaux de la Capitale-Nationale, Quebec, Quebec, Canada
| | - Michel Gilbert
- Centre National d’Excellence en Santé Mentale, Quebec, Quebec, Canada
| | - Marie-Pierre Gagnon
- VITAM Research Centre for Sustainable Health, Quebec, Quebec, Canada
- Faculty of Nursing, Université Laval, Quebec, Quebec, Canada
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Curth NK, Brinck-Claussen UØ, Hjorthøj C, Davidsen AS, Mikkelsen JH, Lau ME, Lundsteen M, Csillag C, Christensen KS, Jakobsen M, Bojesen AB, Nordentoft M, Eplov LF. Collaborative care for depression and anxiety disorders: results and lessons learned from the Danish cluster-randomized Collabri trials. BMC FAMILY PRACTICE 2020; 21:234. [PMID: 33203365 PMCID: PMC7673096 DOI: 10.1186/s12875-020-01299-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 10/26/2020] [Indexed: 11/10/2022]
Abstract
BACKGROUND Meta-analyses suggest that collaborative care (CC) improves symptoms of depression and anxiety. In CC, a care manager collaborates with a general practitioner (GP) to provide evidence-based care. Most CC research is from the US, focusing on depression. As research results may not transfer to other settings, we developed and tested a Danish CC-model (the Collabri-model) for depression, panic disorder, generalized anxiety disorder, and social anxiety disorder in general practice. METHODS Four cluster-randomized superiority trials evaluated the effects of CC. The overall aim was to explore if CC significantly improved depression and anxiety symptoms compared to treatment-as-usual at 6-months' follow-up. The Collabri-model was founded on a multi-professional collaboration between a team of mental-health specialists (psychiatrists and care managers) and GPs. In collaboration with GPs, care managers provided treatment according to a structured plan, including regular reassessments and follow-up. Treatment modalities (cognitive behavioral therapy, psychoeducation, and medication) were offered based on stepped care algorithms. Face-to-face meetings between GPs and care managers took place regularly, and a psychiatrist provided supervision. The control group received treatment-as-usual. Primary outcomes were symptoms of depression (BDI-II) and anxiety (BAI) at 6-months' follow-up. The incremental cost-effectiveness ratio (ICER) was estimated based on 6-months' follow-up. RESULTS Despite various attempts to improve inclusion rates, the necessary number of participants was not recruited. Seven hundred thirty-one participants were included: 325 in the depression trial and 406 in the anxiety trials. The Collabri-model was implemented, demonstrating good fidelity to core model elements. In favor of CC, we found a statistically significant difference between depression scores at 6-months' follow-up in the depression trial. The difference was not significant at 15-months' follow-up. The anxiety trials were pooled for data analysis due to inadequate sample sizes. At 6- and 15-months' follow-up, there was a difference in anxiety symptoms favoring CC. These differences were not statistically significant. The ICER was 58,280 Euro per QALY. CONCLUSIONS At 6 months, a significant difference between groups was found in the depression trial, but not in the pooled anxiety trial. However, these results should be cautiously interpreted as there is a risk of selection bias and lacking statistical power. TRIAL REGISTRATION ClinicalTrials.gov, ID: NCT02678624 and NCT02678845 . Retrospectively registered on 7 February 2016.
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Affiliation(s)
- Nadja Kehler Curth
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Mental Health Services, Gentofte Hospitalsvej 15, 2900, Hellerup, Denmark.
| | - Ursula Ødum Brinck-Claussen
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Mental Health Services, Gentofte Hospitalsvej 15, 2900, Hellerup, Denmark
| | - Carsten Hjorthøj
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Mental Health Services, Gentofte Hospitalsvej 15, 2900, Hellerup, Denmark
- Department of Public Health, Section of Epidemiology, University of Copenhagen, Copenhagen, Denmark
| | - Annette Sofie Davidsen
- The Research Unit for General Practice and Section of General Practice, University of Copenhagen, Øster Farimagsgade 5, Postbox 2099, 1014, Copenhagen K, Denmark
| | - John Hagel Mikkelsen
- Mental Health Center Frederiksberg, Mental Health Services, Nordre Fasanvej 57-59, 2000, Frederiksberg, Denmark
| | - Marianne Engelbrecht Lau
- Stolpegård Psychotherapy Center, Mental Health Services, Stolpegårdsvej 20, 2820, Gentofte, Denmark
| | | | - Claudio Csillag
- Mental Health Center North Zealand, Mental Health Services, Dyrehavevej 48, 3400, Hillerød, Denmark
| | - Kaj Sparle Christensen
- Department of Public Health, Aarhus University, Aarhus, Denmark
- Research Unit for General Practice, Institute of Public Health, Aarhus University, Bartholins Allé 2, 8000, Aarhus C, Denmark
| | - Marie Jakobsen
- VIVE - The Danish Center for Social Science Research, Herluf Trolles Gade 11, 1052, Copenhagen K, Denmark
| | - Anders Bo Bojesen
- VIVE - The Danish Center for Social Science Research, Herluf Trolles Gade 11, 1052, Copenhagen K, Denmark
| | - Merete Nordentoft
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Mental Health Services, Gentofte Hospitalsvej 15, 2900, Hellerup, Denmark
- Institute for Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lene Falgaard Eplov
- Copenhagen Research Center for Mental Health - CORE, Mental Health Center Copenhagen, Mental Health Services, Gentofte Hospitalsvej 15, 2900, Hellerup, Denmark
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Moriarty AS, Coventry PA, Hudson JL, Cook N, Fenton OJ, Bower P, Lovell K, Archer J, Clarke R, Richards DA, Dickens C, Gask L, Waheed W, Huijbregts KM, van der Feltz-Cornelis C, Ali S, Gilbody S, McMillan D. The role of relapse prevention for depression in collaborative care: A systematic review. J Affect Disord 2020; 265:618-644. [PMID: 31791677 DOI: 10.1016/j.jad.2019.11.105] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 10/01/2019] [Accepted: 11/21/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Relapse (the re-emergence of depression symptoms before full recovery) is common in depression and relapse prevention strategies are not well researched in primary care settings. Collaborative care is effective for treating acute phase depression but little is known about the use of relapse prevention strategies in collaborative care. We undertook a systematic review to identify and characterise relapse prevention strategies in the context of collaborative care. METHODS We searched for Randomised Controlled Trials (RCTs) of collaborative care for depression. In addition to published material, we obtained provider and patient manuals from authors to provide more detail on intervention content. We reported the extent to which collaborative care interventions addressed four relapse prevention components. RESULTS 93 RCTs were identified. 31 included a formal relapse prevention plan; 42 had proactive monitoring and follow-up after the acute phase; 39 reported strategies for optimising sustained medication adherence; and 20 of the trials reported psychological or psycho-educational treatments persisting beyond the acute phase or focussing on long-term health/relapse prevention. 30 (32.3%) did not report relapse prevention approaches. LIMITATIONS We did not receive trial materials for approximately half of the trials, which limited our ability to identify relevant features of intervention content. CONCLUSION Relapse is a significant risk amongst people treated for depression and interventions are needed that specifically address and minimise this risk. Given the advantages of collaborative care as a delivery system for depression care, there is scope for more consistency and increased effort to implement and evaluate relapse prevention strategies.
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Affiliation(s)
- Andrew S Moriarty
- Department of Health Sciences and the Hull York Medical School, University of York, Heslington, York, YO10 5DD, UK.
| | - Peter A Coventry
- Department of Health Sciences and Centre for Reviews and Dissemination, University of York, Heslington, York, YO10 5DD, UK.
| | - Joanna L Hudson
- King's College London, Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, 16 De Crespigny Park, London, SE5 8AF, UK.
| | - Natalie Cook
- Department of Health Sciences and the Hull York Medical School, University of York, Heslington, York, YO10 5DD, UK.
| | - Oliver J Fenton
- Tees, Esk and Wear Valleys NHS Foundation Trust, South and West Community Mental Health Team, Acomb Garth, 2 Oak Rise, York, YO24 4LJ, UK.
| | - Peter Bower
- NIHR School for Primary Care Research, Centre for Primary Care, Manchester Academic Health Science Centre, University of Manchester, Oxford Rd, Manchester, M13 9PL, UK.
| | - Karina Lovell
- Division of Nursing, Midwifery & Social Work, University of Manchester, Oxford Rd, Manchester, M13 9PL, UK.
| | - Janine Archer
- School of Health and Society, University of Salford, Mary Seacole Building, Broad St, Frederick Road Campus, Salford, M6 6PU, UK.
| | - Rose Clarke
- Sheffield IAPT, St George's Community Health Centre, Winter Street, Sheffield, South Yorkshire, S3 7ND, UK.
| | - David A Richards
- Institute of Health Research, College of Medicine and Health, University of Exeter, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK.
| | - Chris Dickens
- Institute of Health Research, College of Medicine and Health, University of Exeter, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK.
| | - Linda Gask
- NIHR School for Primary Care Research, Centre for Primary Care, Manchester Academic Health Science Centre, University of Manchester, Oxford Rd, Manchester, M13 9PL, UK.
| | - Waquas Waheed
- NIHR School for Primary Care Research, Centre for Primary Care, Manchester Academic Health Science Centre, University of Manchester, Oxford Rd, Manchester, M13 9PL, UK.
| | - Klaas M Huijbregts
- GGNet, Mental Health, RGC SKB Winterswijk, Beatrixpark 1, 7101 BN Winterswijk, The Netherlands.
| | | | - Shehzad Ali
- Epidemiology and Biostatistics Department, Schulich School of Medicine & Dentistry, Western University, Kresge Building, Room K201, London, Ontario, N6A 5C1, Canada; Department of Health Sciences, University of York, Heslington, York, YO10 5DD, UK.
| | - Simon Gilbody
- Department of Health Sciences and the Hull York Medical School, University of York, Heslington, York, YO10 5DD, UK.
| | - Dean McMillan
- Department of Health Sciences and the Hull York Medical School, University of York, Heslington, York, YO10 5DD, UK.
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Curth NK, Brinck-Claussen U, Jørgensen KB, Rosendal S, Hjorthøj C, Nordentoft M, Eplov LF. Collaborative care vs consultation liaison for depression and anxiety disorders in general practice: study protocol for two randomized controlled trials (the Danish Collabri Flex trials). Trials 2019; 20:607. [PMID: 31653228 PMCID: PMC6814969 DOI: 10.1186/s13063-019-3657-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 08/13/2019] [Indexed: 01/18/2023] Open
Abstract
Background Models of collaborative care and consultation liaison propose organizational changes to improve the quality of care for people with common mental disorders, such as anxiety and depression. Some literature suggests only short-term positive effects of consultation liaison on patient-related outcomes, whereas collaborative care demonstrates both short-term and long-term positive effects. To our knowledge, only one randomized trial has compared the effects of these models. Collaborative care was superior to consultation liaison in reducing symptoms of depression for up to 3 months, but the authors found no difference at 9-months' follow-up. The Collabri Flex Trial for Depression and the Collabri Flex Trial for Anxiety aim to compare the effects of collaborative care with those of a form of consultation liaison that contains potential contaminating elements from collaborative care. The trials build on knowledge from the previous cluster-randomized Collabri trials. Methods Two randomized, investigator-initiated, parallel-group, superiority trials have been established: one investigating the effects of collaborative care vs consultation liaison for depression and one investigating the effects of collaborative care vs consultation liaison for generalized anxiety, panic disorder and social anxiety disorder at 6-months' follow-up. Participants are recruited from general practices in the Capital Region of Denmark: 240 in the depression trial and 284 in the anxiety trial. The primary outcome is self-reported depression symptoms (Beck Depression Inventory (BDI-II)) in the depression trial and self-reported anxiety symptoms (Beck Anxiety Inventory (BAI)) in the anxiety trial. In both trials, the self-reported secondary outcomes are general psychological problems and symptoms (Symptom Checklist 90-Revised), functional impairment (Sheehan Disability Scale) and general well-being (World Health Organization-Five Well-Being Index). In the depression trial, BAI is an additional secondary outcome, and BDI-II is an additional secondary outcome in the anxiety trial. Explorative outcomes will also be collected. Discussion The results will supplement those of the cluster-randomized Collabri trials and provide pivotal information about the effects of collaborative care in Denmark. Trial registration ClinicalTrials.gov, NCT03113175 and NCT03113201. Registered on 13 April 2017. Electronic supplementary material The online version of this article (10.1186/s13063-019-3657-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nadja Kehler Curth
- Research Unit, Mental Health Center Copenhagen, Mental Health Services, Capital Region of Denmark, Kildegårdsvej 28, 15A, 4th floor, DK-2900, Hellerup, Denmark.
| | - Ursula Brinck-Claussen
- Research Unit, Mental Health Center Copenhagen, Mental Health Services, Capital Region of Denmark, Kildegårdsvej 28, 15A, 4th floor, DK-2900, Hellerup, Denmark
| | - Kirstine Bro Jørgensen
- Research Unit, Mental Health Center Copenhagen, Mental Health Services, Capital Region of Denmark, Kildegårdsvej 28, 15A, 4th floor, DK-2900, Hellerup, Denmark
| | - Susanne Rosendal
- Mental Health Center Copenhagen, Mental Health Services, Capital Region of Denmark, Nordre Fasanvej 59, Vej 5, 12, 2nd floor, DK-2000, Frederiksberg, Denmark
| | - Carsten Hjorthøj
- Research Unit, Mental Health Center Copenhagen, Mental Health Services, Capital Region of Denmark, Kildegårdsvej 28, 15A, 4th floor, DK-2900, Hellerup, Denmark
| | - Merete Nordentoft
- Research Unit, Mental Health Center Copenhagen, Mental Health Services, Capital Region of Denmark, Kildegårdsvej 28, 15A, 4th floor, DK-2900, Hellerup, Denmark
| | - Lene Falgaard Eplov
- Research Unit, Mental Health Center Copenhagen, Mental Health Services, Capital Region of Denmark, Kildegårdsvej 28, 15A, 4th floor, DK-2900, Hellerup, Denmark
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Underner M, Cuvelier A, Peiffer G, Perriot J, Jaafari N. Influence de l’anxiété et de la dépression sur les exacerbations au cours de la BPCO. Rev Mal Respir 2018; 35:604-625. [PMID: 29937312 DOI: 10.1016/j.rmr.2018.04.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 01/13/2018] [Indexed: 02/05/2023]
Affiliation(s)
- M Underner
- Unité de recherche clinique, centre hospitalier Henri-Laborit, université de Poitiers, 370, avenue Jacques-Cœur CS 10587, 86021 Poitiers cedex, France.
| | - A Cuvelier
- Service de pneumologie, oncologie thoracique et soins intensifs respiratoires, centre hospitalier universitaire de Rouen, 76031 Rouen, France; Université de Rouen-Normandie, UPRES EA3830 groupe de recherche sur le handicap ventilatoire (GRHV), Institut de recherche et d'innovation biomédicale (IRIB), 76000 Rouen, France
| | - G Peiffer
- Service de pneumologie, centre hospitalier régional Metz-Thionville, 57038 Metz, France
| | - J Perriot
- Dispensaire Émile-Roux, centre de tabacologie, 63100 Clermont-Ferrand, France
| | - N Jaafari
- Unité de recherche clinique, centre hospitalier Henri-Laborit, université de Poitiers, 370, avenue Jacques-Cœur CS 10587, 86021 Poitiers cedex, France
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Curth NK, Brinck-Claussen UØ, Davidsen AS, Lau ME, Lundsteen M, Mikkelsen JH, Csillag C, Hjorthøj C, Nordentoft M, Eplov LF. Collaborative care for panic disorder, generalised anxiety disorder and social phobia in general practice: study protocol for three cluster-randomised, superiority trials. Trials 2017; 18:382. [PMID: 28814317 PMCID: PMC5559780 DOI: 10.1186/s13063-017-2120-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 07/26/2017] [Indexed: 01/17/2023] Open
Abstract
Background People with anxiety disorders represent a significant part of a general practitioner’s patient population. However, there are organisational obstacles for optimal treatment, such as a lack of coordination of illness management and limited access to evidence-based treatment such as cognitive behavioral therapy. A limited number of studies suggest that collaborative care has a positive effect on symptoms for people with anxiety disorders. However, most studies are carried out in the USA and none have reported results for social phobia or generalised anxiety disorder separately. Thus, there is a need for studies carried out in different settings for specific anxiety populations. A Danish model for collaborative care (the Collabri model) has been developed for people diagnosed with depression or anxiety disorders. The model is evaluated through four trials, of which three will be outlined in this protocol and focus on panic disorder, generalised anxiety disorder and social phobia. The aim is to investigate whether treatment according to the Collabri model has a better effect than usual treatment on symptoms when provided to people with anxiety disorders. Methods Three cluster-randomised, clinical superiority trials are set up to investigate treatment according to the Collabri model for collaborative care compared to treatment-as-usual for 364 patients diagnosed with panic disorder, generalised anxiety disorder and social phobia, respectively (total n = 1092). Patients are recruited from general practices located in the Capital Region of Denmark. For all trials, the primary outcome is anxiety symptoms (Beck Anxiety Inventory (BAI)) 6 months after baseline. Secondary outcomes include BAI after 15 months, depression symptoms (Beck Depression Inventory) after 6 months, level of psychosocial functioning (Global Assessment of Functioning) and general psychological symptoms (Symptom Checklist-90-R) after 6 and 15 months. Discussion Results will add to the limited pool of information about collaborative care for patients with anxiety disorders. To our knowledge, these will be the first carried out in a Danish context and the first to report results for generalised anxiety and social phobia separately. If the trials show positive results, they could contribute to the improvement of future treatment of anxiety disorders. Trial registration ClinicalTrials.gov, ID: NCT02678624. Retrospectively registered 7 February 2016; last updated 15 August 2016, Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2120-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nadja Kehler Curth
- Mental Health Center Copenhagen, Mental Health Services, Capital Region of Denmark, Kildegårdsvej 28, 2900, Hellerup, Denmark
| | - Ursula Ødum Brinck-Claussen
- Mental Health Center Copenhagen, Mental Health Services, Capital Region of Denmark, Kildegårdsvej 28, 2900, Hellerup, Denmark.
| | - Annette Sofie Davidsen
- Research Unit for General Practice and Section of General Practice, University of Copenhagen, Øster Farimagsgade 5, PO Box 2099, 1014, Copenhagen K, Denmark
| | - Marianne Engelbrecht Lau
- Stolpegård Psychotherapy Centre, Mental Health Services, Capital Region of Denmark, Stolpegårdsvej 20, 2820, Gentofte, Denmark
| | | | - John Hagel Mikkelsen
- Mental Health Center Frederiksberg, Mental Health Services, Capital Region of Denmark, Nordre Fasanvej 57-59, 2000, Frederiksberg, Denmark
| | - Claudio Csillag
- Mental Health Center North Zealand, Mental Health Services, Capital Region of Denmark, Dyrehavevej 48, 3400, Hillerød, Denmark
| | - Carsten Hjorthøj
- Mental Health Center Copenhagen, Mental Health Services, Capital Region of Denmark, Kildegårdsvej 28, 2900, Hellerup, Denmark
| | - Merete Nordentoft
- Institute for Clinical Medicine, University of Copenhagen, Mental Health Center Copenhagen, Mental Health Services, Capital Region of Denmark, Kildegårdsvej 28, 2900, Hellerup, Denmark
| | - Lene Falgaard Eplov
- Mental Health Center Copenhagen, Mental Health Services, Capital Region of Denmark, Kildegårdsvej 28, 2900, Hellerup, Denmark
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Brinck-Claussen UØ, Curth NK, Davidsen AS, Mikkelsen JH, Lau ME, Lundsteen M, Csillag C, Christensen KS, Hjorthøj C, Nordentoft M, Eplov LF. Collaborative care for depression in general practice: study protocol for a randomised controlled trial. Trials 2017; 18:344. [PMID: 28732523 PMCID: PMC5521147 DOI: 10.1186/s13063-017-2064-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2016] [Accepted: 06/24/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Depression is a common illness with great human costs and a significant burden on the public economy. Previous studies have indicated that collaborative care (CC) has a positive effect on symptoms when provided to people with depression, but CC has not yet been applied in a Danish context. We therefore developed a model for CC (the Collabri model) to treat people with depression in general practice in Denmark. Since systematic identification of patients is an "active ingredient" in CC and some literature suggests case finding as the best alternative to standard detection, the two detection methods are examined as part of the study. The aim is to investigate if treatment according to the Collabri model has an effect on depression symptoms when provided to people with depression in general practice in Denmark, and to examine if case finding is a better method to detect depression in general practice than standard detection. METHODS/DESIGN The trial is a cluster-randomised, clinical superiority trial investigating the effect of treatment according to the Collabri model for CC, compared to treatment as usual for 480 participants diagnosed with depression in general practice in the Capital Region of Denmark. The primary outcome is depression symptoms (Beck's Depression Inventory (BDI-II)) after 6 months. Secondary outcomes include depression symptoms (BDI-II) after 15 months, anxiety symptoms (Beck's Anxiety Inventory (BAI)), level of functioning (Global Assessment of Function (GAF)) and psychological stress (Symptom Checklist-90-Revised (SCL-90-R)). In addition, case finding (with the recommended screening tool Major Depression Inventory (MDI)) and standard detection of depression is examined in a cluster-randomized controlled design. Here, the primary outcome is the positive predictive value of referral diagnosis. DISCUSSION If the Collabri model is shown to be superior to treatment as usual, the study will contribute with important knowledge on how to improve treatment of depression in general practice, with major benefit to patients and society. If case finding is shown to be superior to standard detection, it will be recommended as the detection method in future treatment according to the Collabri model. TRIAL REGISTRATION ClinicalTrials.gov. NCT02678845 . Retrospectively registered on 7 February 2016.
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Affiliation(s)
- Ursula Ødum Brinck-Claussen
- Mental Health Center Copenhagen, Mental Health Services, Kildegårdsvej 28, DK- 2900 Hellerup, Capital Region of Denmark Denmark
| | - Nadja Kehler Curth
- Mental Health Center Copenhagen, Mental Health Services, Kildegårdsvej 28, DK- 2900 Hellerup, Capital Region of Denmark Denmark
| | - Annette Sofie Davidsen
- The Research Unit for General Practice and Section of General Practice, University of Copenhagen, Øster Farimagsgade 5, Postboks 2099, 1014 Copenhagen K, Denmark
| | - John Hagel Mikkelsen
- Mental Health Center Copenhagen, Mental Health Services, Kildegårdsvej 28, DK- 2900 Hellerup, Capital Region of Denmark Denmark
- Mental Health Center Frederiksberg, Mental Health Services, Nordre Fasanvej 57-59, 2000 Frederiksberg, Capital Region of Denmark Denmark
| | - Marianne Engelbrecht Lau
- Mental Health Center Copenhagen, Mental Health Services, Kildegårdsvej 28, DK- 2900 Hellerup, Capital Region of Denmark Denmark
- Stolpegård Psychotherapy Center, Mental Health Services, Stolpegårdsvej 20, 2820 Gentofte, Capital Region of Denmark Denmark
| | | | - Claudio Csillag
- Mental Health Center Copenhagen, Mental Health Services, Kildegårdsvej 28, DK- 2900 Hellerup, Capital Region of Denmark Denmark
- Mental Health Center North Zealand, Mental Health Services, Dyrehavevej 48, 3400 Hillerød, Capital Region of Denmark Denmark
| | - Kaj Sparle Christensen
- Department of Public Health, Aarhus University, Aarhus, Denmark
- Research Unit for General Practice, Institute of Public Health, Aarhus University, Bartholins Allé 2, 8000 Aarhus C, Denmark
| | - Carsten Hjorthøj
- Mental Health Center Copenhagen, Mental Health Services, Kildegårdsvej 28, DK- 2900 Hellerup, Capital Region of Denmark Denmark
| | - Merete Nordentoft
- Mental Health Center Copenhagen, Mental Health Services, Kildegårdsvej 28, DK- 2900 Hellerup, Capital Region of Denmark Denmark
- Institute for Clinical Medicine, University of Copenhagen, Mental Health Center Copenhagen, Mental Health Services, Kildegårdsvej 28, DK-2900 Hellerup, Capital Region of Denmark Denmark
| | - Lene Falgaard Eplov
- Mental Health Center Copenhagen, Mental Health Services, Kildegårdsvej 28, DK- 2900 Hellerup, Capital Region of Denmark Denmark
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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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Vargas I, Mogollón-Pérez AS, De Paepe P, da Silva MRF, Unger JP, Vázquez ML. Do existing mechanisms contribute to improvements in care coordination across levels of care in health services networks? Opinions of the health personnel in Colombia and Brazil. BMC Health Serv Res 2015; 15:213. [PMID: 26022531 PMCID: PMC4447020 DOI: 10.1186/s12913-015-0882-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 05/19/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The fragmentation of healthcare provision has given rise to a wide range of interventions within organizations to improve coordination across levels of care, primarily in high income countries but also in some middle and low-income countries. The aim is to analyze the use of coordination mechanisms in healthcare networks and its implications for the delivery of health care. This is studied from the perspective of health personnel in two countries with different health systems, Colombia and Brazil. METHODS A qualitative, exploratory and descriptive-interpretative study was conducted, based on a case study of healthcare networks in two municipalities in each country. Individual semi-structured interviews were conducted with a three stage theoretical sample of a) health (112) and administrative (66) professionals of different care levels, and b) managers of providers (42) and insurers (14). A thematic content analysis was conducted, segmented by cases, informant groups and themes. RESULTS The results show that care coordination mechanisms are poorly implemented in general. However, the results are marginally better in certain segments of the Colombian networks analyzed (ambulatory centres with primary and secondary care co-location owned by or tied to the contributory scheme insurers, and public providers of the subsidized scheme); and in the network of the state capital in Brazil. Professionals point to numerous problems in the use of existing mechanisms, such as the insufficient recording of information in referral forms, low frequency and level of participation in shared clinical sessions, low adherence to the few available clinical guidelines and the lack of or inadequate referral of patients by the patient referral centres, particularly in the Brazilian networks. The absence or limited use of care coordination mechanisms leads, according to informants, to the inadequate follow-up of patients, interruptions in care and duplication of tests. Professionals use informal strategies to try to overcome these limitations. CONCLUSIONS The results indicate not only the limited implementation of mechanisms for coordination across care levels, but also a limited use of existing mechanisms in the healthcare networks analyzed. This has a negative impact on coordination, efficiency and quality of care. Organizational changes are required in the networks and healthcare systems to address these problems.
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Affiliation(s)
- Ingrid Vargas
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Avenida Tibidabo, 21, 08022, Barcelona, Spain.
| | - Amparo Susana Mogollón-Pérez
- Faculty of Medicine and Health Sciences, Universidad del Rosario, Carrera 24, No. 63C -69, 11001, Bogotá, Colombia.
| | - Pierre De Paepe
- Prince Leopold Institute of Tropical Medicine, Nationalestraat, 5, 2000, Antwerpen, Belgium.
| | | | - Jean Pierre Unger
- Prince Leopold Institute of Tropical Medicine, Nationalestraat, 5, 2000, Antwerpen, Belgium.
| | - María Luisa Vázquez
- Health Policy and Health Services Research Group, Health Policy Research Unit, Consortium for Health Care and Social Services of Catalonia, Avenida Tibidabo, 21, 08022, Barcelona, Spain.
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Haddad MS, Zelenev A, Altice FL. Buprenorphine maintenance treatment retention improves nationally recommended preventive primary care screenings when integrated into urban federally qualified health centers. J Urban Health 2015; 92:193-213. [PMID: 25550126 PMCID: PMC4338126 DOI: 10.1007/s11524-014-9924-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Buprenorphine maintenance therapy (BMT) expands treatment access for opioid dependence and can be integrated into primary health-care settings. Treating opioid dependence, however, should ideally improve other aspects of overall health, including preventive services. Therefore, we examined how BMT affects preventive health-care outcomes, specifically nine nationally recommended primary care quality health-care indicators (QHIs), within federally qualified health centers (FQHCs) from an observational cohort study of 266 opioid-dependent patients initiating BMT between 07/01/07 and 11/30/08 within Connecticut's largest FQHC network. Nine nationally recommended preventive QHIs were collected longitudinally from electronic health records, including screening for chronic infections, metabolic conditions, and cancer. A composite QHI score (QHI-S), based on the percentage of eligible QHIs achieved, was categorized as QHI-S ≥80% (recommended) and ≥90% (optimal). The proportion of subjects achieving a composite QHI-S ≥80 and ≥90 % was 57.1 and 28.6%, respectively. Screening was highest for hypertension (91.0%), hepatitis C (80.1%), hepatitis B (76.3%), human immunodeficiency virus (71.4%), and hyperlipidemia (72.9%) and lower for syphilis (49.3%) and cervical (58.5%), breast (44.4%), and colorectal (48.7%) cancer. Achieving QHI-S ≥80% was positively and independently associated with ≥3-month BMT retention (adjusted odds ratio (AOR) = 2.19; 95% confidence interval (CI) = 1.18-4.04) and BMT prescription by primary care providers (PCPs) rather than addiction psychiatric specialists (AOR = 3.38; 95% CI = 1.78-6.37), and negatively with being female (AOR = 0.30; 95% CI = 0.16-0.55). Within primary health-care settings, achieving greater nationally recommended health-care screenings or QHIs was associated with being able to successfully retain patients on buprenorphine longer (3 months or more) and when buprenorphine was prescribed simultaneously by PCPs rather than psychiatric specialists. Decreased preventive screening for opioid-dependent women, however, may require gender-based strategies for achieving health-care parity. When patients can be retained, integrating BMT into urban FQHCs is associated with improved health outcomes including increased multiple preventive health-care screenings.
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Affiliation(s)
- Marwan S Haddad
- Community Health Center, Inc., 635 Main Street, Middletown, CT, 06457, USA,
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11
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Kilpatrick K, Kaasalainen S, Donald F, Reid K, Carter N, Bryant-Lukosius D, Martin-Misener R, Harbman P, Marshall DA, Charbonneau-Smith R, DiCenso A. The effectiveness and cost-effectiveness of clinical nurse specialists in outpatient roles: a systematic review. J Eval Clin Pract 2014; 20:1106-23. [PMID: 25040492 DOI: 10.1111/jep.12219] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/27/2014] [Indexed: 11/28/2022]
Abstract
RATIONALE, AIMS AND OBJECTIVES Increasing numbers of clinical nurse specialists (CNSs) are working in outpatient settings. The objective of this paper is to describe a systematic review of randomized controlled trials (RCTs) evaluating the cost-effectiveness of CNSs delivering outpatient care in alternative or complementary provider roles. METHODS We searched CINAHL, MEDLINE, EMBASE and seven other electronic databases, 1980 to July 2012 and hand-searched bibliographies and key journals. RCTs that evaluated formally trained CNSs and health system outcomes were included. Study quality was assessed using the Cochrane risk of bias tool and the Quality of Health Economic Studies instrument. We used the Grading of Recommendations Assessment, Development and Evaluation to assess quality of evidence for individual outcomes. RESULTS Eleven RCTs, four evaluating alternative provider (n = 683 participants) and seven evaluating complementary provider roles (n = 1464 participants), were identified. Results of the alternative provider RCTs (low-to-moderate quality evidence) were fairly consistent across study populations with similar patient outcomes to usual care, some evidence of reduced resource use and costs, and two economic analyses (one fair and one high quality) favouring CNS care. Results of the complementary provider RCTs (low-to-moderate quality evidence) were also fairly consistent across study populations with similar or improved patient outcomes and mostly similar health system outcomes when compared with usual care; however, the economic analyses were weak. CONCLUSIONS Low-to-moderate quality evidence supports the effectiveness and two fair-to-high quality economic analyses support the cost-effectiveness of outpatient alternative provider CNSs. Low-to-moderate quality evidence supports the effectiveness of outpatient complementary provider CNSs; however, robust economic evaluations are needed to address cost-effectiveness.
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Affiliation(s)
- Kelley Kilpatrick
- Canadian Centre for Advanced Practice Nursing Research, Hamilton, Ontario, Canada; Faculty of Nursing, Université de Montreal, Montreal, Quebec, Canada; Hôpital Maisonneuve-Rosemont Research Centre, Montreal, Quebec, Canada
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12
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Donald F, Kilpatrick K, Reid K, Carter N, Martin-Misener R, Bryant-Lukosius D, Harbman P, Kaasalainen S, Marshall DA, Charbonneau-Smith R, Donald EE, Lloyd M, Wickson-Griffiths A, Yost J, Baxter P, Sangster-Gormley E, Hubley P, Laflamme C, Campbell–Yeo M, Price S, Boyko J, DiCenso A. A systematic review of the cost-effectiveness of nurse practitioners and clinical nurse specialists: what is the quality of the evidence? Nurs Res Pract 2014; 2014:896587. [PMID: 25258683 PMCID: PMC4167459 DOI: 10.1155/2014/896587] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Revised: 06/26/2014] [Accepted: 06/27/2014] [Indexed: 12/25/2022] Open
Abstract
Background. Improved quality of care and control of healthcare costs are important factors influencing decisions to implement nurse practitioner (NP) and clinical nurse specialist (CNS) roles. Objective. To assess the quality of randomized controlled trials (RCTs) evaluating NP and CNS cost-effectiveness (defined broadly to also include studies measuring health resource utilization). Design. Systematic review of RCTs of NP and CNS cost-effectiveness reported between 1980 and July 2012. Results. 4,397 unique records were reviewed. We included 43 RCTs in six groupings, NP-outpatient (n = 11), NP-transition (n = 5), NP-inpatient (n = 2), CNS-outpatient (n = 11), CNS-transition (n = 13), and CNS-inpatient (n = 1). Internal validity was assessed using the Cochrane risk of bias tool; 18 (42%) studies were at low, 17 (39%) were at moderate, and eight (19%) at high risk of bias. Few studies included detailed descriptions of the education, experience, or role of the NPs or CNSs, affecting external validity. Conclusions. We identified 43 RCTs evaluating the cost-effectiveness of NPs and CNSs using criteria that meet current definitions of the roles. Almost half the RCTs were at low risk of bias. Incomplete reporting of study methods and lack of details about NP or CNS education, experience, and role create challenges in consolidating the evidence of the cost-effectiveness of these roles.
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Affiliation(s)
- Faith Donald
- Daphne Cockwell School of Nursing, Ryerson University, 350 Victoria Street, Toronto, ON, Canada M5B 2K3
| | - Kelley Kilpatrick
- Faculty of Nursing, Université de Montreal and Research Centre of Hôpital Maisonneuve-Rosemont, CSA-RC-Aile Bleue-Room F121, 5415 boulevard l'Assomption, Montréal, QC, Canada H1T 2M4
| | - Kim Reid
- KJ Research, Rosemere, QC, Canada J7A 4N8
| | - Nancy Carter
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
| | - Ruth Martin-Misener
- School of Nursing, Dalhousie University, Box 15000, 5869 University Avenue, Halifax, NS, Canada B3H 4R2
| | - Denise Bryant-Lukosius
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
- Department of Oncology, McMaster University, 1280 Main Street West, HSC-3N28G, Hamilton, ON, Canada L8S 4L8
| | - Patricia Harbman
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
- Health Interventions Research Centre, Ryerson University, 350 Victoria Street, Toronto, ON, Canada M5B 2K3
| | - Sharon Kaasalainen
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
| | - Deborah A. Marshall
- Department of Community Health Sciences, Faculty of Medicine, University of Calgary, Health Research Innovation Centre, Room 3C56, 3280 Hospital Drive NW, Calgary, AB, Canada T2N 4Z6
| | | | - Erin E. Donald
- Fraser Health Authority, Suite 400-13450 102nd Avenue, Surrey, BC, Canada V3T 0H1
| | - Monique Lloyd
- International Affairs and Best Practice Guidelines Centre, Registered Nurses' Association of Ontario, 158 Pearl Street, Toronto, ON, Canada M5H 1L3
| | | | - Jennifer Yost
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
| | - Pamela Baxter
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
| | - Esther Sangster-Gormley
- School of Nursing, University of Victoria, P.O. Box 1700 STN CSC, Victoria, BC, Canada V8W 2Y2
| | - Pamela Hubley
- The Hospital for Sick Children, Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 555 University Avenue, Toronto, ON, Canada M5G 1X8
| | - Célyne Laflamme
- Primary Health Care Nurse Practitioner Program, School of Nursing, University of Ottawa, 600 Peter Morand Crescent, Suite 101, Ottawa, ON, Canada K1G 5Z3
| | - Marsha Campbell–Yeo
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
- School of Nursing, Dalhousie University, Box 15000, 5869 University Avenue, Halifax, NS, Canada B3H 4R2
| | - Sheri Price
- School of Nursing, Dalhousie University, Box 15000, 5869 University Avenue, Halifax, NS, Canada B3H 4R2
| | - Jennifer Boyko
- School of Health Studies, Western University, Health Sciences Building, Room 403, London, ON, Canada N6A 5B9
| | - Alba DiCenso
- School of Nursing, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
- Department of Clinical Epidemiology & Biostatistics, McMaster University, 1280 Main Street West, Hamilton, ON, Canada L8S 4L8
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Fleury MJ, Grenier G, Bamvita JM, Caron J. Determinants and patterns of service utilization and recourse to professionals for mental health reasons. BMC Health Serv Res 2014; 14:161. [PMID: 24712834 PMCID: PMC3996168 DOI: 10.1186/1472-6963-14-161] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 03/25/2014] [Indexed: 11/10/2022] Open
Abstract
Background This study has a dual purpose: 1) identify determinants of healthcare service utilization for mental health reasons (MHR) in a Canadian (Montreal) catchment area; 2) determine the patterns of recourse to healthcare professionals in terms of frequency of visits and type of professionals consulted, and as it relates to the most prevalent mental disorders (MD) and psychological distress. Methods Data was collected from a random sample of 1,823 individuals interviewed after a two-year follow-up period. A regression analysis was performed to identify variables associated with service utilization and complementary analyses were carried out to better understand participants’ patterns of healthcare service utilization in relation to the most prevalent MD. Results Among 243 individuals diagnosed with a MD in the 12 months preceding an interview, 113 (46.5%) reported having used healthcare services for MHR. Determinants of service utilization were emotional and legal problems, number of MD, higher personal income, lower quality of life, inability of individuals to influence events occurring in their neighborhood, female gender and, marginally, lack of alcohol dependence in the past 12 months. Emotional problems were the most significant determinant of healthcare service utilization. Frequent visits with healthcare professionals were more likely associated with major depression and number of MD with or without dependence to alcohol or drugs. People suffering from major depression, psychological distress and social phobia were more likely to consult different professionals, while individuals with panic disorders relied on their family physician only. Concerning social phobia, panic disorders and psychological distress, more frequent visits with professionals did not translate into involvement of a higher number of professionals or vice-versa. Conclusions This study demonstrates the impact of emotional problems, neighborhood characteristics and legal problems in healthcare service utilization for MHR. Interventions based on inter-professional collaboration could be prioritized to increase the ability of healthcare services to take care especially of individuals suffering from social phobia, panic disorders and psychological distress. Others actions that could be prioritized are training of family physicians in the treatment of MD, use of psychiatric consultants, internet outreach, and reimbursement of psychological consultations for individuals with low income.
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Affiliation(s)
- Marie-Josée Fleury
- Department of Psychiatry, McGill University, Douglas Hospital Research Centre, 6875 LaSalle Blvd, Montreal, Quebec H4H 1R3, Canada.
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Miller CJ, Grogan-Kaylor A, Perron BE, Kilbourne AM, Woltmann E, Bauer MS. Collaborative chronic care models for mental health conditions: cumulative meta-analysis and metaregression to guide future research and implementation. Med Care 2013; 51:922-30. [PMID: 23938600 PMCID: PMC3800198 DOI: 10.1097/mlr.0b013e3182a3e4c4] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Prior meta-analysis indicates that collaborative chronic care models (CCMs) improve mental and physical health outcomes for individuals with mental disorders. This study aimed to investigate the stability of evidence over time and identify patient and intervention factors associated with CCM effects to facilitate implementation and sustainability of CCMs in clinical practice. METHODS We reviewed 53 CCM trials that analyzed depression, mental quality of life (QOL), or physical QOL outcomes. Cumulative meta-analysis and metaregression were supplemented by descriptive investigations across and within trials. RESULTS Most trials targeted depression in the primary care setting, and cumulative meta-analysis indicated that effect sizes favoring CCM quickly achieved significance for depression outcomes, and more recently achieved significance for mental and physical QOL. Four of 6 CCM elements (patient self-management support, clinical information systems, system redesign, and provider decision support) were common among reviewed trials, whereas 2 elements (health care organization support and linkages to community resources) were rare. No single CCM element was statistically associated with the success of the model. Similarly, metaregression did not identify specific factors associated with CCM effectiveness. Nonetheless, results within individual trials suggest that increased illness severity predicts CCM outcomes. CONCLUSIONS Significant CCM trials have been derived primarily from 4 original CCM elements. Nonetheless, implementing and sustaining this established model will require health care organization support. Although CCMs have typically been tested as population-based interventions, evidence supports stepped care application to more severely ill individuals. Future priorities include developing implementation strategies to support adoption and sustainability of the model in clinical settings while maximizing fit of this multicomponent framework to local contextual factors.
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Affiliation(s)
- Christopher J Miller
- *Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System †Department of Psychiatry, Harvard Medical School, Boston, MA ‡School of Social Work, University of Michigan §VA Ann Arbor Center for Clinical Management Research ∥Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI ¶The Brown School, Washington University, St Louis, MO
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McCusker J, Yaffe M, Sussman T, Kates N, Mulvale G, Jayabarathan A, Law S, Haggerty J. Developing an evaluation framework for consumer-centred collaborative care of depression using input from stakeholders. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2013; 58:160-8. [PMID: 23461887 DOI: 10.1177/070674371305800306] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To develop a framework for research and evaluation of collaborative mental health care for depression, which includes attributes or domains of care that are important to consumers. METHODS A literature review on collaborative mental health care for depression was completed and used to guide discussion at an interactive workshop with pan-Canadian participants comprising people treated for depression with collaborative mental health care, as well as their family members; primary care and mental health practitioners; decision makers; and researchers. Thematic analysis of qualitative data from the workshop identified key attributes of collaborative care that are important to consumers and family members, as well as factors that may contribute to improved consumer experiences. RESULTS The workshop identified an overarching theme of partnership between consumers and practitioners involved in collaborative care. Eight attributes of collaborative care were considered to be essential or very important to consumers and family members: respectfulness; involvement of consumers in treatment decisions; accessibility; provision of information; coordination; whole-person care; responsiveness to changing needs; and comprehensiveness. Three inter-related groups of factors may affect the consumer experience of collaborative care, namely, organizational aspects of care; consumer characteristics and personal resources; and community resources. CONCLUSION A preliminary evaluation framework was developed and is presented here to guide further evaluation and research on consumer-centred collaborative mental health care for depression.
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Affiliation(s)
- Jane McCusker
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada.
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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: 457] [Impact Index Per Article: 38.1] [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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Engel AG, Malta LS, Davies CA, Baker MM. Clinical effectiveness of using an integrated model to treat depressive symptoms in veterans affairs primary care clinics and its impact on health care utilization. Prim Care Companion CNS Disord 2011; 13:10m01096. [PMID: 22132351 DOI: 10.4088/pcc.10m01096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Accepted: 01/31/2011] [Indexed: 10/17/2022] Open
Abstract
OBJECTIVE To determine if veterans treated in an integrated mental health program within a Veterans Affairs (VA) primary care clinic sustained long-term improvement in depressive symptoms and changed their use of health care. METHOD In this pilot program, 72 veterans were offered short-term treatment for depressive symptoms by a colocated psychiatrist who was integrated into a VA primary care team (October 1, 1997, through September 30, 1999). Patients were assessed initially and at their final session using the Hamilton Depression Rating Scale. Veterans who completed treatment were referred back to their primary care provider or to specialty mental health services. Patients were contacted and invited to be reevaluated 3 to 5 years later using the same measure (December 1, 2001, through November 30, 2002). Health care utilization data were collected for 1 year preintervention and 2 years postintervention. Outcomes for treatment completers were compared to outcomes for those who declined or dropped out of treatment. RESULTS Of 48 patients who agreed to participate in the study, 27 completed treatment and showed a significant decline in symptoms from pretreatment to follow-up (P = .008) compared to 16 noncompleters, as well as a moderate-to-large between-group effect size (d = 0.78) and trends for higher remission and response rates. Completers ranked significantly higher in the number of antidepressant prescriptions filled before (P = .002) and after treatment (P = .001) and in the number of medical visits postintervention (year 1: P = .021; year 2: P = .023), without an associated cost increase. CONCLUSIONS Colocated mental health care integrated into VA primary care is associated with sustained improvement of depressive symptoms in a heterogeneous patient population with a high incidence of psychiatric comorbidities. This finding compares favorably with the results of earlier controlled clinical trials and suggests a potential effect on health care utilization.
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Affiliation(s)
- Anna G Engel
- Department of Psychiatry, Boston VA Healthcare System, West Roxbury, and Department of Psychiatry, Boston University School of Medicine, Boston, Massachusetts, USA.
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Kelly BJ, Perkins DA, Fuller JD, Parker SM. Shared care in mental illness: A rapid review to inform implementation. Int J Ment Health Syst 2011; 5:31. [PMID: 22104323 PMCID: PMC3235059 DOI: 10.1186/1752-4458-5-31] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Accepted: 11/21/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While integrated primary healthcare for the management of depression has been well researched, appropriate models of primary care for people with severe and persistent psychotic disorders are poorly understood. In 2010 the NSW (Australia) Health Department commissioned a review of the evidence on "shared care" models of ambulatory mental health services. This focussed on critical factors in the implementation of these models in clinical practice, with a view to providing policy direction. The review excluded evidence about dementia, substance use and personality disorders. METHODS A rapid review involving a search for systematic reviews on The Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effects (DARE). This was followed by a search for papers published since these systematic reviews on Medline and supplemented by limited iterative searching from reference lists. RESULTS Shared care trials report improved mental and physical health outcomes in some clinical settings with improved social function, self management skills, service acceptability and reduced hospitalisation. Other benefits include improved access to specialist care, better engagement with and acceptability of mental health services. Limited economic evaluation shows significant set up costs, reduced patient costs and service savings often realised by other providers. Nevertheless these findings are not evident across all clinical groups. Gains require substantial cross-organisational commitment, carefully designed and consistently delivered interventions, with attention to staff selection, training and supervision. Effective models incorporated linkages across various service levels, clinical monitoring within agreed treatment protocols, improved continuity and comprehensiveness of services. CONCLUSIONS "Shared Care" models of mental health service delivery require attention to multiple levels (from organisational to individual clinicians), and complex service re-design. Re-evaluation of the roles of specialist mental health staff is a critical requirement. As expected, no one model of "shared" care fits diverse clinical groups. On the basis of the available evidence, we recommended a local trial that examined the process of implementation of core principles of shared care within primary care and specialist mental health clinical services.
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Affiliation(s)
- Brian J Kelly
- Centre for Brain and Mental Health Research, School of Medicine and Public Health, Faculty of Health University of Newcastle, University Drive, Callaghan 2308, Australia
| | - David A Perkins
- School of Nursing & Midwifery, Flinders University, Sturt Rd, Bedford Park 5024, Australia
| | - Jeffrey D Fuller
- Centre for Remote Health Research, Broken Hill University Department of Rural Health, University of Sydney, Corrindah Court, Broken Hill 2880, Australia
| | - Sharon M Parker
- Centre for Remote Health Research, Broken Hill University Department of Rural Health, University of Sydney, Corrindah Court, Broken Hill 2880, Australia
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Roundy K, Cully JA, Stanley MA, Veazey C, Souchek J, Wray NP, Kunik ME. Are anxiety and depression addressed in primary care patients with chronic obstructive pulmonary disease? A chart review. PRIMARY CARE COMPANION TO THE JOURNAL OF CLINICAL PSYCHIATRY 2011; 7:213-8. [PMID: 16308576 PMCID: PMC1257405 DOI: 10.4088/pcc.v07n0501] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/25/2005] [Accepted: 06/14/2005] [Indexed: 10/20/2022]
Abstract
OBJECTIVE Screening for mental illness in primary care is widely recommended, but little is known about the evaluation, treatment, and long-term management processes that follow screening. The aim of this study was to examine and describe the quality of mental health care for persons with chronic obstructive pulmonary disease (COPD) and anxiety/depressive disorders, as measured by adherence to practice guidelines. METHOD This retrospective chart review examined data for 102 primary care and mental health care patients with COPD who were diagnosed, using Structured Clinical Interview for DSM-IV criteria, with major depressive disorder, dysthymia, depression not otherwise specified, generalized anxiety disorder, or anxiety not otherwise specified. Data were gathered from primary care progress notes from the year prior to enrollment in a randomized controlled trial (enrollment was from July 2002 to April 2004). We compared the care received by these patients over 1 year with that recommended by practice guidelines. Charts were abstracted using a checklist of recommended practice guidelines for diagnostic evaluation, acute treatment, and long-term management of anxiety and depressive disorders. RESULTS Fifty (49%) of the 102 patients were recognized during the review year as having an anxiety or depressive disorder. Eighteen patients were newly assessed for depressive or anxiety disorders during the chart review year. Patients followed in primary care alone, compared with those who were comanaged by mental health care providers, were less likely to have guideline-adherent care. CONCLUSION Depressive and anxiety disorders are recognized in about half of patients; however, guideline-supported diagnostic evaluation, acute treatment (except for medications), and long-term management rarely occur in the primary care setting. To improve the treatment of depressive and anxiety disorders in primary care, the process of care delivery must be understood and changed.
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Affiliation(s)
- Kent Roundy
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX, USA
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Abstract
Care management-based interventions promoting integrated care by combining primary care with mental health services in a coordinated and colocated manner are increasingly popular; yet, the benefits of specific approaches are not well established. We conducted a systematic review of integrated care trials in US primary care settings to assess whether the level of integration of provider roles or care process affects clinical outcomes. Although most trials showed positive effects, the degree of integration was not significantly related to depression outcomes. Integrated care appears to improve depression management in primary care patients, but questions remain about its specific form and implementation.
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Abstract
Care management-based interventions promoting integrated care by combining primary care with mental health services in a coordinated and colocated manner are increasingly popular; yet, the benefits of specific approaches are not well established. We conducted a systematic review of integrated care trials in US primary care settings to assess whether the level of integration of provider roles or care process affects clinical outcomes. Although most trials showed positive effects, the degree of integration was not significantly related to depression outcomes. Integrated care appears to improve depression management in primary care patients, but questions remain about its specific form and implementation.
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Beaucage C, Cardinal L, Kavanagh M, Aubé D. [Major depression in primary care and clinical impacts of treatment strategies: a literature review]. SANTE MENTALE AU QUEBEC 2009; 34:77-100. [PMID: 19475195 DOI: 10.7202/029760ar] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Major or clinical depression represents a frequent mental illness that is often associated with a high level of morbidity and mortality. Yet, major depression remains under-diagnosed and under-treated. On the level of treatment, it would appear desirable for reasons of better prognosis, to aim more than the simple reduction of depressive symptoms and target their remission resolutely and the fastest return to the individual's optimal functioning. This article presents a systematic review of the literature relating to the clinical impacts of treatment strategies aiming at the improvement of services offered to people who suffer of clinical depression and who consult in primary care. The authors summarize results drawn from 41 studies that include a measurement of the clinical impacts (reduction of symptoms, response, remission and functioning) of various treatment strategies. It appears that using complex treatment strategies favour positive outcomes. The authors propose various paths of research to further increase current knowledge.
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Harkness EF, Bower PJ. 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. Cochrane Database Syst Rev 2009; 2009:CD000532. [PMID: 19160181 PMCID: PMC7068168 DOI: 10.1002/14651858.cd000532.pub2] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
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.
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Affiliation(s)
- Elaine F Harkness
- University of ManchesterNational Primary Care Research and Development CentreWilliamson BuildingOxford RoadManchesterUKM13 9PL
| | - Peter J Bower
- University of ManchesterNational Primary Care Research and Development CentreWilliamson BuildingOxford RoadManchesterUKM13 9PL
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Younès N, Hardy-Bayle MC, Falissard B, Kovess V, Gasquet I. Impact of shared mental health care in the general population on subjects' perceptions of mental health care and on mental health status. Soc Psychiatry Psychiatr Epidemiol 2008; 43:113-20. [PMID: 18026680 DOI: 10.1007/s00127-007-0285-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2007] [Accepted: 10/23/2007] [Indexed: 11/27/2022]
Abstract
OBJECTIVE A community survey evaluated whether the development of a shared mental health care intervention had an impact on health care perceptions and mental health status of subjects with common mental health problems (MHP). METHODS Adults <70 years old with common MHP (DSM-IV/CIDI-SF major depressive disorder, generalized anxiety or MHI-SF 36 psychic distress diagnoses), were randomly drawn from the general population in the intervention area (IA, n = 349) and in a control area (CA, n = 360), and evaluated twice at an interval of 18 months (percentage of follow-up: IA = 69.3%, CA = 71.9%, P = .44). CA and IA groups did not differ for the criteria of interest at baseline. RESULTS At 18 months, compared to CA, IA reported significantly different help-seeking attitudes or behaviours (P = .02 for all subjects and .006 for subjects with current MHP) and greater general satisfaction with care (P = .03 for both). Remission rates and daily life functioning did not differ. CONCLUSIONS After 4 years of development of a mental health network based on a consultation-liaison model, Shared Mental Health Care was associated with greater satisfaction and access with care among subjects with common MHP. The association was not found with mental health status, but the study lacked power to adequately address the issues.
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Affiliation(s)
- Nadia Younès
- Academic Unit of Psychiatry, Centre Hospitalier de Versailles, 177 Rue de Versailles, Le Chesnay Cedex, France.
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Smith SM, Allwright S, O'Dowd T. Effectiveness of shared care across the interface between primary and specialty care in chronic disease management. Cochrane Database Syst Rev 2007:CD004910. [PMID: 17636778 DOI: 10.1002/14651858.cd004910.pub2] [Citation(s) in RCA: 117] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Shared care has been used in the management of many chronic conditions with the assumption that it delivers better care than either primary or specialty care alone. It has been defined as the joint participation of primary care physicians and specialty care physicians in the planned delivery of care, informed by an enhanced information exchange over and above routine discharge and referral notices. It has the potential to offer improved quality and coordination of care delivery across the primary-specialty care interface and to improve outcomes for patients. 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. SEARCH STRATEGY We searched the Cochrane Effective Practice and Organisation of Care Group (EPOC) Specialised Register (and the database of studies awaiting assessment); Cochrane Central Register of Controlled Trials (CENTRAL); Database of Abstracts of Reviews of Effects (DARE); MEDLINE (from 1966); EMBASE (from 1980) and CINAHL (from 1982). We also searched the reference lists of included studies. SELECTION CRITERIA Randomised controlled trials, controlled before and after studies and interrupted time series analyses of shared-care interventions for chronic disease management. The participants were primary care providers, specialty care providers and patients. The outcomes included physical health outcomes, mental health outcomes, and psychosocial health outcomes, treatment satisfaction, measures of care delivery including participation in services, delivery of care and prescribing of appropriate medications, and costs of shared care. DATA COLLECTION AND ANALYSIS Three review authors independently assessed studies for eligibility, extracted data and assessed study quality. MAIN RESULTS Twenty studies of shared care interventions for chronic disease management were identified, 19 of which were randomised controlled trials. The majority of studies examined complex multifaceted interventions and were of relatively short duration. The results were mixed. Overall there were no consistent improvements in physical or mental health outcomes, psychosocial outcomes, psychosocial measures including measures of disability and functioning, hospital admissions, default or participation rates, recording of risk factors and satisfaction with treatment. However, there were clear improvements in prescribing in the studies that considered this outcome. The methodological quality of studies varied considerably with only a minority of studies of high-quality design. Cost data were limited and difficult to interpret across studies. AUTHORS' CONCLUSIONS This review indicates that there is, at present, insufficient evidence to demonstrate significant benefits from shared care apart from improved prescribing. Methodological shortcomings, particularly inadequate length of follow-up, may partially account for this lack of evidence. This review indicates that there is no evidence to support the widespread introduction of shared care services at present. Future shared-care interventions should only be developed within research settings and with account taken of the complexity of such interventions and the need to carry out longer studies to test the effectiveness and sustainability of shared care over time.
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Affiliation(s)
- S M Smith
- Trinity College Centre for Health Sciences, Tallaught Hospital, Department of Public Health and Primary Care, Dublin, Ireland.
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Akincigil A, Bowblis JR, Levin C, Walkup JT, Jan S, Crystal S. Adherence to antidepressant treatment among privately insured patients diagnosed with depression. Med Care 2007; 45:363-9. [PMID: 17496721 PMCID: PMC2882940 DOI: 10.1097/01.mlr.0000254574.23418.f6] [Citation(s) in RCA: 111] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Antidepressants are effective in treatment of depression, but poor adherence to medication is a major obstacle to effective care. OBJECTIVE We sought to describe patient and provider level factors associated with treatment adherence. METHODS This was a retrospective, observational study using medical and pharmacy claims from a large health plan, for services provided between January 2003 and January 2005. We studied a total of 4312 subjects ages 18 or older who were continuously enrolled in the health plan with a new episode of major depression and who initiated antidepressant treatment. Treatment adherence was measured by using pharmacy refill records during the first 16 weeks (acute phase) and the 17-33 weeks after initiation of antidepressant therapy (continuation phase). Measures were based on Health Plan Employer Data and Information Set (HEDIS) quality measures for outpatient depression care. RESULTS Fifty-one percent of patients were adherent through the acute phase; of those, 42% remained adherent in the continuation phase. Receipt of follow-up care from a psychiatrist and higher general pharmacy utilization (excluding psychotropics) were associated with better adherence in both phases. Younger age, comorbid alcohol or other substance abuse, comorbid cardiovascular/metabolic conditions, use of older generation antidepressants, and residence in lower-income neighborhoods were associated with lower acute-phase adherence. Continuation-phase adherence was lower for HMO participants than for others. CONCLUSION In an insured population, many patients fall short of adherence to guideline recommended therapy for depression. Information from existing administrative data can be used to predict patients at highest risk of nonadherence, such as those with substance abuse, and to target interventions.
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Affiliation(s)
- Ayse Akincigil
- School of Social Work, The State University of New Jersey, New Brunswick, New Jersey, USA.
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Hsiao FH, Yang TT, Chen CC, Tsai SY, Wang KC, Lai YM, Tsai CJ, Chang WY. The comparison of effectiveness of two modalities of mental health nurse follow-up programmes for female outpatients with depression in Taipei, Taiwan. J Clin Nurs 2007; 16:1141-50. [PMID: 17518889 DOI: 10.1111/j.1365-2702.2007.01718.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
AIMS AND OBJECTIVES This study compares the effectiveness of two modalities of mental health nurse three-month follow-up programmes: telephone counselling programme and group therapy programme for female outpatients with depression. BACKGROUND The lifetime prevalence of major depression is 15% and is about twice as common in women as in men. Outpatients with depression often discontinue their treatment after the initial visits to their physicians. METHODS This study used a quasi-experimental, pre-post-test comparison group design. Twenty-six female outpatients with depression were assigned to one of follow-up programmes: telephone counselling programme or group therapy programme. To qualify for group therapy programme, potential participants were required to come to group sessions weekly. To be accepted into telephone counselling programme, potential participants had to be able to be contacted by phone regularly. Mental health nurse three-month follow-up programmes included care management and structured psychotherapy. Patients in telephone counselling programme received 10 regular telephone calls of 30-60 minutes each. Patients in group therapy programme received 12 sessions of weekly group meetings of 90-120 minutes each. RESULTS Wilcoxon signed ranks tests provided evidence that the group therapy programme (S = -52.5, p < 0.001; S = 31.5, p = 0.046) and telephone counselling programme (S = -36, p = 0.002; S = 25, p = 0.050) follow-up programmes were effective in terms of relieving depressed symptoms and improving quality of life. According to Quade's analysis of covariance, telephone counselling programme and group therapy programme appeared to have similar effects of relieving depressed symptoms (F(1,24) = 0.06, p = 0.813) and increasing quality of life (F(1,24) = 0.07, p = 0.792). While there was no significant difference in using emergency services ( chi(2)(1)= 0.89, p = 0.539) between telephone counselling programme and group therapy programme, the rate of adherence to scheduled outpatient appointments with psychiatrists was higher among patients in group therapy programme than patients in telephone counselling programme (chi(2)(3) = 8.67, p = 0.034). CONCLUSIONS Establishing two modalities of mental health nurse follow-up programmes in Taiwan could benefit patients with different needs. RELEVANCE TO CLINICAL PRACTICE Mental health nurses specialized in management of depression could provide not only care management but also structured psychotherapy.
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Affiliation(s)
- Fei-Hsiu Hsiao
- College of Nursing, Taipei Medical University, No. 250 Wu-Hsing Street, Taipei, Taiwan.
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Wolf NJ, Hopko DR. Psychosocial and pharmacological interventions for depressed adults in primary care: a critical review. Clin Psychol Rev 2007; 28:131-161. [PMID: 17555857 DOI: 10.1016/j.cpr.2007.04.004] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2006] [Revised: 02/09/2007] [Accepted: 04/20/2007] [Indexed: 11/25/2022]
Abstract
Primary care settings are the principal context for treating clinical depression, with researchers beginning to explore the efficacy of psychosocial and pharmacological treatments for depression within this infrastructure. Feasibility and process variables also are being assessed, including issues of cost-effectiveness, viability of collaborative care models, predictors of treatment outcome, and effectiveness of treatment providers without specialized mental health training. The Agency for Health Care Policy and Research and American Psychiatric Association initially released guidelines for the treatment of depression in primary care [American Psychiatric Association, 1993. Practice Guidelines for major depressive disorder in adults. American Journal of Psychiatry, 150, 1-26., American Psychiatric Association, 2000. Practice Guideline for the treatment of patients with major depressive disorder (revision). American Journal of Psychiatry, 157, 1-45], however, a vast literature has accumulated over the past several years, calling for a systematic re-evaluation of the status of depression treatment in primary care. The present study provides a contemporary review of outcome data for psychosocial and pharmacological interventions in primary care and extends beyond AHCPR guidelines insofar as focusing on feasibility and process variables, including the training and proficiency of primary care treatment providers, cost-effectiveness of primary care interventions, and predictors of treatment response and relapse. Based on current guidelines, problem-solving therapy (PST-PC), interpersonal psychotherapy, and pharmacotherapy would be considered efficacious interventions for major depression, with cognitive-behavioral and cognitive therapy considered possibly efficacious. Psychotherapy and pharmacotherapy generally are of comparable efficacy, and both modalities are superior to usual care in treating depression. Methodological limitations and directions for future research are discussed.
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Affiliation(s)
- Nicole J Wolf
- The University of Tennessee - Knoxville, United States
| | - Derek R Hopko
- The University of Tennessee - Knoxville, United States.
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Williams JW, Gerrity M, Holsinger T, Dobscha S, Gaynes B, Dietrich A. Systematic review of multifaceted interventions to improve depression care. Gen Hosp Psychiatry 2007; 29:91-116. [PMID: 17336659 DOI: 10.1016/j.genhosppsych.2006.12.003] [Citation(s) in RCA: 179] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2006] [Revised: 12/04/2006] [Accepted: 12/05/2006] [Indexed: 11/23/2022]
Abstract
OBJECTIVE Depression is a prevalent high-impact illness with poor outcomes in primary care settings. We performed a systematic review to determine to what extent multifaceted interventions improve depression outcomes in primary care and to define key elements, patients who are likely to benefit and resources required for these interventions. METHOD We searched Medline, HealthSTAR, CINAHL, PsycINFO and a specialized registry of depression trials from 1966 to February 2006; reviewed bibliographies of pertinent articles; and consulted experts. Searches were limited to the English language. We included 28 randomized controlled trials that: (a) involved primary care patients receiving acute-phase treatment; (b) tested a multicomponent intervention involving a patient-directed component; and (c) reported effects on depression severity. Pairs of investigators independently abstracted information regarding (a) setting and subjects, (b) components of the intervention and (c) outcomes. RESULTS Twenty of 28 interventions improved depression outcomes over 3-12 months (an 18.4% median absolute increase in patients with 50% improvement in symptoms; range, 8.3-46%). Sustained improvements at 24-57 months were demonstrated in three studies addressing acute-phase and continuation-phase treatments. All interventions involved care management and required additional resources or staff reassignment to implement; interventions were delivered exclusively or predominantly by telephone in 16 studies. The most commonly used intervention features were: patient education and self-management, monitoring of depressive symptoms and treatment adherence, decision support for medication management, a patient registry and mental health supervision of care managers. Other intervention features were highly variable. CONCLUSION There is strong evidence supporting the short-term benefits of care management for depression; critical elements for successful programs are emerging.
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Affiliation(s)
- John W Williams
- Center for Health Services Research in Primary Care, Durham VA Medical Center, Durham, NC, USA.
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Bower P, Gilbody S, Richards D, Fletcher J, Sutton A. Collaborative care for depression in primary care. Making sense of a complex intervention: systematic review and meta-regression. Br J Psychiatry 2006; 189:484-93. [PMID: 17139031 DOI: 10.1192/bjp.bp.106.023655] [Citation(s) in RCA: 269] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The management of depression in primary care is a significant issue for health services worldwide. "Collaborative care" interventions are effective, but little is known about which aspects of these complex interventions are essential. AIMS To use meta-regression to identify "active ingredients" in collaborative care models for depression in primary care. METHOD Studies were identified using systematic searches of electronic databases. The content of collaborative care interventions was coded, together with outcome data on antidepressant use and depressive symptoms. Meta-regression was used to examine relationships between intervention content and outcomes. RESULTS There was no significant predictor of the effect of collaborative care on antidepressant use. Key predictors of depressive symptom outcomes included systematic identification of patients, professional background of staff and specialist supervision. CONCLUSIONS Meta-regression may be useful in examining "active ingredients" in complex interventions in mental health.
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Affiliation(s)
- Peter Bower
- National Primary Care Research and Development Centre, University of Manchester, Manchester M13 9PL, UK.
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