Clinical effectiveness and cost-effectiveness of collaborative care for depression in UK primary care (CADET): a cluster randomised controlled trial

Effectiveness of a task-sharing collaborative care model for the detection and management of depression among adults receiving antiretroviral therapy in primary care facilities in South Africa: A pragmatic cluster randomised controlled trial

BACKGROUND

HIV is characterised by high rates of comorbidity with mental health conditions including depression, as such, the detection and treatment of comorbid depression is critical to achieve viral load suppression. This study evaluated the effectiveness of a collaborative care intervention for depression among adults with comorbid depression symptoms receiving ART in primary health care (PHC) facilities.

METHODS

We conducted a pragmatic cluster-randomised trial in 40 clinics in the North West province of South Africa. PHC clinics were stratified by sub-district and randomised in a 1:1 ratio. Participants were ≥ 18 years, receiving ART, and had depression symptoms indicated by Patient Health Questionnaire-9 (PHQ-9) score ≥ 9. Intervention clinics received: i) supplementary mental health training and clinical communication skills for PHC nurses; ii) workshops for PHC doctors on treating depression; and iii) lay counselling services. Using mixed effects regression models, we assessed co-primary outcomes of PHQ-9 response at 6 months (≥50 % reduction in baseline PHQ-9 score) and viral load suppression at 12 months (viral load<1000 copies/mL).

RESULTS

The intervention had no effect in PHQ-9 response (49 % vs 57 %, risk difference (RD) = -0.08, 95 % CI = -0.19; 0.03, p = 0.184) or viral load suppression (85 % vs 84 %, RD = 0.02, 95 % CI = -0.01; 0.04, p = 0.125). Nurses referred 4298 clinic patients to counsellors, however, only 66/1008 (7 %) of intervention arm participants were referred to counsellors at any point during the study.

LIMITATIONS

The highly pragmatic approach of this trial limited exposure to the counselling component of the intervention and referral to doctors for initiation of antidepressant treatment was extremely low.

CONCLUSION

The trial showed no effect of a district-based intervention to strengthen collaborative care for depression. The trial revealed the extent of the treatment gap in the context of scaling up mental health services.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT02407691); Pan African Clinical Trials Registry (201504001078347).

Integrated care models for youth mental health: A systematic review and meta-analysis

OBJECTIVES

To evaluate the effectiveness of integrated models of mental healthcare in enhancing clinical outcomes, quality of life, satisfaction with care and health service delivery outcomes in young people aged 12-25 years. A secondary objective was to identify common components of integrated mental health interventions.

METHODS

A systematic review and meta-analysis of studies published 2001-2023 that assessed clinical or health service use outcomes of integrated care, relative to treatment as usual, for any mental health condition in 12-25 years old accessing community-based care.

RESULTS

Of 11,444 titles identified, 15 studies met inclusion criteria and 6 studies were entered in the meta-analysis. Pooled effect size found integrated care was associated with a greater reduction in depressive symptoms relative to treatment as usual at 4-6 months (standardised mean difference = -0.260, 95% confidence interval = [-0.39, -0.13], p = 0.001). Of the seven studies reporting access or engagement, all reported higher rates of both in the intervention arm. The most frequent components of integration were use of a multidisciplinary team (13/15 studies), shared treatment planning (11/15) and workforce training in the model (14/15).

CONCLUSIONS

Integrated models of mental healthcare are associated with a small, but significant, increase in effectiveness for depressive symptoms relative to treatment as usual. Given integrated care may increase access and engagement, future research should focus on assessing the impact of integrated care in a wider range of settings and outcomes, including clinical and functional recovery, satisfaction with care and system-level outcomes such as cost-effectiveness.

The burden of major depressive disorder in the Middle East and North Africa region, 1990-2019

BACKGROUND

Major depressive disorder (MDD) is one of the leading causes of disability. We aimed to report the MDD-attributable prevalence, incidence and years lived with disability (YLDs) in the Middle East and North Africa (MENA) region from 1990 to 2019 by age, sex and socio-demographic index (SDI).

METHODS

Publicly available data on the burden of MDD were retrieved from the Global Burden of Disease (GBD) study 2019 for the 21 countries in MENA. The counts and age-standardised rates (per 100,000) were presented, along with their corresponding 95% uncertainty intervals.

RESULTS

In 2019, MDD had an age-standardised point prevalence of 3322.1 and an incidence rate of 4921.7 per 100,000 population in MENA. Furthermore, there were 4.1 million YLDs in 2019. However, there were no substantial changes in the MDD burden over the period 1990-2019. In 2019, Palestine had the highest burden of MDD. The highest prevalence, incidence and YLDs attributable to MDD were found in the 35-39 age group. In 2019, the YLD rate in MENA was higher than the global rate for almost all age groups. Furthermore, there was a broadly negative association between the YLD rate and SDI.

CONCLUSION

The study highlights the need to prevent the disorder using a multidisciplinary approach and for the provision of cost-effective treatments for those affected, in order to increase their quality of life.

Collaborative care approaches for people with severe mental illness

BACKGROUND

Collaborative care for severe mental illness (SMI) is a community-based intervention that promotes interdisciplinary working across primary and secondary care. Collaborative care interventions aim to improve the physical and/or mental health care of individuals with SMI. This is an update of a 2013 Cochrane review, based on new searches of the literature, which includes an additional seven studies.

OBJECTIVES

To assess the effectiveness of collaborative care approaches in comparison with standard care (or other non-collaborative care interventions) for people with diagnoses of SMI who are living in the community.

SEARCH METHODS

We searched the Cochrane Schizophrenia Study-Based Register of Trials (10 February 2021). We searched the Cochrane Common Mental Disorders (CCMD) controlled trials register (all available years to 6 June 2016). Subsequent searches on Ovid MEDLINE, Embase and PsycINFO together with the Cochrane Central Register of Controlled Trials (with an overlap) were run on 17 December 2021.

SELECTION CRITERIA

Randomised controlled trials (RCTs) where interventions described as 'collaborative care' were compared with 'standard care' for adults (18+ years) living in the community with a diagnosis of SMI. SMI was defined as schizophrenia, other types of schizophrenia-like psychosis or bipolar affective disorder. The primary outcomes of interest were: quality of life, mental state and psychiatric admissions at 12 months follow-up.

DATA COLLECTION AND ANALYSIS

Pairs of authors independently extracted data. We assessed the quality and certainty of the evidence using RoB 2 (for the primary outcomes) and GRADE. We compared treatment effects between collaborative care and standard care. We divided outcomes into short-term (up to six months), medium-term (seven to 12 months) and long-term (over 12 months). For dichotomous data we calculated the risk ratio (RR) and for continuous data we calculated the standardised mean difference (SMD), with 95% confidence intervals (CIs). We used random-effects meta-analyses due to substantial levels of heterogeneity across trials. We created a summary of findings table using GRADEpro.

MAIN RESULTS

Eight RCTs (1165 participants) are included in this review. Two met the criteria for type A collaborative care (intervention comprised of the four core components). The remaining six met the criteria for type B (described as collaborative care by the trialists, but not comprised of the four core components). The composition and purpose of the interventions varied across studies. For most outcomes there was low- or very low-certainty evidence. We found three studies that assessed the quality of life of participants at 12 months. Quality of life was measured using the SF-12 and the WHOQOL-BREF and the mean endpoint mental health component scores were reported at 12 months. Very low-certainty evidence did not show a difference in quality of life (mental health domain) between collaborative care and standard care in the medium term (at 12 months) (SMD 0.03, 95% CI -0.26 to 0.32; 3 RCTs, 227 participants). Very low-certainty evidence did not show a difference in quality of life (physical health domain) between collaborative care and standard care in the medium term (at 12 months) (SMD 0.08, 95% CI -0.18 to 0.33; 3 RCTs, 237 participants). Furthermore, in the medium term (at 12 months) low-certainty evidence did not show a difference between collaborative care and standard care in mental state (binary) (RR 0.99, 95% CI 0.77 to 1.28; 1 RCT, 253 participants) or in the risk of being admitted to a psychiatric hospital at 12 months (RR 5.15, 95% CI 0.67 to 39.57; 1 RCT, 253 participants). One study indicated an improvement in disability (proxy for social functioning) at 12 months in the collaborative care arm compared to usual care (RR 1.38, 95% CI 0.97 to 1.95; 1 RCT, 253 participants); we deemed this low-certainty evidence. Personal recovery and satisfaction/experience of care outcomes were not reported in any of the included studies. The data from one study indicated that the collaborative care treatment was more expensive than standard care (mean difference (MD) international dollars (Int$) 493.00, 95% CI 345.41 to 640.59) in the short term. Another study found the collaborative care intervention to be slightly less expensive at three years.

AUTHORS' CONCLUSIONS

This review does not provide evidence to indicate that collaborative care is more effective than standard care in the medium term (at 12 months) in relation to our primary outcomes (quality of life, mental state and psychiatric admissions). The evidence would be improved by better reporting, higher-quality RCTs and the assessment of underlying mechanisms of collaborative care. We advise caution in utilising the information in this review to assess the effectiveness of collaborative care.

Cost-effectiveness of behavioral activation compared to treatment as usual for depressed older adults in primary care: A cluster randomized controlled trial

INTRODUCTION

Depression in older adults is associated with decreased quality of life and increased utilization of healthcare services. Behavioral activation (BA) is an effective treatment for late-life depression, but the cost-effectiveness compared to treatment as usual (TAU) is unknown.

METHODS

An economic evaluation was performed alongside a cluster randomized controlled multicenter trial including 161 older adults (≥65 years) with moderate to severe depressive symptoms (PHQ-9 ≥ 10). Outcome measures were depression (response on the QIDS-SR), quality-adjusted life-years (QALYs) and societal costs. Missing data were imputed using multiple imputation. Cost and effect differences were estimated using bivariate linear regression models, and statistical uncertainty was estimated with bootstrapping. Cost-effectiveness acceptability curves showed the probability of cost-effectiveness at different ceiling ratios.

RESULTS

Societal costs were statistically non-significantly lower in BA compared to TAU (mean difference (MD) -€485, 95 % CI -3861 to 2792). There were no significant differences in response on the QIDS-SR (MD 0.085, 95 % CI -0.015 to 0.19), and QALYs (MD 0.026, 95 % CI -0.0037 to 0.055). On average, BA was dominant over TAU (i.e., more effective and less expensive), although the probability of dominance was only 0.60 from the societal perspective and 0.85 from the health care perspective for both QIDS-SR response and QALYs.

DISCUSSION

Although the results suggest that BA is dominant over TAU, there was considerable uncertainty surrounding the cost-effectiveness estimates which precludes firm conclusions.

Eliciting Depression Patients' Preferences for Medication Management: A Protocol for Discrete Choice Experiment

Introduction

Depression threatens people's lives and imposes huge economic burden. Antidepressant therapy is the first-line treatment for depression, and patient adherence to medication is the key to successful treatment. Depression patients have poor medication adherence, which leads to failure of depression management and significantly poorer clinical outcomes. Incorporating patient preferences into clinical decisions can improve uptake rates, optimize treatment adherence. A discrete choice experiment (DCE) can elicit and quantify individual preferences. Previous DCE studies were conducted in developed countries and ignored the influences of factors other than the medication. This paper outlines an ongoing DCE that aims to (1) explore medication-management-related characteristics that may affect depression patients' adherence to antidepressant, (2) elicit how depression patients consider the trade-offs among different medication managements.

Methods

The six attributes and their levels were developed through a literature review, semi-structured interviews and experts and focus group discussions. A fractional factorial design in the software Ngene 1.2 version was used to generate 36 choice sets, and they were divided into 3 blocks. A mixed logit model will be used to explore the patients' preferences, willingness to pay and uptake rate of depression patients for medication management attributes.

Results

The final questionnaire consists of three parts. The first is the introduction, which introduces the purpose of the study and the requirements of completing the questionnaire. This was followed by a general information questionnaire, which included sociodemographic characteristics. The last part is DCE tasks, which include 13 DCE choice sets, and each choice set include two alternative and one "opt-out" option. The pilot-test results showed the questionnaire was easy to understand and could be used in formal surveys.

Conclusion

Our study shows how the development process of the study can be conducted and reported systematically and rigorously according to the theoretical foundation and design principles in DCE.

Cost-effectiveness analysis of physical activity interventions for people with schizophrenia or bipolar disorder: systematic review

BACKGROUND

Clinical guidelines recommend providing physical activity interventions (PAIs) to people with schizophrenia or bipolar disorder for weight management. However, the cost-effectiveness of PAIs is unknown.

AIMS

To evaluate the availability and methodological quality of economic evaluations of PAIs for people with schizophrenia or bipolar disorder.

METHOD

Four databases (MEDLINE, Embase, PsycInfo and Scopus) were searched on 5 July 2022. Based on the retrieved studies, forward and backward citation searches were conducted. Two reviewers independently selected studies for inclusion. Study quality was assessed using the Drummond checklist. Review results were presented using narrative synthesis.

RESULTS

Fourteen articles reporting nine studies were included. All included studies assessed PAIs within a multicomponent lifestyle intervention. Mixed findings were reported on the cost-effectiveness of multicomponent lifestyle intervention: three studies reported it as cost-effective; four studies reported it as not cost-effective; and two studies did not conclude whether it was cost-effective or not. Very limited evidence suggests that certain patient subgroups might be more likely to benefit from multicomponent lifestyle interventions with a PAI component: men; individuals with comorbid type 2 diabetes; and individuals who have been psychiatric hospital in-patients for ≥1 year. The quality of included studies ranged from moderate to high.

CONCLUSIONS

The current economic evidence suggests that not all modalities of multicomponent lifestyle intervention including a PAI component are cost-effective for people with schizophrenia or bipolar disorder; and not all people with schizophrenia or bipolar disorder would benefit equally from the intervention. Future research is urgently needed to identify the cost-effective modality of PAI for different patient subgroups.

Attitudes of primary healthcare chief physicians towards research in Finland - a national study

OBJECTIVE

To illustrate the views of chief physicians in Finnish primary healthcare health centres (HCs) on the existing research capacity of their centres, their attitudes to practice-based research network activity, and research topics of interest to them.

DESIGN

A cross-sectional survey study.

SETTING

Finnish HCs.

SUBJECTS

Chief physicians in Finnish HCs.

MAIN OUTCOME MEASURES

We used a questionnaire that included five-point Likert scales and multiple choice and open-ended questions to identify the chief physician's profile, the HC content, the attitudes of chief physicians towards engagement in research, research topics of interest to them, and factors that may influence their motivation. Descriptive methods were used for the analysis of the quantitative data, while the qualitative data were processed using inductive thematic analysis.

RESULTS

There was a relatively good representation of all hospital districts. One-third of HCs had at least one person doing research, and 61% of chief physicians would support research in their setting. Their stimulus for research was primarily testing new therapies, protocols, and care processes, as well as effectiveness and healthcare improvement. The expected benefits that motivate engagement in Practice-based research networks (PBRNs) are evidence-based practice and raised professional capacity and profile of the HC.

CONCLUSIONS

Chief physicians regard research as an elementary part of the development of primary care practices and health policy. Their motivation to engage in PBRN activity is determined by the relevance of the research to their interests and the management of competing priorities and resource limitations.

A hybrid approach to comparing parallel-group and stepped-wedge cluster-randomized trials with a continuous primary outcome when there is uncertainty in the intra-cluster correlation

BACKGROUND/AIMS

To evaluate how uncertainty in the intra-cluster correlation impacts whether a parallel-group or stepped-wedge cluster-randomized trial design is more efficient in terms of the required sample size, in the case of cross-sectional stepped-wedge cluster-randomized trials and continuous outcome data.

METHODS

We motivate our work by reviewing how the intra-cluster correlation and standard deviation were justified in 54 health technology assessment reports on cluster-randomized trials. To enable uncertainty at the design stage to be incorporated into the design specification, we then describe how sample size calculation can be performed for cluster- randomized trials in the 'hybrid' framework, which places priors on design parameters and controls the expected power in place of the conventional frequentist power. Comparison of the parallel-group and stepped-wedge cluster-randomized trial designs is conducted by placing Beta and truncated Normal priors on the intra-cluster correlation, and a Gamma prior on the standard deviation.

RESULTS

Many Health Technology Assessment reports did not adhere to the Consolidated Standards of Reporting Trials guideline of indicating the uncertainty around the assumed intra-cluster correlation, while others did not justify the assumed intra-cluster correlation or standard deviation. Even for a prior intra-cluster correlation distribution with a small mode, moderate prior densities on high intra-cluster correlation values can lead to a stepped-wedge cluster-randomized trial being more efficient because of the degree to which a stepped-wedge cluster-randomized trial is more efficient for high intra-cluster correlations. With careful specification of the priors, the designs in the hybrid framework can become more robust to, for example, an unexpectedly large value of the outcome variance.

CONCLUSION

When there is difficulty obtaining a reliable value for the intra-cluster correlation to assume at the design stage, the proposed methodology offers an appealing approach to sample size calculation. Often, uncertainty in the intra-cluster correlation will mean a stepped-wedge cluster-randomized trial is more efficient than a parallel-group cluster-randomized trial design.

Assessment of a Primary Support Program: family physicians and mental health professionals' perspective

BACKGROUND

Mental health (MH) disorders are increasingly prevalent in primary care (PC) and this has generated, in recent years, the development of strategies based on the collaborative model and the stepped care model. The Primary Support Program (PSP) was implemented in the community of Catalonia (Spain) during 2006 to improve, from the first level of care, treatment of the population with mild-moderate complexity MH problems along with identification and referral of severe cases to specialized care. The aim of the present study was to identify the strengths and limitations of the PSP from the perspective of health professionals involved in the programme.

METHODS

An explanatory qualitative study based on Grounded Theory. We conducted group semistructured interviews with 37 family physicians and 34 MH professionals. A constant comparative method of analysis was performed.

RESULTS

Operation of the PSP is influenced by internal factors, such as the programme framework, MH liaison, management of service supply and demand, and the professional team involved. Additionally, external factors which had an impact were related to the patient, the professionals, the Health System, and community resources.

CONCLUSIONS

The operation of the PSP could benefit from a review of the programme framework and optimization of MH liaison. Improvements are also proposed for MH training in PC, intraprofessional coordination, use of community resources, and creation of efficient continuous assessment systems.

Effectiveness of interventions to improve medication adherence in adults with depressive disorders: a meta-analysis

BACKGROUND

Non-adherence to medication is a major obstacle in the treatment of depressive disorders. We systematically reviewed the literature to evaluate the effectiveness of interventions aimed at improving adherence to medication among adults with depressive disorders with emphasis on initiation and implementation phase.

METHODS

We searched Medline, EMBASE, The Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, Social Science Citation Index and Science Citation Index for randomized or non-randomized controlled trials up to January 2022. Risk of bias was assessed using the criteria of the Cochrane Collaboration. Meta-analyses, cumulative and meta-regression analyses for adherence were conducted.

RESULTS

Forty-six trials (n = 24,324) were included. Pooled estimate indicates an increase in the probability of adherence to antidepressants at 6 months with the different types of interventions (OR 1.33; 95% CI: 1.09 to 1.62). The improvement in adherence is obtained from 3 months (OR 1.62, 95% CI: 1.25 to 2.10) but it is attenuated at 12 months (OR 1.25, 95% CI: 1.02 to 1.53). Selected articles show methodological differences, mainly the diversity of both the severity of the depressive disorder and intervention procedures. In the samples of these studies, patients with depression and anxiety seem to benefit most from intervention (OR 2.77, 95% CI: 1.74 to 4.42) and collaborative care is the most effective intervention to improve adherence (OR 1.88, 95% CI: 1.40 to 2.54).

CONCLUSIONS

Our findings indicate that interventions aimed at improving adherence to medication among adults with depressive disorders are effective up to six months. However, the evidence on the effectiveness of long-term adherence is insufficient and supports the need for further research efforts.

TRIAL REGISTRATION

International Prospective Register for Systematic Reviews (PROSPERO) number: CRD42017065723 .

How much change is enough? Evidence from a longitudinal study on depression in UK primary care

BACKGROUND

The Patient Health Questionnaire (PHQ-9), the Beck Depression Inventory (BDI-II) and the Generalised Anxiety Disorder Assessment (GAD-7) are widely used in the evaluation of interventions for depression and anxiety. The smallest reduction in depressive symptoms that matter to patients is known as the Minimum Clinically Important Difference (MCID). Little empirical study of the MCID for these scales exists.

METHODS

A prospective cohort of 400 patients in UK primary care were interviewed on four occasions, 2 weeks apart. At each time point, participants completed all three questionnaires and a 'global rating of change' scale (GRS). MCID estimation relied on estimated changes in symptoms according to reported improvement on the GRS scale, stratified by baseline severity on the Clinical Interview Schedule (CIS-R).

RESULTS

For moderate baseline severity, those who reported improvement on the GRS had a reduction of 21% (95% confidence interval (CI) -26.7 to -14.9) on the PHQ-9; 23% (95% CI -27.8 to -18.0) on the BDI-II and 26.8% (95% CI -33.5 to -20.1) on the GAD-7. The corresponding threshold scores below which participants were more likely to report improvement were -1.7, -3.5 and -1.5 points on the PHQ-9, BDI-II and GAD-7, respectively. Patients with milder symptoms require much larger reductions as percentage of their baseline to endorse improvement.

CONCLUSIONS

An MCID representing 20% reduction of scores in these scales, is a useful guide for patients with moderately severe symptoms. If treatment had the same effect on patients irrespective of baseline severity, those with low symptoms are unlikely to notice a benefit.

FUNDING

Funding. National Institute for Health Research.

World of Change: Reflections within an educational and health care perspective in a time with COVID-19

BACKGROUND

Besides handling the physical impacts of COVID-19 there is more than ever a need to understand what can help when mental health is challenged. Within this context our practical wisdom - our ability to understand and recognise when 'the other', for example the patient, is feeling lonely or anxious is particularly important.

AIM

This article aims to contribute to the understanding of how the competence of health professionals may be advanced by helping them develop the self-understanding essential to being wise practitioners.

METHOD

The article is based on a discussion informed by reflections (written in Danish and translated into English) by Masters students (and registered nurses) participating in a university programme "Patient and user focused nursing".

FINDINGS

The first part of the article considers a student nurse's reflection on understanding herself and one of her patients. The second part considers reflections on the contemporary world of change from a student nurse trying to engage with a world she experiences as falling apart. The third part addresses the impact of resonant places and encounters on developing self/other understandings; encounters that may also be produced through songs and lyrics. The final part draws conclusions on how it is possible to reach understandings of oneself and others as student health practitioners in time of a pandemic.

CONCLUSION

In the process of developing understanding and recognition, competence built on self-understanding is central for helping form health professionals into 'wise practitioners'. It is concluded that the existential implications of the COVID-19 pandemic, paradoxically, may direct many people's awareness to a more sensitive, resonant, attitude towards the other. For some, this may produce a more humanized world and perception of others. Within this perspective the arts may help us develop self-understanding and recognition of 'the other'.

The differences between referred and non-referred patients to a psychiatric consultation-liaison service in a general hospital

OBJECTIVE

The primary aim of this study was to investigate whether there are clinical differences between patients who are referred or not referred for psychiatric consultation and liaison service. The secondary aim was to compare the perspectives of doctors, nurses and patients.

METHODS

This naturalistic, prospective and comparative study (N = 294) utilised a control sample of non-referrals (n = 177, consenting 81) and referrals (n = 177, consenting 49). The normality of the data was examined with the Shapiro-Wilk test; bivariate group comparisons were made using Mann-Whitney, Wilcoxon tests and bivariate regression analyses. Statistically adjusted group comparisons were performed with multivariate median regressions.

RESULTS

The sample presented limited representativeness. Referred patients were predominantly women, mostly living alone and not working. Compared to the non-referred patients, their disease episode and length of hospital stay were significantly longer, self-efficacy and quality of life lower and psychological stress was higher. For referred patients, there were no differences between the estimations of mental burden and the need for care among doctors, nurses and patients. Self-efficacy and appraisal of one's own burden were the best predictors of the extent of mental symptoms.

DISCUSSION

Patients in an admission ward for internal medicine referred to a psychiatric consultation-liaison service displayed a more adverse psychosocial profile and were more psychologically burdened than non-referred patients, but they are also relevantly subsyndromal burdened. Identifying and supporting burdened patients is an endeavour that requires collaborative care, especially in the transition to specialised mental health and to primary care.

Clinical efficacy of a Decision Support Tool (Link-me) to guide intensity of mental health care in primary practice: a pragmatic stratified randomised controlled trial

BACKGROUND

The volume and heterogeneity of mental health problems that primary care patients present with is a substantial challenge for health systems, and both undertreatment and overtreatment are common. We developed Link-me, a patient-completed Decision Support Tool, to predict severity of depression or anxiety, identify priorities, and recommend interventions. In this study, we aimed to examine if Link-me reduces psychological distress among individuals predicted to have minimal/mild or severe symptoms of anxiety or depression.

METHODS

In this pragmatic stratified randomised controlled trial, adults aged 18-75 years reporting depressive or anxiety symptoms or use of mental health medication were recruited from 23 general practices in Australia. Participants completed the Decision Support Tool and were classified into three prognostic groups (minimal/mild, moderate, severe), and those in the minimal/mild and severe groups were eligible for inclusion. Participants were individually and randomly assigned (1:1) by a computer-generated allocation sequence to receive either prognosis-matched care (intervention group) or usual care plus attention control (control group). Participants were not blinded but intervention providers were only notified of those allocated to the intervention group. Outcome assessment was blinded. The primary outcome was the difference in the change in scores between the intervention and control group, and within prognostic groups, on the 10-item Kessler Psychological Distress Scale at 6 months post randomisation. The trial was registered on the Australian and New Zealand Clinical Trials Registry, ACTRN12617001333303.

OUTCOMES

Between Nov 21, 2017, and Oct 31, 2018, 24 616 patients were invited to complete the eligibility screening survey. 1671 of these patients were included and randomly assigned to either the intervention group (n=834) or the control group (n=837). Prognosis-matched care was associated with greater reductions in psychological distress than usual care plus attention control at 6 months (p=0·03), with a standardised mean difference (SMD) of -0·09 (95% CI -0·17 to -0·01). This reduction was also seen in the severe prognostic group (p=0·003), with a SMD of -0·26 (-0·43 to -0·09), but not in the minimal/mild group (p=0·73), with a SMD of 0·04 (-0·17 to 0·24). In the complier average causal effect analysis in the severe prognostic group, differences were larger among those who received some or all aspects of the intervention (SMD range -0·58 to -1·15). No serious adverse effects were recorded.

INTERPRETATION

Prognosis-based matching of interventions reduces psychological distress in patients with anxiety or depressive symptoms, particularly in those with severe symptoms, and is associated with better outcomes when patients access the recommended treatment. Optimisation of the Link-me approach and implementation into routine practice could help reduce the burden of disease associated with common mental health conditions such as anxiety and depression.

FUNDING

Australian Government Department of Health.

The voice of mental health practice in Australia: a mixed-method cross-sectional study of gaps and areas of need

OBJECTIVES

To examine the perceptions of health professionals regarding the gaps in mental health service provision in Australia and their need for assistance in managing patients with mental illness.

METHOD

A total of 570 health professionals participated in an anonymous online survey in January 2018 that assessed: i) health professionals' current levels of need for assistance in the management of patients with mental health conditions; and ii) perceived gaps in the mental health care system, and how these can be addressed. Data were analysed using a mixed-methods approach.

RESULTS

Of those surveyed, 71.2% of health professionals and 77.3% of general practitioners reported that they required assistance in managing their patients with at least one stage of care for at least one type of mental disorder. Qualitative analyses revealed eight major themes in health professionals' perceptions of gaps in mental health service provision, including affordability and accessibility, the problems with crisis-driven care and the 'missing middle'.

CONCLUSION

Overall, the results of this study provide a concerning insight into the substantial gaps in mental health care within the Australian system. Implications for public health: The results of this study add weight to ongoing calls for reform of and increased investment in the Australian mental health care system.

Matching depression management to severity prognosis in primary care: results of the Target-D randomised controlled trial

BACKGROUND

Mental health treatment rates are increasing, but the burden of disease has not reduced. Tools to support efficient resource distribution are required.

AIM

To investigate whether a person-centred e-health (Target-D) platform matching depression care to symptom severity prognosis can improve depressive symptoms relative to usual care.

DESIGN AND SETTING

Stratified individually randomised controlled trial in 14 general practices in Melbourne, Australia, from April 2016 to February 2019. In total, 1868 participants aged 18-65 years who had current depressive symptoms; internet access; no recent change to antidepressant; no current antipsychotic medication; and no current psychological therapy were randomised (1:1) via computer-generated allocation to intervention or usual care.

METHOD

The intervention was an e-health platform accessed in the GP waiting room, comprising symptom feedback, priority-setting, and prognosis-matched management options (online self-help, online guided psychological therapy, or nurse-led collaborative care). Management options were flexible, neither participants nor staff were blinded, and there were no substantive protocol deviations. The primary outcome was depressive symptom severity (9-item Patient Health Questionnaire [PHQ-9]) at 3 months.

RESULTS

In intention to treat analysis, estimated between- arm difference in mean PHQ-9 scores at 3 months was -0.88 (95% confidence interval [CI] = -1.45 to -0.31) favouring the intervention, and -0.59 at 12 months (95% CI = -1.18 to 0.01); standardised effect sizes of -0.16 (95% CI = -0.26 to -0.05) and -0.10 (95% CI = -0.21 to 0.002), respectively. No serious adverse events were reported.

CONCLUSION

Matching management to prognosis using a person-centred e-health platform improves depressive symptoms at 3 months compared to usual care and could feasibly be implemented at scale. Scope exists to enhance the uptake of management options.

Bridging the mental health treatment gap: effects of a collaborative care intervention (matrix support) in the detection and treatment of mental disorders in a Brazilian city

Objective

To analyse temporal trends in diagnosis and treatment of mental disorders in primary care following implementation of a collaborative care intervention (matrix support).

Design

Dynamic cohort design with retrospective time-series analysis. Structured secondary data on medical visits to general practitioners of all study clinics were extracted from the municipal electronic records database. Annual changes in the odds of mental disorders diagnoses and antidepressants prescriptions were estimated by multiple logistic regression at visit and patient-year levels with diagnoses or prescriptions as outcomes. Annual changes during two distinct stages of the intervention (stage 1 when it was restricted to mental health (2005–2009), and stage 2 when it was expanded to other areas (2010–2015)) were compared by adding year–period interaction terms to each model.

Setting

49 primary care clinics in the city of Florianópolis, Brazil.

Participants

All adults attending primary care clinics of the study setting between 2005 and 2015.

Results

3 131 983 visits representing 322 100 patients were analysed. At visit level, the odds of mental disorder diagnosis increased by 13% per year during stage 1 (OR 1.13, 95% CI 1.11 to 1.14, p<0.001) and decreased by 5% thereafter (OR 0.95, 95% CI 0.94 to 0.95, p<0.001). The odds of incident mental disorder diagnoses decreased by 1% per year during stage 1 (OR 0.99, 95% CI 0.98 to 1.00, p=0.012) and decreased by 7% per year during stage 2 (OR 0.93, 95% CI 0.92 to 0.93, p<0.001). The odds of antidepressant prescriptions in patients with a mental disorder diagnosis increased by 7% per year during stage 1 (OR 1.07, 95% CI 1.05 to 1.20, p<0.001); this was driven by selective serotonin reuptake inhibitor prescriptions which increased 14% per year during stage 1 (OR 1.14, 95% CI 1.12 to 1.18, p<0.001) and 9% during stage 2 (OR 1.09, 95% CI 1.08 to 1.10, p<0.001). The odds of incident antidepressant prescriptions did not increase during stage 1 (OR 1.00, 95% CI 0.97 to 1.02, p=0.665) and increased by 3% during stage 2 (OR 1.03, 95% CI 1.00 to 1.04, p<0.001). Changes per year were all significantly greater during stage 1 than stage 2 (p values for interaction terms <0.05), except for antidepressant prescriptions during visits (p=0.172).

Conclusion

The matrix support intervention may increase diagnosis and treatment of mental disorders when inter-professional collaboration is adequately supported. Competing demands to the primary care teams can subsequently reduce these effects. Future studies should assess clinical outcomes and identify active components and factors associated with successful implementation.

Considering the societal perspective in economic evaluations: a systematic review in the case of depression

BACKGROUND

Depressive disorders are associated with a high burden of disease. However, due to the burden posed by the disease on not only the sufferers, but also on their relatives, there is an ongoing debate about which costs to include and, hence, which perspective should be applied. Therefore, the aim of this paper was to examine whether the change between healthcare payer and societal perspective leads to different conclusions of cost-utility analyses in the case of depression.

METHODS

A systematic literature search was conducted to identify economic evaluations of interventions in depression, launched on Medline and the Cost-Effectiveness Registry of the Tufts University using a ten-year time horizon (2008-2018). In a two-stepped screening process, cost-utility studies were selected by means of specified inclusion and exclusion criteria. Subsequently, relevant findings was extracted and, if not fully stated, calculated by the authors of this work.

RESULTS

Overall, 53 articles with 92 complete economic evaluations, reporting costs from healthcare payer/provider and societal perspective, were identified. More precisely, 22 estimations (24%) changed their results regarding the cost-effectiveness quadrant when the societal perspective was included. Furthermore, 5% of the ICURs resulted in cost-effectiveness regarding the chosen threshold (2% of them became dominant) when societal costs were included. However, another four estimations (4%) showed the opposite result: these interventions were no longer cost-effective after the inclusion of societal costs.

CONCLUSIONS

Summarising the disparities in results and applied methods, the results show that societal costs might alter the conclusions in cost-utility analyses. Hence, the relevance of the perspectives chosen should be taken into account when carrying out an economic evaluation. This systematic review demonstrates that the results of economic evaluations can be affected by different methods available for estimating non-healthcare costs.

Implementation of care managers for patients with depression: a cross-sectional study in Swedish primary care

OBJECTIVES

To perform an analysis of collaborative care with a care manager implementation in a primary healthcare setting. The study has a twofold aim: (1) to examine clinicians' and directors' perceptions of implementing collaborative care with a care manager for patients with depression at the primary care centre (PCC), and (2) to identify barriers and facilitators that influenced this implementation.

DESIGN

A cross-sectional study was performed in 2016-2017 in parallel with a cluster-randomised controlled trial.

SETTING

36 PCCs in south-west Sweden.

PARTICIPANTS

PCCs' directors and clinicians.

OUTCOME

Data regarding the study's aims were collected by two web-based questionnaires (directors, clinicians). Descriptive statistics and qualitative content analysis were used for analysis.

RESULTS

Among the 36 PCCs, 461 (59%) clinicians and 36 (100%) directors participated. Fifty-two per cent of clinicians could cooperate with the care manager without problems. Forty per cent regarded to their knowledge of the care manager assignment as insufficient. Around two-thirds perceived that collaborating with the care manager was part of their duty as PCC staff. Almost 90% of the PCCs' directors considered that the assignment of the care manager was clearly designed, around 70% considered the priority of the implementation to be high and around 90% were positive to the implementation. Facilitators consisted of support from colleagues and directors, cooperative skills and positive attitudes. Barriers were high workload, shortage of staff and extensive requirements and demands from healthcare management.

CONCLUSIONS

Our study confirms that the care manager puts collaborative care into practice. Facilitators and barriers of the implementation, such as time, information, soft values and attitudes, financial structure need to be considered when implementing care managers at PCCs.

Changes in health-related quality of life scores in patients with depression in the Thai health care delivery system

Purpose

Although health-related quality of life (HRQOL) has become an important outcome, specifically in regard to the impact of illness and treatment in patients with depression, few studies have explored the HRQOL of patients from different types of hospitals. This study aimed at examining a change in HRQOL of patients from various types of hospitals

Design/methodology/approach

A repeated measure was used in this study. Thirty participants in psychiatric outpatient units per center from the different types of hospitals, including a psychiatric hospital, regional hospital, general hospital and community hospital, were assessed with the Thai version of the World Health Organization Quality of Life Brief (WHOQOL-BREF-THAI) questionnaire at the first visit, and after the 6th and 12th weeks of the treatment course.

Findings

The HRQOL scores for the participants were increased in each type of hospital from their first visit to the 6th week and 12th week (p < 0.001; except for the 6th week in the regional hospital, p < 0.01).

Originality/value

The findings reflected HRQOL in patients with depression in terms of the resources available in different types of hospitals that could be used as baseline data for the development of Thai mental health service systems.

Strategies for engaging patients and families in collaborative care programs for depression and anxiety disorders: A systematic review

BACKGROUND

Patients and families are often referred to as important partners in collaborative mental health care (CMHC). However, how to meaningfully engage them as partners remains unclear. We aimed to identify strategies for engaging patients and families in CMHC programs for depression and anxiety disorders.

METHODS

We updated a Cochrane review of CMHC programs for depression and anxiety disorders. Searches were conducted in Cochrane CCDAN and CINAHL, complemented by additional database searches, trial registry searches, and cluster searches for 'sibling' articles. Coding and data extraction of engagement strategies was an iterative process guided by a conceptual framework. We used narrative synthesis and descriptive statistics to report on findings.

FINDINGS

We found 148 unique CMCH programs, described in 578 articles. Most programs (96%) featured at least one strategy for engaging patients or families. Programs adopted 15 different strategies overall, with a median of two strategies per program (range 0-9 strategies). The most common strategies were patient education (87% of programs) and self-management supports (47% of programs). Personalized care planning, shared decision making, and family or peer supports were identified in fewer than one third of programs.

LIMITATIONS

Our search strategy was designed to capture programs evaluated in clinical trials and so other innovative programs not studied in trials were likely missed.

CONCLUSION

Most CMHC programs for depression and anxiety disorders adopted a limited number of strategies to engage patients and families in their care. However, this review identifies numerous strategies that can be used to strengthen the patient- and family-centeredness of collaborative care.

Componentes do apoio matricial e cuidados colaborativos em saúde mental: uma revisão narrativa

Resumo Cuidados colaborativos entre saúde mental e atenção primária são efetivos em melhorar desfechos de saúde. O apoio matricial tem semelhanças com cuidados colaborativos pouco exploradas na literatura. Este artigo compara os dois modelos e analisa o apoio matricial a partir de evidências sobre cuidados colaborativos. Revisão narrativa. Componentes de cada modelo (atividades e dimensões) foram identificados e comparados. Evidências sobre cuidados colaborativos informaram análise de componentes semelhantes do apoio matricial. Foram identificadas dimensões do apoio matricial – suporte educacional, cuidado especializado, regulação, cogestão – e dos cuidados colaborativos – cuidado multiprofissional, comunicação sistemática, cuidado estruturado, suporte organizacional. A principal semelhança entre os modelos está nas atividades colaborativas diretas em torno de problemas clínicos, relacionadas a efetividade em estudos sobre cuidados colaborativos. Atividades colaborativas diretas são ponto positivo do apoio matricial. Cuidado estruturado e suporte em nível organizacional devem ser encorajados. Futuros estudos devem refinar as categorias propostas e explorar seu uso para desenvolvimento do apoio matricial.

Outcomes of two quality improvement implementation interventions for depression services in adults with substance use problems

Background: Comorbid depression and substance use disorders (SUDs) are associated with poor health and social outcomes disproportionately affecting under-resourced communities.Objectives: To test the hypothesis that a coalition approach to collaborative care (CC) for depression would improve outcomes of hazardous drinking and behavioral health hospitalizations, relative to technical assistance, for individuals with comorbid substance use problems. Substance use problems were defined by meeting criteria for DSM-IV substance abuse or dependence, hazardous drinking by AUDIT-C, or treatment in a SUD program within the prior 6 months.Methods: Two depression CC implementation approaches were compared: Resources for Services (RS) provided expert technical support for CC toolkits to individual programs. Community engagement and planning (CEP) supported multi-sector coalitions in collaborating in planning, adapting, implementing and monitoring CC toolkits. One thousand eighteen individuals with depression (PHQ-8 ≥10) enrolled. Regression analyses estimated intervention effects in participants with comorbid substance use problems (n = 588, 281 females, 307 males). Substance use problems were defined by meeting criteria for DSM-IV substance abuse or dependence, hazardous drinking by AUDIT-C, or treatment in a SUD program within the prior 6 months.Results: There were no significant baseline differences by intervention status among participants with depression and substance use problems. Intervention effects on primary outcomes including depression were not significant at 6 months. Compared to RS, CEP significantly reduced alcohol consumption (CEP = 1.6, RS = 2.1, p = .038), probability of behavioral health hospitalizations (OR = 0.50, p = .036), and use of specialty mental health visits (IRR = 0.52, p = .027), while increasing use of faith-based depression services (IRR = 3.4, p = .001).Conclusions: Given feasibility and possible benefits, CEP should be considered a promising approach to implementing depression CC with potential benefits to adults with comorbid substance use problems.

The Role of the Patient-Centered Medical Home in Treating Depression

PURPOSE OF REVIEW

This review discusses the role of the patient-centered medical home (PCMH) in treating depression, focusing on findings from primary care-based studies and their implications for the PCMH.

RECENT FINDINGS

Pharmacotherapy, psychotherapy, and collaborative care are evidence-based treatments for depression that can be delivered in primary care and extended to diverse populations. Recent research aligns with the core components of the PCMH model. The core components of the PCMH are critical elements of depression treatment. Comprehensive care within the PCMH addresses medical and behavioral health concerns, including depression. Psychiatric and psychological care must be flexibly delivered so services remain accessible yet patient-centered. To ensure the quality and safety of treatment, depression symptoms must be consistently monitored. Coordination within and occasionally outside of the PCMH is needed to ensure patients receive the appropriate level of care. More research is needed to empirically evaluate depression treatment within the PCMH.

Impact of telephone delivered case-management on the effectiveness of collaborative care for depression and anti-depressant use: A systematic review and meta-regression

BACKGROUND

The health service delivery framework collaborative care is an effective intervention for depression. However, uncertainties remain about how to optimise its delivery at scale. Structured case management is a core component of collaborative care; its delivery via the telephone may improve access.

AIMS

To examine using meta-regression if telephone delivered case management diminishes the clinical effectiveness of collaborative care on depressive symptoms and anti-depressant use relative to face-to-face delivery methods.

METHODS

Randomised controlled trials were eligible if they included collaborative care interventions for adults with depression identified using self-report measures or diagnostic interviews and reported depression outcomes. Sociodemographics, intervention characteristics, depressive symptoms, and anti-depressant use were extracted. Random effects univariable and multivariable meta-regression analyses were used to examine the moderating effect of telephone delivered case-management on outcomes.

RESULTS

Ninety-four trials were identified comprising of 103 comparisons across 24, 132 participants with depression outcomes and 67 comparisons from 15,367 participants with anti-depressant use outcomes. Telephone delivered case management did not diminish the effects of collaborative care on depressive symptoms (β = -0.01, 95% CI -0.12 to 0.10; p = 0.86). Telephone delivered case management decreased anti-depressant medication use (relative risk 0.76, 95% CI 0.63 to 0.92; p = 0.005); this effect remained when assessed simultaneously alongside other study-level moderators of collaborative care.

CONCLUSION

Using remote platforms such as the telephone to deliver case management may be a feasible way to implement collaborative care with no loss of effectiveness on depressive symptoms. However, adherence to anti-depressant medication may decrease when telephone case management is used.

Use of a Mobile Phone App to Treat Depression Comorbid With Hypertension or Diabetes: A Pilot Study in Brazil and Peru

BACKGROUND

Depression is underdiagnosed and undertreated in primary health care. When associated with chronic physical disorders, it worsens outcomes. There is a clear gap in the treatment of depression in low- and middle-income countries (LMICs), where specialists and funds are scarce. Interventions supported by mobile health (mHealth) technologies may help to reduce this gap. Mobile phones are widely used in LMICs, offering potentially feasible and affordable alternatives for the management of depression among individuals with chronic disorders.

OBJECTIVE

This study aimed to explore the potential effectiveness of an mHealth intervention to help people with depressive symptoms and comorbid hypertension or diabetes and explore the feasibility of conducting large randomized controlled trials (RCTs).

METHODS

Emotional Control (CONEMO) is a low-intensity psychoeducational 6-week intervention delivered via mobile phones and assisted by a nurse for reducing depressive symptoms among individuals with diabetes or hypertension. CONEMO was tested in 3 pilot studies, 1 in São Paulo, Brazil, and 2 in Lima, Peru. Depressive symptoms were assessed using the Patient Health Questionnaire-9 (PHQ-9) at enrollment and at 6-week follow-up.

RESULTS

The 3 pilot studies included a total of 66 people. Most participants were females aged between 41 and 60 years. There was a reduction in depressive symptoms as measured by PHQ-9 in all pilot studies. In total, 58% (38/66) of the participants reached treatment success rate (PHQ-9 <10), with 62% (13/21) from São Paulo, 62% (13/21) from the first Lima pilot, and 50% (12/24) from the second Lima pilot study. The intervention, the app, and the support offered by the nurse and nurse assistants were well received by participants in both settings.

CONCLUSIONS

The intervention was feasible in both settings. Clinical data suggested that CONEMO may help in decreasing participants' depressive symptoms. The findings also indicated that it was possible to conduct RCTs in these settings.

Link-me: Protocol for a randomised controlled trial of a systematic approach to stepped mental health care in primary care

Primary care in Australia is undergoing significant reform, with a particular focus on cost-effective tailoring of mental health care to individual needs. Link-me is testing whether a patient-completed Decision Support Tool (DST), which predicts future severity of depression and anxiety symptoms and triages individuals into care accordingly, is clinically effective and cost-effective relative to usual care. The trial is set in general practices, with English-speaking patients invited to complete eligibility screening in their general practitioner's waiting room. Eligible and consenting patients will then complete the DST assessment and are randomised and stratified according to predicted symptom severity. Participants allocated to the intervention arm will receive feedback on DST responses, select treatment priorities, assess motivation to change, and receive a severity-matched treatment recommendation (information about and links to low intensity services for those with mild symptoms, or assistance from a specially trained health professional (care navigator) for those with severe symptoms). All patients allocated to the comparison arm will receive usual GP care plus attention control. Primary (psychological distress) and secondary (depression, anxiety, quality of life, days out of role) outcomes will be assessed at 6 and 12 months. Differences in outcome means between trial arms both across and within symptom severity group will be examined using intention-to-treat analyses. Within trial and modelled economic evaluations will be conducted to determine the value for money of credentials of Link-me. Findings will be reported to the Federal Government to inform how mental health services across Australia are funded and delivered in the future.

Effectiveness and cost-effectiveness of a multicomponent intervention to improve medication adherence in people with depressive disorders - MAPDep: a study protocol for a cluster randomized controlled trial

PURPOSE

Depression is a widespread mental disorder which can be treated effectively. However, low adherence to antidepressants is very common. The study of medication adherence in depression (MAPDep study) assesses the effectiveness and cost-effectiveness of a multicomponent strategy to enhance adherence toward medications in patients with depression.

INTERVENTION

The intervention is a multicomponent one consisting of an educational program for psychiatrists and/or a collaborative care program for patients and relatives, plus a reminder system that works through the use of an already available high-quality medication reminder application.

STUDY DESIGN

MAPDep study is an open, multicenter, four-arm cluster randomized controlled trial. The clusters are mental health units where psychiatrists are invited to participate. The clusters are randomly allocated to one of the three interventions or to usual care (control arm). Patients (18-65 years of age) diagnosed with depressive disorder, those taking antidepressant medication for an existing diagnosis of depression, and mobile phone users are selected. In group 1, only patients and relatives receive intervention; in group 2, only psychiatrists receive intervention; and in group 3, patients/relatives and psychiatrists receive intervention. The primary outcome is adherence to the antidepressant drug. The calculated sample size is 400 patients. To examine changes across time, generalized linear mixed model with repeated measures will be used. A cost-effectiveness analysis will be conducted. The effectiveness measure is quality-adjusted life years. Deterministic sensitivity analyses are planned.

CONCLUSION

MAPDep study aims to assess a multicomponent strategy to improve adherence toward medications in patients with depression, based not only on clinical effectiveness but also on cost-effectiveness. This methodology will enhance the transferability of the expected results beyond mental health services (patients and psychiatrists) to health care policy decision making.

CLINICAL TRIAL IDENTIFIER

NCT03668457.

Cost-effectiveness of a care manager collaborative care programme for patients with depression in primary care: economic evaluation of a pragmatic randomised controlled study

OBJECTIVE

To evaluate the cost-effectiveness of a care manager (CM) programme compared with care as usual (CAU) for treatment of depression at primary care centres (PCCs) from a healthcare as well as societal perspective.

DESIGN

Cost-effectiveness analysis.

SETTING

23 PCCs in two Swedish regions.

PARTICIPANTS

Patients with depression (n=342).

MAIN OUTCOME MEASURES

A cost-effectiveness analysis was applied on a cluster randomised trial at PCC level where patients with depression had 3 months of contact with a CM (11 intervention PCCs, n=163) or CAU (12 control PCCs, n=179), with follow-up 3 and 6 months. Effectiveness measures were based on the number of depression-free days (DFDs) calculated from the Montgomery-Åsberg Depression Rating Scale-Self and quality-adjusted life years (QALYs). Results were expressed as the incremental cost-effectiveness ratio: ∆Cost/∆QALY and ∆Cost/∆DFD. Sampling uncertainty was assessed based on non-parametric bootstrapping.

RESULTS

Health benefits were higher in intervention group compared with CAU group: QALYs (0.357 vs 0.333, p<0.001) and DFD reduction of depressive symptom score (79.43 vs 60.14, p<0.001). The mean costs per patient for the 6-month period were €368 (healthcare perspective) and €6217 (societal perspective) for the intervention patients and €246 (healthcare perspective) and €7371 (societal perspective) for the control patients (n.s.). The cost per QALY gained was €6773 (healthcare perspective) and from a societal perspective the CM programme was dominant.

DISCUSSION

The CM programme was associated with a gain in QALYs as well as in DFD, while also being cost saving compared with CAU from a societal perspective. This result is of high relevance for decision-makers on a national level, but it must be observed that a CM programme for depression implies increased costs at the primary care level.

TRIAL REGISTRATION NUMBER

NCT02378272; Results.

Cognitive-behaviour therapy for health anxiety in medical patients (CHAMP): a randomised controlled trial with outcomes to 5 years

BACKGROUND

Health anxiety is an under-recognised but frequent cause of distress that is potentially treatable, but there are few studies in secondary care.

OBJECTIVE

To determine the clinical effectiveness and cost-effectiveness of a modified form of cognitive-behaviour therapy (CBT) for health anxiety (CBT-HA) compared with standard care in medical outpatients.

DESIGN

Randomised controlled trial.

SETTING

Five general hospitals in London, Middlesex and Nottinghamshire.

PARTICIPANTS

A total of 444 patients aged 16-75 years seen in cardiology, endocrinology, gastroenterology, neurology and respiratory medicine clinics who scored ≥ 20 points on the Health Anxiety Inventory (HAI) and satisfied diagnostic requirements for hypochondriasis. Those with current psychiatric disorders were excluded, but those with concurrent medical illnesses were not.

INTERVENTIONS

Cognitive-behaviour therapy for health anxiety - between 4 and 10 1-hour sessions of CBT-HA from a health professional or psychologist trained in the treatment. Standard care was normal practice in primary and secondary care.

MAIN OUTCOME MEASURES

Primary - researchers masked to allocation assessed patients at baseline, 3, 6, 12, 24 months and 5 years. The primary outcome was change in the HAI score between baseline and 12 months. Main secondary outcomes - costs of care in the two groups after 24 and 60 months, change in health anxiety (HAI), generalised anxiety and depression [Hospital Anxiety and Depression Scale (HADS)] scores, social functioning using the Social Functioning Questionnaire and quality of life using the EuroQol-5 Dimensions (EQ-5D), at 6, 12, 24 and 60 months, and deaths over 5 years.

RESULTS

Of the 28,991 patients screened over 21 months, 5769 had HAI scores of ≥ 20 points. Improvement in HAI scores at 3 months was significantly greater in the CBT-HA group (mean number of sessions = 6) than in the standard care, and this was maintained over the 5-year period (overall p < 0.0001), with no loss of efficacy between 2 and 5 years. Differences in the generalised anxiety (p = 0.0018) and depression scores (p = 0.0065) on the HADS were similar in both groups over the 5-year period. Gastroenterology and cardiology patients showed the greatest CBT gains. The outcomes for nurses were superior to those of other therapists. Deaths (n = 24) were similar in both groups; those in standard care died earlier than those in CBT-HA. Patients with mild personality disturbance and higher dependence levels had the best outcome with CBT-HA. Total costs were similar in both groups over the 5-year period (£12,590.58 for CBT-HA; £13,334.94 for standard care). CBT-HA was not cost-effective in terms of quality-adjusted life-years, as measured using the EQ-5D, but was cost-effective in terms of HAI outcomes, and offset the cost of treatment.

LIMITATIONS

Many eligible patients were not randomised and the population treated may not be representative.

CONCLUSIONS

CBT-HA is a highly effective treatment for pathological health anxiety with lasting benefit over 5 years. It also improves generalised anxiety and depressive symptoms more than standard care. The presence of personality abnormality is not a bar to successful outcome. CBT-HA may also be cost-effective, but the high costs of concurrent medical illnesses obscure potential savings. This treatment deserves further research in medical settings.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN14565822.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 50. See the NIHR Journals Library website for further project information.

Collaborative care for the detection and management of depression among adults receiving antiretroviral therapy in South Africa: study protocol for the CobALT randomised controlled trial

Background

The scale-up of antiretroviral treatment (ART) programmes has seen HIV/AIDS transition to a chronic condition characterised by high rates of comorbidity with tuberculosis, non-communicable diseases (NCDs) and mental health disorders. Depression is one such disorder that is associated with higher rates of non-adherence, progression to AIDS and greater mortality. Detection and treatment of comorbid depression is critical to achieve viral load suppression in more than 90% of those on ART and is in line with the recent 90-90-90 Joint United Nations Programme on HIV/AIDS (UNAIDS) targets. The CobALT trial aims to provide evidence on the effectiveness and cost-effectiveness of scalable interventions to reduce the treatment gap posed by the growing burden of depression among adults on lifelong ART.

Methods

The study design is a pragmatic, parallel group, stratified, cluster randomised trial in 40 clinics across two rural districts of the North West Province of South Africa. The unit of randomisation is the clinic, with outcomes measured among 2000 patients on ART who screen positive for depression using the Patient Health Questionnaire (PHQ-9). Control group clinics are implementing the South African Department of Health’s Integrated Clinical Services Management model, which aims to reduce fragmentation of care in the context of rising multimorbidity, and which includes training in the Primary Care 101 (PC101) guide covering communicable diseases, NCDs, women’s health and mental disorders. In intervention clinics, we supplemented this with training specifically in the mental health components of PC101 and clinical communications skills training to support nurse-led chronic care. We strengthened the referral pathways through the introduction of a clinic-based behavioural health counsellor equipped to provide manualised depression counselling (eight sessions, individual or group), as well as adherence counselling sessions (one session, individual). The co-primary patient outcomes are a reduction in PHQ-9 scores of at least 50% from baseline and viral load suppression rates measured at 6 and 12 months, respectively.

Discussion

The trial will provide real-world effectiveness of case detection and collaborative care for depression including facility-based counselling on the mental and physical outcomes for people on lifelong ART in resource-constrained settings.

Trial registration

ClinicalTrials.gov (NCT02407691) registered on 19 March 2015; Pan African Clinical Trials Registry (201504001078347) registered on 19/03/2015; South African National Clinical Trials Register (SANCTR) (DOH-27-0515-5048) NHREC number 4048 issued on 21/04/2015.

Electronic supplementary material

The online version of this article (10.1186/s13063-018-2517-7) contains supplementary material, which is available to authorized users.

The effectiveness of Culturally Sensitive Collaborative Treatment of depressed Chinese in family medicine clinics: A randomized controlled trial

OBJECTIVE

To investigate whether the Culturally Sensitive Collaborative Treatment (CSCT) would improve outcomes for patients with major depression who were managed in family medicine clinics in Taiwan.

METHOD

A single-blinded randomized trial was conducted in 26 family medicine clinics. Patients with major depressive disorder were consecutively randomized to either CSCT or treatment as usual (TAU). The primary outcome was the severity of depression. Secondary outcomes included treatment response, treatment remission, quality of life, and medication adherence. Outcomes were compared using hierarchical linear models (mixed-effects models) from baseline to 26-week follow-up assessments.

RESULTS

Of the 280 patients, 141 were randomized to TAU and 139 to CSCT. Hierarchical linear modeling revealed that the CSCT group displayed significantly greater improvement in depressive symptoms over the study period when compared to the TAU group (B=-2.60, P<0.001). The odds of achieving the response, remission, and medication adherence were significantly greater for the CSCT group compared to the TAU group (odds ratio=4.65, 4.12, and 2.06, respectively; all Ps<0.05). However, both groups did not differ significantly in quality of life.

CONCLUSION

CSCT is effective in improving treatment outcomes for major depression in family medicine clinics in Taiwan.

Tailored online cognitive behavioural therapy with or without therapist support calls to target psychological distress in adults receiving haemodialysis: A feasibility randomised controlled trial

BACKGROUND

Psychological distress is prevalent in haemodialysis (HD) patients yet access to psychotherapy remains limited. This study assessed the feasibility and acceptability of online cognitive-behavioural therapy (CBT) tailored for HD patients, with or without therapist support, for managing psychological distress.

METHODS

This feasibility randomised controlled trial recruited patients from a UK HD centre. Following psychological distress screens, patients with mild-moderate psychological distress (Patient Health Questionnaire PHQ-9; score: 5-19 and/or Generalised Anxiety Disorder; GAD-7 score: 5-14) who met remaining inclusion criteria were approached for consent. Consenters were individually randomised (1:1) to online-CBT or online-CBT plus three therapist support calls. Outcomes included recruitment, retention, and adherence rates. Exploratory change analyses were performed for: psychological distress, quality of life (QoL), illness perceptions, and costs. The statistician was blinded to allocation.

RESULTS

182 (44%) out of 410 patients approached completed psychological distress screens. 26% found screening unacceptable; a further 30% found it unfeasible. Psychological distress was detected in 101 (55%) patients, 60 of these met remaining inclusion criteria. The primary reason for ineligibility was poor computer literacy (N=17, 53%). Twenty-five patients were randomised to the supported (N=18) or unsupported arm (N=7); 92% were retained at follow-up. No differences in psychological distress or cost-effectiveness were observed. No trial adverse events occurred.

CONCLUSION

Online CBT appears feasible but only for computer literate patients who identify with the label psychological distress. A definitive trial using the current methods for psychological distress screening and online care delivery is unfeasible. ClinicalTrials.gov Identifier: NCT02352870.

Target-D: a stratified individually randomized controlled trial of the diamond clinical prediction tool to triage and target treatment for depressive symptoms in general practice: study protocol for a randomized controlled trial

BACKGROUND

Depression is a highly prevalent and costly disorder. Effective treatments are available but are not always delivered to the right person at the right time, with both under- and over-treatment a problem. Up to half the patients presenting to general practice report symptoms of depression, but general practitioners have no systematic way of efficiently identifying level of need and allocating treatment accordingly. Therefore, our team developed a new clinical prediction tool (CPT) to assist with this task. The CPT predicts depressive symptom severity in three months' time and based on these scores classifies individuals into three groups (minimal/mild, moderate, severe), then provides a matched treatment recommendation. This study aims to test whether using the CPT reduces depressive symptoms at three months compared with usual care.

METHODS

The Target-D study is an individually randomized controlled trial. Participants will be 1320 general practice patients with depressive symptoms who will be approached in the practice waiting room by a research assistant and invited to complete eligibility screening on an iPad. Eligible patients will provide informed consent and complete the CPT on a purpose-built website. A computer-generated allocation sequence stratified by practice and depressive symptom severity group, will randomly assign participants to intervention (treatment recommendation matched to predicted depressive symptom severity group) or comparison (usual care plus Target-D attention control) arms. Follow-up assessments will be completed online at three and 12 months. The primary outcome is depressive symptom severity at three months. Secondary outcomes include anxiety, mental health self-efficacy, quality of life, and cost-effectiveness. Intention-to-treat analyses will test for differences in outcome means between study arms overall and by depressive symptom severity group.

DISCUSSION

To our knowledge, this is the first depressive symptom stratification tool designed for primary care which takes a prognosis-based approach to provide a tailored treatment recommendation. If shown to be effective, this tool could be used to assist general practitioners to implement stepped mental-healthcare models and contribute to a more efficient and effective mental health system.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR 12616000537459 ). Retrospectively registered on 27 April 2016. See Additional file 1 for trial registration data.

Low intensity interventions for Obsessive-Compulsive Disorder (OCD): a qualitative study of mental health practitioner experiences

BACKGROUND

Obsessive-compulsive disorder (OCD) is a debilitating mental health disorder that can substantially impact upon quality of life and everyday functioning. Guidelines recommend pharmacological and psychological treatments, using a cognitive behaviour therapy approach (CBT) including exposure and response prevention, but access has generally been poor. Low intensity psychological interventions have been advocated. The evidence base for these interventions is emerging but there is a paucity of information regarding practitioners' perceptions and experiences of supporting individuals with OCD using this approach.

METHODS

Qualitative interviews were undertaken with psychological wellbeing practitioners (PWPs) (n = 20) delivering low intensity psychological interventions for adults with OCD within the context of a large pragmatic effectiveness trial. Interviews explored the feasibility and acceptability of delivering two interventions; guided self-help and supported computerised cognitive behaviour therapy (cCBT), within Improving Access to Psychological Therapies (IAPT) services in NHS Trusts. Interviews were recorded with consent, transcribed and analysed using thematic analysis.

RESULTS

PWPs acknowledged the benefits of low intensity psychological interventions for individuals experiencing OCD symptoms on an individual and population level. Offering low intensity support provided was perceived to have the opportunity to overcome existing service barriers to access treatment, improve patient choice and flexibility. Professional and service relevant issues were also recognised including self-beliefs about supporting people with OCD and personal training needs. Challenges to implementation were recognised in relation to practitioner resistance and intervention delivery technical complications.

CONCLUSIONS

This study has provided insight into the implementation of new low intensity approaches to the management of OCD within existing mental health services. Benefits from a practitioner, service and patient perspective are identified and potential challenges highlighted.

TRIAL REGISTRATION

Current Controlled Trials: ISRCTN73535163 . Date of registration: 5 April 2011.

Evaluation of the performance of general practitioners in a collaborative care program by employing simulated patients

OBJECTIVE

To compare the performance of the general practitioners (GPs) in a collaborative care (CC) program in Iran with a control group of GPs in the usual care by employing simulated patients.

METHODS

Six trained simulated patients (SPs) made unannounced visits to 26 GP offices participating in the CC program and to 26 age and sex matched controls. The SPs role played five clinical scenarios of mental disorders and filled out checklists to evaluate the GPs' performance regarding interviewing, taking history, establishing rapport, showing empathy, and giving advice to patients. Additionally, the GPs' plan of care and prescriptions were evaluated later by a psychiatrist based on the documents provided by the SPs.

RESULTS

There was a significant difference between collaborative care and control group physicians in their global performance; CC physicians built up better patient-physician relationship. They performed better in evaluating a psychotic patient, although not better in their management. CC physicians were marginally better in approach to patients with generalized anxiety disorder (GAD) and mild major depressive disorder.

CONCLUSION

The overall performance of physicians in CC was better than the GPs in the control group in making an effective patient-physician relationship, and evaluating a psychotic patient. The main weakness of the GPs was in proper treatment of the minor and more common psychiatric disorders and in evaluation of patients with suicidal ideations who were in need for emergent referral. Evaluating performance of the practitioners is feasible employing SPs and the findings can be translated into improvements in the available services.