Embedding effective depression care: using theory for primary care organisational and systems change

BACKGROUND

Depression and related disorders represent a significant part of general practitioners (GPs) daily work. Implementing the evidence about what works for depression care into routine practice presents a challenge for researchers and service designers. The emerging consensus is that the transfer of efficacious interventions into routine practice is strongly linked to how well the interventions are based upon theory and take into account the contextual factors of the setting into which they are to be transferred. We set out to develop a conceptual framework to guide change and the implementation of best practice depression care in the primary care setting.

METHODS

We used a mixed method, observational approach to gather data about routine depression care in a range of primary care settings via: audit of electronic health records; observation of routine clinical care; and structured, facilitated whole of organisation meetings. Audit data were summarised using simple descriptive statistics. Observational data were collected using field notes. Organisational meetings were audio taped and transcribed. All the data sets were grouped, by organisation, and considered as a whole case. Normalisation Process Theory (NPT) was identified as an analytical theory to guide the conceptual framework development.

RESULTS

Five privately owned primary care organisations (general practices) and one community health centre took part over the course of 18 months. We successfully developed a conceptual framework for implementing an effective model of depression care based on the four constructs of NPT: coherence, which proposes that depression work requires the conceptualisation of boundaries of who is depressed and who is not depressed and techniques for dealing with diffuseness; cognitive participation, which proposes that depression work requires engagement with a shared set of techniques that deal with depression as a health problem; collective action, which proposes that agreement is reached about how care is organised; and reflexive monitoring, which proposes that depression work requires agreement about how depression work will be monitored at the patient and practice level. We describe how these constructs can be used to guide the design and implementation of effective depression care in a way that can take account of contextual differences.

CONCLUSIONS

Ideas about what is required for an effective model and system of depression care in primary care need to be accompanied by theoretically informed frameworks that consider how these can be implemented. The conceptual framework we have presented can be used to guide organisational and system change to develop common language around each construct between policy makers, service users, professionals, and researchers. This shared understanding across groups is fundamental to the effective implementation of change in primary care for depression.

Climate change and Australia's healthcare system - risks, research and responses

Climate change will affect human health, mostly adversely, resulting in a greater burden on the health care system, in addition to any other coexistent increases in demand (e.g. from Australia’s increasingly ageing population). Understanding the extent to which health is likely to be affected by climate change will enable policy makers and practitioners to prepare for changing demands on the health care system. This will require prioritisation of key research questions and building research capacity in the field. There is an urgent need to better understand the implications of climate change for the distribution and prevalence of diseases, disaster preparedness and multidisciplinary service planning. Research is needed to understand the relationship of climate change to health promotion, policy evaluation and strategic financing of health services. Training of health care professionals about climate change and its effects will also be important in meeting long-term workforce demands.

Australian primary mental health care: improving access and outcomes

The progressive achievements over time of the Access to Allied Psychological Services (ATAPS) component of the Better Outcomes in Mental Health Care program are examined using a web-based, purpose-designed minimum dataset that collects provider-, consumer- and session-level data on the projects. Findings indicate that the ATAPS projects have established themselves over time as a cornerstone of mental health service provision in Australia. Despite the more recent introduction of the complementary Better Access to Psychiatrists, Psychologists and General Practitioners through the Medicare Benefits Schedule program, the ATAPS projects have continued, since 2001, to attract substantial numbers of general practitioners and allied health professionals and deliver services to significant numbers of consumers. The profile of consumers being referred to the projects is now very consistent, with the majority being women with high prevalence disorders who may have had difficulty accessing mental health care in the past. The nature of sessions being delivered through the projects has also reached a point of consistency, with the majority being individual-level, cognitive behavioural therapy-based sessions of around 1 h in length. The only variation in session delivery is related to the charging of a co-payment. There is good evidence that the projects are achieving positive outcomes for consumers.

Hope, despair and transformation: Climate change and the promotion of mental health and wellbeing

Background

This article aims to provide an introduction to emerging evidence and debate about the relationship between climate change and mental health.

Discussion and Conclusion

The authors argue that:

i) the direct impacts of climate change such as extreme weather events will have significant mental health implications;

ii) climate change is already impacting on the social, economic and environmental determinants of mental health with the most severe consequences being felt by disadvantaged communities and populations;

iii) understanding the full extent of the long term social and environmental challenges posed by climate change has the potential to create emotional distress and anxiety; and

iv) understanding the psycho-social implications of climate change is also an important starting point for informed action to prevent dangerous climate change at individual, community and societal levels.

Impact of an educational intervention on general practitioners' skills in cognitive behavioural strategies: a randomised controlled trial

OBJECTIVE

To evaluate the impact of an educational intervention on general practitioners' skills in cognitive behavioural strategies (CBS).

DESIGN

Randomised controlled trial, with baseline and post-training measurement of GP competency in CBS using standardised simulated patient consultations, conducted between January 2005 and December 2006.

PARTICIPANTS AND SETTING

55 GPs in Victoria with a special interest in mental health issues.

INTERVENTION

A 20-hour multifaceted educational program facilitated by mental health experts, incorporating rehearsal of CBS and provision of resources such as patient education material and worksheets.

MAIN OUTCOME MEASURES

Objective ratings of videotaped consultations of a standardised simulated patient using the Cognitive Therapy Scale.

RESULTS

32 doctors completed all phases of the intervention and the evaluation protocol. The intervention group showed greater improvements than the control group in both general therapeutic and specific CBS skills after the training.

CONCLUSION

Competency in CBS in highly motivated GPs can be improved by a brief training intervention.

TRIAL REGISTRATION

International Standard Randomised Controlled Trial Number -- ISRCTN62481969.

Who is identified when screening for depression is undertaken in general practice? Baseline findings from the Diagnosis, Management and Outcomes of Depression in Primary Care (diamond) longitudinal study

OBJECTIVES

To report the baseline characteristics of the Diagnosis, Management and Outcomes of Depression in Primary Care (diamond) study cohort and discuss the implications for depression care in general practice.

DESIGN

A prospective longitudinal study beginning in January 2005.

PARTICIPANTS AND SETTING

Adult patients with depressive symptoms identified via screening with the Center for Epidemiologic Studies Depression Scale (CES-D > or = 16) in 30 randomly selected Victorian general practices.

MAIN OUTCOME MEASURE

Depression status on the Patient Health Questionnaire (PHQ).

RESULTS

789 patients form the cohort (71% women). At baseline, 47% were married, 21% lived alone, 36% received a pension or benefit, 15% were unable to work, 23% reported hazardous drinking, 32% were smokers, 39% used antidepressants and 19% used sedatives. 27% satisfied criteria for current major depressive syndrome (MDS) on the PHQ, while 52% had "persistent" depressive symptoms, and 22% had "transient" depressive symptoms, lasting at most a few weeks. Of those satisfying criteria for MDS, 49% were also classified with an anxiety syndrome, 40% reported childhood sexual abuse, 57% reported childhood physical abuse, 42% had at some time been afraid of their partner, and 72% reported a chronic physical condition; 84% were receiving mental health care (either taking antidepressants or seeing a health practitioner specifically for mental health care) compared with 66% of those with persistent depressive symptoms and 57% with transient depressive symptoms.

CONCLUSION

This method of screening for depressive symptoms in general practice identifies a group of patients with substantial multiple comorbidities -- psychiatric, physical and social problems coexist with depressive symptoms, raising challenges for the management of depression in general practice.

Evidence into practice: the mental health hurdle is high

Guidelines for GPs need to tackle the tough issues.

The contribution of general practice based research to the development of national policy: case studies from Ireland and Australia

Background

This paper aims to describe the influence of general practice based research on the development of two specific policy initiatives, namely the Heartwatch Programme in Ireland and the Better Outcomes in Mental Health Care (BOiMHC) program in Australia. A case study approach was used to explore the extent to which relevant general practice based research shaped these initiatives.

Results

In both case studies, a range of factors beyond general practice based research shaped the initiative in question, including political will, the involvement of stakeholders (including key opinion leaders), and the historical context. Nonetheless, the research played an important role, and was not merely put to 'symbolic use' to support a position that had already been reached independently. Rather, both case studies provide examples of 'instrumental use': in the case of Heartwatch, the research was considered early in the piece; in the case of the BOiMHC program, it had a specific impact on the detail of the components of the initiative.

Conclusion

General practice based research can influence policy-making and planning processes by strengthening the foundation of evidence upon which they draw. This influence will not occur in a vacuum, however, and general practice researchers can maximise the likelihood of their work being 'picked up' in policy if they consider the principles underpinning knowledge transfer.

General practitioners’ response to depression and anxiety in the Australian community: a preliminary analysis

OBJECTIVES

To examine the uptake by general practitioners (GPs) of the five key components of the Better Outcomes in Mental Health Care (BOiMHC) initiative: education and training for GPs; the three-step mental health process; focussed psychological strategies; access to allied health services; and access to psychiatrist support.

SETTING

All Australian states and territories during the first 15 months of the initiative (1 July 2002 - 30 September 2003).

DESIGN

Retrospective survey of de-identified registration data held by the General Practice Mental Health Standards Collaboration (training uptake), de-identified Health Insurance Commission (HIC) billing data (provision of the three-step mental health process, focussed psychological strategies and case conferences with psychiatrists), and reports from "access to allied health services" projects to the Australian Department of Health and Ageing (project participation).

MAIN OUTCOME MEASURES

Number and percentage of Australian GPs certified as eligible to participate in the initiative; provision of the three-step mental health process and focussed psychological strategies by GPs; participation in allied health pilot projects; and access to psychiatrist support.

RESULTS

Within 15 months of the BOiMHC initiative commencing, 3046 GPs (about 15% of Australian GPs) had been certified as eligible to participate, including 387 who had registered to provide focussed psychological strategies. GPs had completed 11 377 three-step mental health processes and 6472 sessions of focussed psychological strategies. Sixty-nine "access to allied health services" projects had been funded, with the original 15 pilot projects enabling 346 GPs to refer 1910 consumers to 134 individual allied health professionals and 10 agencies. In contrast, the "access to psychiatrist support" component was less successful, with the HIC billed for 62 case conferences at which a psychiatrist and a GP were present.

CONCLUSION

The level of uptake of the main components of the BOiMHC initiative has expanded the national capacity to respond to the needs of people with common mental disorders, such as depression and anxiety.