Collaborative Care Models for Depression: Time to Move From Evidence to Practice

Department of Psychiatry and Behavioral Sciences, University of Washington Seattle, Seattle, Washington, United States
Archives of Internal Medicine (Impact Factor: 17.33). 12/2006; 166(21):2304-6. DOI: 10.1001/archinte.166.21.2304
Source: PubMed


In this issue of the ARCHIVES

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    • ". Yet, SCC implementation in daily practice is difficult and produces variable results [4] [16] [18] [24] [33]. "
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    ABSTRACT: The mental health burden on primary care is substantial and increasing. Anxiety is a major contributor. Stepped collaborative care (SCC) is implemented worldwide to improve patient outcomes, but long term real-world evaluations of SCC do not exist. Using routinely used electronic medical records from more than a decade, we investigated changes in anxiety prevalences, whether physicians made distinction between non-severe and severe anxiety, and whether these groups were referred and treated differently, both non-pharmacologically and pharmacologically. Retrospective assessment of anxiety care parameters recorded by 54 general practitioners between 2003 and 2014, in the electronic medical records of a dynamic population of 49,841-69,413 primary care patients. Substantial shifts in anxiety care parameters have occurred. The prevalence of anxiety symptoms doubled to 0.9% and of anxiety disorders almost tripled to 1.1%. Use of ICPC codes seemed comprehensive and use of instruments to support in anxiety level differentiation increased to 13% of anxiety symptom and 7% of anxiety disorder patients in 2014. Minimal interventions were used more frequently, especially for anxiety symptoms (OR 21 [95% CI 5.1-85]). The antidepressant prescription rates decreased significantly for anxiety symptoms (OR 0.5 [95% CI 0.4-0.8]) and anxiety disorders (OR 0.6 [95% CI 0.4-0.8]). More patients were referred to psychologists and psychiatrists. We found shifts in anxiety care parameters that follow the principles of SCC. Future primary care research should comprehensively assess the use of the SCC range of therapeutic options, tailored to patients with all different anxiety severity levels. Copyright © 2015 Elsevier Masson SAS. All rights reserved.
    European Psychiatry 07/2015; 30(6). DOI:10.1016/j.eurpsy.2015.06.002 · 3.44 Impact Factor
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    • "In the US, collaborative care has also been shown to improve depression in people with LTCs [10,11]. However, despite the growing evidence base for collaborative care, there remains a gap between the demonstrated efficacy of collaborative care in trials and its implementation in everyday practice [12,13]. This is particularly true in the English National Health Service (NHS) where the National Institute for Health and Care Excellence (NICE) have recommended using collaborative care for patients with depression and LTCs where mental health status has not improved as a result of medication and/or a high intensity intervention. "
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    ABSTRACT: Mental-physical multi-morbidities pose challenges for primary care services that traditionally focus on single diseases. Collaborative care models encourage inter-professional working to deliver better care for patients with multiple chronic conditions, such as depression and long-term physical health problems. Successive trials from the United States have shown that collaborative care effectively improves depression outcomes, even in people with long-term conditions (LTCs), but little is known about how to implement collaborative care in the United Kingdom. The aim of the study was to explore the extent to which collaborative care was implemented in a naturalistic National Health Service setting. A naturalistic pilot study of collaborative care was undertaken in North West England. Primary care mental health professionals from IAPT (Increasing Access to Psychological Therapies) services and general practice nurses were trained to collaboratively identify and manage patients with co-morbid depression and long-term conditions. Qualitative interviews were performed with health professionals at the beginning and end of the pilot phase. Normalization Process Theory guided analysis. Health professionals adopted limited elements of the collaborative care model in practice. Although benefits of co-location in primary care practices were reported, including reduced stigma of accessing mental health treatment and greater ease of disposal for identified patients, existing norms around the division of mental and physical health work in primary care were maintained, limiting integration of the mental health practitioners into the practice setting. Neither the mental health practitioners nor the practice nurses perceived benefits to joint management of patients. Established divisions between mental and physical health may pose particular challenges for multi-morbidity service delivery models such as collaborative care. Future work should explore patient perspectives about whether greater inter-professional working enhances experiences of care. The study demonstrates that research into implementation of novel treatments must consider how the introduction of innovation can be balanced with the need for integration into existing practice.
    Implementation Science 09/2013; 8(1):110. DOI:10.1186/1748-5908-8-110 · 4.12 Impact Factor
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    • "Although a considerable evidence base exists for the role of collaborative care in improving treatment of depression [89], there is a recognized gap between the efficacy demonstrated in trials and the implementation of the intervention in everyday practice [28], with particular uncertainty around whether the model will effectively translate to UK healthcare systems [36]. The UK Medical Research Council has highlighted the need for process evaluations to understand the problems of integrating interventions into healthcare settings. "
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    ABSTRACT: Background: Depression is up to two to three times as common in people with long-term conditions. It negatively affects medical management of disease and self-care behaviors, and leads to poorer quality of life and high costs in primary care. Screening and treatment of depression is increasingly prioritized, but despite initiatives to improve access and quality of care, depression remains under-detected and under-treated, especially in people with long-term conditions. Collaborative care is known to positively affect the process and outcome of care for people with depression and long-term conditions, but its effectiveness outside the USA is still relatively unknown. Furthermore, collaborative care has yet to be tested in settings that resemble more naturalistic settings that include patient choice and the usual care providers. The aim of this study was to test the effectiveness of a collaborative-care intervention, for people with depression and diabetes/coronary heart disease in National Health Service (NHS) primary care, in which low-intensity psychological treatment services are delivered by the usual care provider - Increasing Access to Psychological Therapies (IAPT) services. The study also aimed to evaluate the cost-effectiveness of the intervention over 6 months, and to assess qualitatively the extent to which collaborative care was implemented in the intervention general practices. Methods: This is a cluster randomized controlled trial of 30 general practices allocated to either collaborative care or usual care. Fifteen patients per practice will be recruited after a screening exercise to detect patients with recognized depression (≥10 on the nine-symptom Patient Health Questionnaire; PHQ-9). Patients in the collaborative-care arm with recognized depression will be offered a choice of evidence-based low-intensity psychological treatments based on cognitive and behavioral approaches. Patients will be case managed by psychological well-being practitioners employed by IAPT in partnership with a practice nurse and/or general practitioner. The primary outcome will be change in depressive symptoms at 6 months on the 90-item Symptoms Checklist (SCL-90). Secondary outcomes include change in health status, self-care behaviors, and self-efficacy. A qualitative process evaluation will be undertaken with patients and health practitioners to gauge the extent to which the collaborative-care model is implemented, and to explore sustainability beyond the clinical trial. Discussion: COINCIDE will assess whether collaborative care can improve patient-centered outcomes, and evaluate access to and quality of care of co-morbid depression of varying intensity in people with diabetes/coronary heart disease. Additionally, by working with usual care providers such as IAPT, and by identifying and evaluating interventions that are effective and appropriate for routine use in the NHS, the COINCIDE trial offers opportunities to address translational gaps between research and implementation. Trial registration number: ISRCTN80309252 TRIAL STATUS: Open.
    Trials 08/2012; 13(1):139. DOI:10.1186/1745-6215-13-139 · 1.73 Impact Factor
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