ArticlePDF AvailableLiterature Review

Abstract

Common mental health problems, such as depression and anxiety, are estimated to affect up to 15% of the UK population at any one time, and health care systems worldwide need to implement interventions to reduce the impact and burden of these conditions. Collaborative care is a complex intervention based on chronic disease management models that may be effective in the management of these common mental health problems. To assess the effectiveness of collaborative care for patients with depression or anxiety. We searched the following databases to February 2012: The Cochrane Collaboration Depression, Anxiety and Neurosis Group (CCDAN) trials registers (CCDANCTR-References and CCDANCTR-Studies) which include relevant randomised controlled trials (RCTs) from MEDLINE (1950 to present), EMBASE (1974 to present), PsycINFO (1967 to present) and the Cochrane Central Register of Controlled Trials (CENTRAL, all years); the World Health Organization (WHO) trials portal (ICTRP); ClinicalTrials.gov; and CINAHL (to November 2010 only). We screened the reference lists of reports of all included studies and published systematic reviews for reports of additional studies. Randomised controlled trials (RCTs) of collaborative care for participants of all ages with depression or anxiety. Two independent researchers extracted data using a standardised data extraction sheet. Two independent researchers made 'Risk of bias' assessments using criteria from The Cochrane Collaboration. We combined continuous measures of outcome using standardised mean differences (SMDs) with 95% confidence intervals (CIs). We combined dichotomous measures using risk ratios (RRs) with 95% CIs. Sensitivity analyses tested the robustness of the results. We included seventy-nine RCTs (including 90 relevant comparisons) involving 24,308 participants in the review. Studies varied in terms of risk of bias.The results of primary analyses demonstrated significantly greater improvement in depression outcomes for adults with depression treated with the collaborative care model in the short-term (SMD -0.34, 95% CI -0.41 to -0.27; RR 1.32, 95% CI 1.22 to 1.43), medium-term (SMD -0.28, 95% CI -0.41 to -0.15; RR 1.31, 95% CI 1.17 to 1.48), and long-term (SMD -0.35, 95% CI -0.46 to -0.24; RR 1.29, 95% CI 1.18 to 1.41). However, these significant benefits were not demonstrated into the very long-term (RR 1.12, 95% CI 0.98 to 1.27).The results also demonstrated significantly greater improvement in anxiety outcomes for adults with anxiety treated with the collaborative care model in the short-term (SMD -0.30, 95% CI -0.44 to -0.17; RR 1.50, 95% CI 1.21 to 1.87), medium-term (SMD -0.33, 95% CI -0.47 to -0.19; RR 1.41, 95% CI 1.18 to 1.69), and long-term (SMD -0.20, 95% CI -0.34 to -0.06; RR 1.26, 95% CI 1.11 to 1.42). No comparisons examined the effects of the intervention on anxiety outcomes in the very long-term.There was evidence of benefit in secondary outcomes including medication use, mental health quality of life, and patient satisfaction, although there was less evidence of benefit in physical quality of life. Collaborative care is associated with significant improvement in depression and anxiety outcomes compared with usual care, and represents a useful addition to clinical pathways for adult patients with depression and anxiety.
A preview of the PDF is not available
... The least confident treatments included veneers, critical teeth bleaching, treating chronically compromised patients, suturing, repairing and relining existing dentures, and molar RCT. These results were unsurprising given dental students' scant clinical training in these fields over the course of their five academic years [22,23,27]. According to a new American Academy of Cosmetic Dentistry study of dentists in North America performed by the Levin Group, the most often ordered cosmetic treatment was "bleaching/whitening. ...
... Complicated The least confident treatments included veneers, critical teeth bleaching, treating chronically compromised patients, suturing, repairing and relining existing dentures, and molar RCT. These results were unsurprising given dental students' scant clinical training in these fields over the course of their five academic years [22,23,30]. "Bleaching/whitening" was the most often requested cosmetic procedure by dentists in North America, according to a recent survey by the Levin Group. ...
... Unützer et al. found greater overall QOL at 12-month follow up, compared with usual care [57]. More specifically, evidence exists that collaborative care has a more positive effect than usual care on mental health QOL outcomes in the short-, medium-, and long-term [58]. With regard to social role functioning, a systematic review by Hudson et al. (2016) investigated the positive effect of collaborative care in patients with depression on the degree to which patients returned to normal behaviour in their work and recreational environments, and assumed their usual social roles [59]. ...
Article
Full-text available
Background The interdisciplinary research training group (POKAL) aims to improve care for patients with depression and multimorbidity in primary care. POKAL includes nine projects within the framework of the Chronic Care Model (CCM). In addition, POKAL will train young (mental) health professionals in research competences within primary care settings. POKAL will address specific challenges in diagnosis (reliability of diagnosis, ignoring suicidal risks), in treatment (insufficient patient involvement, highly fragmented care and inappropriate long-time anti-depressive medication) and in implementation of innovations (insufficient guideline adherence, use of irrelevant patient outcomes, ignoring relevant context factors) in primary depression care. Methods In 2021 POKAL started with a first group of 16 trainees in general practice (GPs), pharmacy, psychology, public health, informatics, etc. The program is scheduled for at least 6 years, so a second group of trainees starting in 2024 will also have three years of research-time. Experienced principal investigators (PIs) supervise all trainees in their specific projects. All projects refer to the CCM and focus on the diagnostic, therapeutic, and implementation challenges. Results The first cohort of the POKAL research training group will develop and test new depression-specific diagnostics (hermeneutical strategies, predicting models, screening for suicidal ideation), treatment (primary-care based psycho-education, modulating factors in depression monitoring, strategies of de-prescribing) and implementation in primary care (guideline implementation, use of patient-assessed data, identification of relevant context factors). Based on those results the second cohort of trainees and their PIs will run two major trials to proof innovations in primary care-based a) diagnostics and b) treatment for depression. Conclusion The research and training programme POKAL aims to provide appropriate approaches for depression diagnosis and treatment in primary care.
... The Collaborative Care model (CoCM) is an evidence-based method of treating mental health conditions within primary care, demonstrated to improve clinical outcomes. 93 The CoCM team consists of a primary care provider, a behavioral health care manager, and a psychiatric consultant. 94 The intervention utilizes a registry to track and follow a population of patients, delivering measurement-based care to target specific outcomes. ...
Article
Full-text available
Heather Huang,1 Nicholas Nissen,2 Christopher T Lim,3 Jessica L Gören,2,4 Margaret Spottswood,5,6 Hsiang Huang2 1Department of Psychiatry, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA; 2Department of Psychiatry, Cambridge Health Alliance, Harvard Medical School, Cambridge, MA, USA; 3Department of Psychiatry, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA; 4Department of Pharmacy, Cambridge Health Alliance, Cambridge, MA, USA; 5Community Health Centers of Burlington, Burlington, VT, USA; 6Department of Psychiatry, University of Vermont College of Medicine, Burlington, VT, USACorrespondence: Hsiang Huang, Department of Psychiatry, Cambridge Health Alliance, 1493 Cambridge St, Cambridge, MA, 02139, USA, Tel +1-206-414-8198, Email hhuang@cha.harvard.eduAbstract: Bipolar disorder is a chronic mental illness associated with early mortality, elevated risk of comorbid cardiovascular disease, enormous burden of disability, and large societal costs. Patients often seek treatment for symptoms of bipolar disorder in the primary care setting but are frequently misdiagnosed. This article provides primary care providers with an evidence-based approach to the screening, diagnosis, and pharmacological management of bipolar disorder. Guidance is also provided for helping patients connect with higher levels of specialty psychiatric care when clinically indicated.Keywords: bipolar disorder, mood disorders, integrated behavioral care, primary care mental health
... When available, patients with BPD can be referred to therapists or behavioral care managers working in an integrated model, such as Collaborative Care. The Collaborative Care model (CoCM) is an evidence-based method of treating mental health conditions within primary care, demonstrated to improve clinical outcomes (58). The CoCM team consists of a primary care physician, a behavioral health care manager, and psychiatric consultants. ...
Article
Full-text available
Borderline personality disorder (BPD) is a common mental health diagnosis observed in the primary care population and is associated with a variety of psychological and physical symptoms. BPD is a challenging disorder to recognize due to the limitations of accurate diagnosis and identification in primary care settings. It is also difficult to treat due to its complexity (e.g., interpersonal difficulties and patterns of unsafe behaviors, perceived stigma) and healthcare professionals often feel overwhelmed when treating this population. The aim of this article is to describe the impact of BPD in primary care, review current state of knowledge, and provide practical, evidence-based treatment approaches for these patients within this setting. Due to the lack of evidence-based pharmacological treatments, emphasis is placed on describing the framework for treatment, identifying psychotherapeutic opportunities, and managing responses to difficult clinical scenarios. Furthermore, we discuss BPD treatment as it relates to populations of special interest, including individuals facing societal discrimination and adolescents. Through this review, we aim to highlight gaps in current knowledge around managing BPD in primary care and provide direction for future study.
... The main benefit that the integrated and collaborative perinatal mental health represents for women is the titrated care to the treatment intensity required for a given patient ( Archer et al., 2012 ). The finding that Czech women use help seeking pattern following the integrated stepped mental health care with elements of collaborative care by themselves is of major interest in the planning of innovations in the perinatal mental health care in Czechia. ...
Article
Objective To understand both, women´s perception of emotional difficulties in perinatal period and their related coping strategies. Further, we mapped and analysed help-seeking patterns utilized by these women to overcome their emotional difficulties. This study serve as an important piece of information for women-centred innovations in perinatal mental health care in Czechia, and more broadly in the region of Central and Eastern Europe. Design A qualitative study with an exploratory and descriptive approach using thematic analysis. Setting Online survey consisting of open-ended questions mapping women´s perception of emotional difficulties in perinatal period and their related coping strategies and help-seeking patterns. Participants Two hundred women self-reporting emotional difficulties in perinatal period, from whom 108 (54 %) stated that they had sought professional help with their emotional difficulties. Findings Two themes were identified in the analysis of women´s perception of emotional difficulties including Experience of symptoms of mental disorders, and Mother-child relationship. Three themes were identified in the analysis of women´s coping with these difficulties (Personal resources, External resources, and No coping strategy used). Four themes were identified in the analysis of help seeking patterns utilized by study participants (Mental health specialists, Physicians of the first line of contact, Midwifes, and Peer consultants). Key conclusions Emotional difficulties of perinatal women stemmed in both, general symptoms of mental disorders and specific concerns connected to mother-child relationship. Therefore, the perinatal mental health services should cover both topics, preferably by a multidisciplinary team. Women search information about perinatal mental health, so thus, easy to reach valid resources are needed. Finally, Czech perinatal women experiencing emotional difficulties utilize various help-seeking patterns. Some of them naturalistically utilize integrated stepped care even when it is not systematically established.
... Collaborative care has been a breakthrough development in care delivery in the treatment of depression in primary care settings and consistently demonstrates improved access and outcomes compared to care as usual. 12 In addition, the Improving Access to Psychological Therapies (IAPT) program has been effective in treating over one million people with depression in the United Kingdom per year utilizing a stepped-care approach with a critical focus on measuring and improving clinical outcomes. 13 An overall mental health integration suite of services should include not only collaborative care, but also electronic and other forms of asynchronous psychiatric consultation and digital mental health access through guided and unguided self-help. ...
Article
Collaborative Care Programs (CCPs) integrate mental health services into primary care settings to help patients access much needed treatment. Technologies could increase the effectiveness of CCPs, but we know little about what collaboration challenges technologies must address in this complex clinical setting. To investigate these challenges and technology opportunities, we conducted interviews and contextual inquiries with 30 patients and providers in an obstetric CCP. Using the Parallel Journeys Framework as a lens, we uncover new collaboration challenges (e.g., weighing risks and benefits of treatment, conflicting opinions and ambiguous responsibilities) at the intersection of patients' obstetric and psychosocial care journeys. We discuss new CSCW implications and technology opportunities, such as the importance of addressing support gaps in cyclical experiences, and the need to resolve provider conflicts to refocus on patient needs. These contributions inform how technologies can support patient engagement and collaboration with providers to access and receive treatment, as well as improve health outcomes.
Chapter
Over the last decade, the integration of psychiatry into primary care has shifted from a niche endeavor to widespread utilization and acceptance. In fact, integration is now seen as central to solving for both the worsening psychiatric workforce shortage and the psychiatric access problems that have long created difficulties for the field of psychiatry. Furthermore, robust evidence showing that individuals with serious mental illness and/or substance use disorders suffer markedly worse physical health outcomes has spurned significant attention and investment in the integration of general health interventions into settings that focus on behavioral health service delivery. This chapter provides an overview of the two most common models of integrating behavioral health into primary care, as well as the multitude of efforts aimed at improving the physical health outcomes of individuals with serious mental illness, reviews the evidence base exploring their utility, and considers factors pertinent to effective implementation, including considerations specific to community psychiatry settings.
Chapter
Community psychiatry must practice methods of population health to value the health of everyone. While still important, individual appointments will never be enough to serve those in need. More efficient and effective ways to deliver mental health outcomes for groups of people exist at different levels of care: for individual clinicians, healthcare systems, public health systems, and public policy addressing social determinants of health. Tackling social determinants, like poverty, would not only improve the mental health of many; it would also help prevent future mental health disorders. Shifts in psychiatric training, culture and care practices, and mental health reimbursement would support the shift to population health and improve mental health for all.
Article
Integrated primary and behavioral healthcare (IPBH) programs have been investigated extensively in community settings, but few studies have included the effect of such programs on college campuses, and fewer have focused on outcomes with students with severe symptoms. We analyzed the recovery curves of 267 students with severe mental health symptoms in a collegiate IPBH program using ex post facto design and growth curve modeling. Students fit into three subgroups according with type of services received: (1) counseling only; (2) counseling and primary care; and (3) counseling, primary care, and psychiatric care. Results showed all treatment groups demonstrated positive growth trajectories. The outcome of this study is discussed in relationship with existing literature. Implications for future collegiate IPBH research and clinical practice for counselors, primary care staff, and psychiatrists are presented.
Article
Objective: The authors compared the incremental cost-effectiveness of a stepped-care, multicomponent program with usual care for the treatment of depressed women in primary care in Santiago, Chile. Method: A cost-effectiveness study was conducted of a previous randomized controlled trial involving 240 eligible women with DSM-IV major depression who were selected from a consecutive sample of adult women attending primary care clinics. The patients were randomly allocated to usual care or a multicomponent stepped-care program led by a nonmedical health care worker. Depression-free days and health care costs derived from local sources were assessed after 3 and 6 months. A health service perspective was used in the economic analysis. Results: Complete data were determined for 80% of the randomly assigned patients. After we adjusted for initial severity, women receiving the stepped-care program had a mean of 50 additional depression-free days over 6 months relative to patients allocated to usual care. The stepped-care program was marginally more expensive than usual care (an extra 216 Chilean pesos per depression-free day). There was a 90% probability that the incremental cost of obtaining an extra depression-free day with the intervention would not exceed 300 pesos ($1.04 U.S.). Conclusions: The stepped-care program was significantly more effective and marginally more expensive than usual care for the treatment of depressed women in primary care. Small investments to improve depression appear to yield larger gains in poorer environments. Simple and inexpensive treatment programs tested in developing countries might provide good study models for developed countries.
Article
Objective: Despite well-established links between poverty and poor mental illness outcome as well as recent reports exploring racial and ethnic health disparities, little is known about the outcomes of evidence-based psychiatric treatment for poor individuals. Method: Primary care patients with panic disorder (N=232) who were participating in a randomized controlled trial comparing a cognitive behavior therapy (CBT) and pharmacotherapy intervention to usual care were divided into those patients above (N=152) and below (N=80) the poverty line. Telephone assessments at 3, 6, 9, and 12 months were used to compare the amount of evidence-based care received as well as clinical and functional outcomes. Results: Poor subjects were more severely ill at baseline, with more medical and psychiatric comorbidity. The increases in the amount of evidence-based care and reductions in clinical symptoms and disability were comparable in the two groups such that poorer individuals, although responding equivalently, continued to be more ill and disabled at 12 months. Conclusions: The comparable response of poor individuals in this study suggests that standard CBT and pharmacotherapy treatments for panic disorder do not need to be "tailored" to be effective in poor populations. However, the more severe illness both at baseline and follow-up in these poor individuals suggests that treatment programs may need to be extended in order to treat residual symptoms and disability in these patients so that they might achieve comparable levels of remission.
Article
Objective: The authors analyzed data from 615 depressed primary care patients to determine their willingness to pay for depression treatment. Methods: A sample of 615 adult patients from four primary care clinics participated in a randomized controlled trial of a disease management program for depression in primary care. Participants were asked at baseline interviews and six-month follow-up interviews how much they would be willing to pay per month for a six-month treatment that would eliminate their symptoms of depression. Multiple regression analyses were used to estimate the association between demographic and clinical factors and willingness to pay for depression treatment and to examine changes. Results: The mean amount that participants were willing to pay for depression treatment at baseline was $270±187 per month, or about 9 percent of the participants' household income. Willingness to pay was significantly associated with household income and with the severity of depressive symptoms. Over six months, the amount that participants were willing to pay decreased along with their severity of depressive symptoms. Conclusions: The amount that participants were willing to pay was comparable to that reported for the treatment of other chronic medical disorders and higher than the actual cost of depression treatment. Measurements of willingness to pay may be a promising method for assessing the value of treatments for common mental disorders.
Article
Objective: This study assessed treatment preferences among low-income Latino patients in public-sector primary care clinics and examined whether a collaborative care intervention that included patient education and allowed patients to choose between medication, therapy, or both would increase the likelihood that patients received preferred treatment. Methods: A total of 339 Latino patients with probable depressive disorders were recruited; participants completed a baseline conjoint analysis preference survey and were randomly assigned to receive the intervention or enhanced usual care. At 16 weeks, a patient survey assessed depression treatment received during the study period. Logistic regression models were constructed to estimate treatment preferences, examine patient characteristics associated with treatment preferences, and examine patient characteristics associated with a match between stated preference and actual treatment received. Results: The conjoint analysis preference survey showed that patients preferred counseling or counseling plus medication over antidepressant medication alone and that they preferred treatment in primary care over specialty mental health care, but they showed no significant preference for individual versus group treatment. Patients also indicated that individual education sessions, telephone sessions, transportation assistance, and family involvement were barrier reduction strategies that would enhance their likelihood of accepting treatment. Compared with patients assigned to usual care, those in the intervention group were 21 times as likely to receive preferred treatment. Among all participants, women, unemployed persons, those who spoke English, and those referred by providers were more likely to receive preferred treatment. Conclusions: Collaborative care interventions that include psychotherapy can increase the likelihood that Latino patients receive preferred care; however, special efforts may be needed to address preferences of working persons, men, and Spanish-speaking patients.
Article
Objective: This study assessed longer-term outcomes of low-income patients with cancer (predominantly female and Hispanic) after treatment in a collaborative model of depression care or in enhanced usual care. Methods: The randomized controlled trial, conducted in safety-net oncology clinics, recruited 472 patients with major depression symptoms. Patients randomly assigned to a 12-month intervention (a depression care manager and psychiatrist provided problem-solving therapy, antidepressants, and symptom monitoring and relapse prevention) or enhanced usual care (control group) were interviewed at 18 and 24 months after enrollment. Results: At 24 months, 46% of patients in the intervention group and 32% in the control group had a ≥50% decrease in depression score over baseline (odds ratio=2.09, 95% confidence interval=1.13-3.86; p=.02); intervention patients had significantly better social (p=.03) and functional (p=.01) well-being. Treatment receipt among intervention patients declined (72%, 21%, and 18% at 12, 18, and 24 months, respectively); few control group patients reported treatment receipt (10%, 6%, and 13%, respectively). Significant differences in receipt of counseling or antidepressants disappeared at 24 months. Depression recurrence was similar between groups (intervention, 36%; control, 39%). Among patients with depression recurrence, intervention patients were more likely to receive treatment after 12 months (34% versus 10%; p=.03). At 24 months, attrition (262 patients, 56%) did not vary by group; 22% were deceased, 20% declined further participation, and 14% could not be located. Conclusions: Collaborative care reduced depression symptoms and enhanced quality of life; however, results call for ongoing depression symptom monitoring and treatment for low-income cancer survivors.
Article
Objective: To assess the association of baseline anxiety with depression persistence and change in depressive symptoms 6 months after cardiac hospitalization. Methods: Data were analyzed from 137 depressed patients hospitalized on inpatient cardiac units for acute coronary syndrome, decompensated heart failure, or arrhythmia and who were enrolled in a randomized trial of collaborative care depression management. Subjects' demographic, medical, and psychiatric information at baseline was compiled. Measures of health-related quality of life, cardiac symptoms, and psychiatric symptoms, including the Hospital Anxiety and Depression Scale-anxiety subscale (HADS-A) for anxiety, were obtained at baseline and serially during a 6-month follow-up period. The association between baseline HADS-A score and depression persistence (<50% reduction in depressive symptoms on the Patient Health Questionnaire-9) at 6 months was assessed by multivariate logistic regression accounting for the effects of multiple relevant medical and psychological covariates. The association between baseline HADS-A score and improvement in depressive symptoms (Patient Health Questionnaire-9) from baseline at 6 months was assessed by linear regression accounting for the same covariates. Results: Baseline HADS-A score was independently associated with depression persistence at 6 months (odds ratio = 1.11, 95% confidence interval = 1.01-1.22, p = .03). Likewise, higher baseline HADS-A score was associated with less improvement in depressive symptoms at 6 months (β =-0.34, p = .01). Conclusions: Among a cohort of depressed cardiac patients, higher baseline anxiety score was linked with lesser improvement in depressive symptoms and increased likelihood of depression persistence at 6 months, independent of multiple relevant covariates. Trial Registration: clinicaltrials.gov Identifier: NCT00847132.