[Show abstract][Hide abstract] ABSTRACT: Background: Collaborative care is an effective treatment for the management of depression but evidence on its cost-effectiveness in the UK is lacking. Aims: To assess the cost-effectiveness of collaborative care in a UK primary care setting. Methods: An economic evaluation alongside a multi-centre cluster randomised controlled trial comparing collaborative care with usual primary care for adults with depression (n = 581). Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICER) were calculated over a 12-month follow-up, from the perspective of the UK National Health Service and Personal Social Services (i.e. Third Party Payer). Sensitivity analyses are reported, and uncertainty is presented using the cost-effectiveness acceptability curve (CEAC) and the cost-effectiveness plane. Results: The collaborative care intervention had a mean cost of 272.50 pound per participant. Health and social care service use, excluding collaborative care, indicated a similar profile of resource use between collaborative care and usual care participants. Collaborative care offered a mean incremental gain of 0.02 (95% CI: -0.02, 0.06) quality-adjusted life-years over 12 months, at a mean incremental cost of 270.72 pound (95% CI: -202.98, 886.04), and resulted in an estimated mean cost per QALY of 14,248 pound. Where costs associated with informal care are considered in sensitivity analyses collaborative care is expected to be less costly and more effective, thereby dominating treatment as usual. Conclusion: Collaborative care offers health gains at a relatively low cost, and is cost-effective compared with usual care against a decision-maker willingness to pay threshold of 20,000 per QALY gained. Results here support the commissioning of collaborative care in a UK primary care setting.
[Show abstract][Hide abstract] ABSTRACT: Describe the development and psychometric validation of a brief scale (the Sleep Condition Indicator (SCI)) to evaluate insomnia disorder in everyday clinical practice.
The SCI was evaluated across five study samples. Content validity, internal consistency and concurrent validity were investigated.
30 941 individuals (71% female) completed the SCI along with other descriptive demographic and clinical information.
Data acquired on dedicated websites.
The eight-item SCI (concerns about getting to sleep, remaining asleep, sleep quality, daytime personal functioning, daytime performance, duration of sleep problem, nights per week having a sleep problem and extent troubled by poor sleep) had robust internal consistency (α≥0.86) and showed convergent validity with the Pittsburgh Sleep Quality Index and Insomnia Severity Index. A two-item short-form (SCI-02: nights per week having a sleep problem, extent troubled by poor sleep), derived using linear regression modelling, correlated strongly with the SCI total score (r=0.90).
The SCI has potential as a clinical screening tool for appraising insomnia symptoms against Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria.
[Show abstract][Hide abstract] ABSTRACT: To compare the clinical effectiveness of collaborative care with usual care in the management of patients with moderate to severe depression.
Cluster randomised controlled trial.
51 primary care practices in three primary care districts in the United Kingdom.
581 adults aged 18 years and older who met ICD-10 (international classification of diseases, 10th revision) criteria for a depressive episode on the revised Clinical Interview Schedule. We excluded acutely suicidal patients and those with psychosis, or with type I or type II bipolar disorder; patients whose low mood was associated with bereavement or whose primary presenting problem was alcohol or drug abuse; and patients receiving psychological treatment for their depression by specialist mental health services. We identified potentially eligible participants by searching computerised case records in general practices for patients with depression.
Collaborative care, including depression education, drug management, behavioural activation, relapse prevention, and primary care liaison, was delivered by care managers. Collaborative care involved six to 12 contacts with participants over 14 weeks, supervised by mental health specialists. Usual care was family doctors' standard clinical practice.
Depression symptoms (patient health questionnaire 9; PHQ-9), anxiety (generalised anxiety disorder 7; GAD-7), and quality of life (short form 36 questionnaire; SF-36) at four and 12 months; satisfaction with service quality (client satisfaction questionnaire; CSQ-8) at four months.
276 participants were allocated to collaborative care and 305 allocated to usual care. At four months, mean depression score was 11.1 (standard deviation 7.3) for the collaborative care group and 12.7 (6.8) for the usual care group. After adjustment for baseline depression, mean depression score was 1.33 PHQ-9 points lower (95% confidence interval 0.35 to 2.31, P=0.009) in participants receiving collaborative care than in those receiving usual care at four months, and 1.36 points lower (0.07 to 2.64, P=0.04) at 12 months. Quality of mental health but not physical health was significantly better for collaborative care than for usual care at four months, but not 12 months. Anxiety did not differ between groups. Participants receiving collaborative care were significantly more satisfied with treatment than those receiving usual care. The number needed to treat for one patient to drop below the accepted diagnostic threshold for depression on the PHQ-9 was 8.4 immediately after treatment, and 6.5 at 12 months.
Collaborative care has persistent positive effects up to 12 months after initiation of the intervention and is preferred by patients over usual care.
[Show abstract][Hide abstract] ABSTRACT: Background
Generalized anxiety disorder (GAD) is one of the most prevalent anxiety disorders, with important implications for patients and healthcare resources. However, few economic evaluations of pharmacological treatments for GAD have been published to date, and those available have assessed only a limited number of drugs.
To assess the cost effectiveness of pharmacological interventions for patients with GAD in the UK.
A decision-analytic model in the form of a decision tree was constructed to compare the costs and QALYs of six drugs used as first-line pharmacological treatments in people with GAD (duloxetine, escitalopram, paroxetine, pregabalin, sertraline and venlafaxine extended release [XL]) and ‘no pharmacological treatment’. The analysis adopted the perspective of the NHS and Personal Social Services (PSS) in the UK. Efficacy data were derived from a systematic literature review of double-blind, randomized controlled trials and were synthesized using network meta-analytic techniques. Two network meta-analyses were undertaken to assess the comparative efficacy (expressed by response rates) and tolerability (expressed by rates of discontinuation due to intolerable side effects) of the six drugs and no treatment in the study population. Cost data were derived from published literature and national sources, supplemented by expert opinion. The price year was 2011. Probabilistic sensitivity analysis was conducted to evaluate the underlying uncertainty of the model input parameters.
Sertraline was the best drug in limiting discontinuation due to side effects and the second best drug in achieving response in patients not discontinuing treatment due to side effects. It also resulted in the lowest costs and highest number of QALYs among all treatment options assessed. Its probability of being the most cost-effective drug reached 75 % at a willingness-to-pay threshold of £20,000 per extra QALY gained.
Sertraline appears to be the most cost-effective drug in the treatment of patients with GAD. However, this finding is based on limited evidence for sertraline (two published trials). Sertraline is not licensed for the treatment of GAD in the UK, but is commonly used by primary care practitioners for the treatment of depression and mixed depression and anxiety.
No preview · Article · Mar 2013 · PharmacoEconomics
[Show abstract][Hide abstract] ABSTRACT: In the United Kingdom, clinical guidelines recommend that services for depression and anxiety should be structured around a stepped care model, where patients receive treatment at different 'steps,' with the intensity of treatment (i.e., the amount and type) increasing at each step if they fail to benefit at previous steps. There are very limited data available on the implementation of this model, particularly on the intensity of psychological treatment at each step. Our objective was to describe patient pathways through stepped care services and the impact of this on patient flow and management.
We recorded service design features of four National Health Service sites implementing stepped care (e.g., the types of treatments available and their links with other treatments), together with the actual treatments received by individual patients and their transitions between different treatment steps. We computed the proportions of patients accessing, receiving, and transiting between the various steps and mapped these proportions visually to illustrate patient movement.
We collected throughput data on 7,698 patients referred. Patient pathways were highly complex and very variable within and between sites. The ratio of low (e.g., self-help) to high-intensity (e.g., cognitive behaviour therapy) treatments delivered varied between sites from 22:1, through 2.1:1, 1.4:1 to 0.5:1. The numbers of patients allocated directly to high-intensity treatment varied from 3% to 45%. Rates of stepping up from low-intensity treatment to high-intensity treatment were less than 10%.
When services attempt to implement the recommendation for stepped care in the National Institute for Health and Clinical Excellence guidelines, there were significant differences in implementation and consequent high levels of variation in patient pathways. Evaluations driven by the principles of implementation science (such as targeted planning, defined implementation strategies, and clear activity specification around service organisation) are required to improve evidence on the most effective, efficient, and acceptable stepped care systems.
Full-text · Article · Jan 2012 · Implementation Science
[Show abstract][Hide abstract] ABSTRACT: Mental health problems are common in primary care and most are managed solely by the GP. Patients strive to understand their mental health problems, and facilitating patients' understanding may be important in their care, yet little is known about this process in GP consultations.
To explore how patients' understanding of common mental health problems is developed in GP consultations.
Ten general practices in North Central London.
Fourteen patients and their GPs were interviewed using the taped-assisted recall (TAR) method, and asked how understanding of the patients' mental health problems had been discussed in a recent consultation. The resulting 42 transcripts of the GP-patient consultations and separate GP and patient TAR interviews were analysed using qualitative thematic and process analytic methods.
Patients considered understanding their mental health problems to be important, and half reported their GP consultations as helpful in this respect. The process of coming to an understanding was predominantly patient-led. Patients suggested their own explanations, and these were facilitated and focused by the doctors' questioning, listening, validating, and elaborating aspects they considered important. Both doctors and patients experienced constraints on the extent to which developing understanding of problems was possible in GP consultations.
GPs can help patients understand their mental health problems by recognising patients' own attempts at explanation and helping to shape and develop these.
Full-text · Article · Oct 2010 · British Journal of General Practice
[Show abstract][Hide abstract] ABSTRACT: Psychological therapies provided in primary care are usually briefer than in secondary care. There has been no recent comprehensive review comparing their effectiveness for common mental health problems. We aimed to compare the effectiveness of different types of brief psychological therapy administered within primary care across and between anxiety, depressive and mixed disorders.
Meta-analysis and meta-regression of randomized controlled trials of brief psychological therapies of adult patients with anxiety, depression or mixed common mental health problems treated in primary care compared to primary care treatment as usual.
Thirty-four studies, involving 3962 patients, were included. Most were of brief cognitive behaviour therapy (CBT; n = 13), counselling (n = 8) or problem solving therapy (PST; n = 12). There was differential effectiveness between studies of CBT, with studies of CBT for anxiety disorders having a pooled effect size [d -1.06, 95% confidence interval (CI) -1.31 to -0.80] greater than that of studies of CBT for depression (d -0.33, 95% CI -0.60 to -0.06) or studies of CBT for mixed anxiety and depression (d -0.26, 95% CI -0.44 to -0.08). Counselling for depression and mixed anxiety and depression (d -0.32, 95% CI -0.52 to -0.11) and problem solving therapy (PST) for depression and mixed anxiety and depression (d -0.21, 95% CI -0.37 to -0.05) were also effective. Controlling for diagnosis, meta-regression found no difference between CBT, counselling and PST.
Brief CBT, counselling and PST are all effective treatments in primary care, but effect sizes are low compared to longer length treatments. The exception is brief CBT for anxiety, which has comparable effect sizes.
[Show abstract][Hide abstract] ABSTRACT: To assess the effectiveness of consultation-liaison services, involving mental health professionals working to advise and support primary care professionals in the management of depression.
Studies of consultation-liaison for depression in primary care were identified from a systematic search of electronic databases, augmented by identification of papers from reference lists, published reviews and from hand searching. Data on study quality, intervention characteristics and outcomes were extracted by two reviewers, and outcome data were meta-analyzed.
Five studies met the criteria. There was no significant effect of consultation-liaison on antidepressant use (risk ratio 1.23, 95% CI 0.91 to 1.66) or depression outcomes in the short- (standardized mean difference -0.04, 95% CI -0.21 to 0.14) or long-term (standardized mean difference 0.06, 95% CI -0.13 to 0.26).
Evidence concerning consultation-liaison for depression in primary care remains limited, but the existing studies do not suggest it is more effective than usual care. Further research is required to explore the mechanisms by which consultation-liaison might be made more effective, including the potential role of consultation-liaison in combination with other models of care, and in other patient populations.
No preview · Article · May 2010 · General hospital psychiatry
[Show abstract][Hide abstract] ABSTRACT: Comprising of both organisational and patient level components, collaborative care is a potentially powerful intervention for improving depression treatment in UK primary Care. However, as previous models have been developed and evaluated in the United States, it is necessary to establish the effect of collaborative care in the UK in order to determine whether this innovative treatment model can replicate benefits for patients outside the US. This Phase III trial was preceded by a Phase II patient level RCT, following the MRC Complex Intervention Framework.
A multi-centre controlled trial with cluster-randomised allocation of GP practices. GP practices will be randomised to usual care control or to "collaborative care" - a combination of case manager coordinated support and brief psychological treatment, enhanced specialist and GP communication. The primary outcome will be symptoms of depression as assessed by the PHQ-9.
If collaborative care is demonstrated to be effective we will have evidence to enable the NHS to substantially improve the organisation of depressed patients in primary care, and to assist primary care providers to deliver a model of enhanced depression care which is both effective and acceptable to patients.
Full-text · Article · Oct 2009 · BMC Health Services Research
[Show abstract][Hide abstract] ABSTRACT: Psychological therapies are effective treatments for common mental health problems, but access is limited. GPs face difficult decisions as to whom to refer, but little is known about this decision-making process.
To explore GPs' accounts of decisions to refer, or not refer, patients for psychological therapy.
A qualitative study, using a matched-patient procedure.
General practices in two inner London boroughs.
In semi-structured interviews, GPs were asked to compare and contrast five matched-patient pairs, consisting of patients who had been referred for psychological therapy paired with patients not referred. The interviews were analysed using a general thematic analysis.
Fourteen GPs discussed 130 matched patients (65 patient pairs). Three main factors distinguished GPs' accounts of the patients they referred compared with the matched patients they did not refer. These factors were: patient initiative in requesting or showing interest in referral; estimated capacity of the patient to benefit from psychological therapy; and the GP's own capacity to help the patient in terms of skills, expertise, and time.
GPs gave accounts of themselves acting as rational decision makers, judging how effective they thought a referral would be based on a patient's clinical presentation and motivation, compared with the GPs' own ability to help.
Preview · Article · Sep 2009 · British Journal of General Practice
[Show abstract][Hide abstract] ABSTRACT: In the last 5 years there has been a huge increase in interest in clinical effectiveness. Clinical effectiveness is often used loosely to describe health care that is based on scientific evidence, but properly refers to population based approaches to quality improvement involving facilitation of evidence-based and cost effective practice. It overlaps with evidence-based medicine, which is individually and clinically based. The history of development of clinical effectiveness in the UK is reviewed, including the significant NHS policy initiatives of the last decade. Key components of clinical effectiveness programs are methods to inform clinicians of research evidence as to the effectiveness of interventions, methods to encourage practitioners to use this information to change practice, and methods to monitor changes to practice and clinical outcomes. The minimum requirements to use clinical effectiveness as an approach to quality improvement in mental health and psychotherapy are outlined.
No preview · Article · Jul 2009 · Journal of Mental Health
[Show abstract][Hide abstract] ABSTRACT: Background: Copying to patients the letters sent between health professionals is an increasing trend and in the UK National Health Service has become a national requirement. Aims: To explore patients' immediate reactions to, and views of, the routine clinical assessment letters that their psychiatrists and psychologists send to their referring general practitioner (GP). Methods: Thirty-two outpatients, most with depression or anxiety disorders, were interviewed and asked their views of the letter sent by their psychiatrist or psychologist to their GP. Results: Patients were generally satisfied with their letters. The letters were considered accurate, clear and comprehensive. Drugs, sex and unfavourable history about family members were identified as sensitive areas. Realizing their psychiatrist or psychologist had understood and taken on board their problems, better understanding of their problems, feeling greater involvement in their care, being able to correct misunderstandings, and being able to show significant others the letter, were common reported benefits. Conclusions: The results suggest that outpatients with non-psychotic disorders will find few problems with reading their standard assessment letters and some will find it beneficial.
No preview · Article · Jul 2009 · Journal of Mental Health
[Show abstract][Hide abstract] ABSTRACT: How GPs understand mental health problems determines their treatment choices; however, measures describing GPs' thinking about such problems are not currently available.
To develop a measure of the complexity of GP explanations of common mental health problems and to pilot its reliability and validity.
A qualitative development of the measure, followed by inter-rater reliability and validation pilot studies.
General practices in North London.
Vignettes of simulated consultations with patients with mental health problems were videotaped, and an anchored measure of complexity of psychosocial explanation in response to these vignettes was developed. Six GPs, four psychologists, and two lay people viewed the vignettes. Their responses were rated for complexity, both using the anchored measure and independently by two experts in primary care mental health. In a second reliability and revalidation study, responses of 50 GPs to two vignettes were rated for complexity. The GPs also completed a questionnaire to determine their interest and training in mental health, and they completed the Depression Attitudes Questionnaire.
Inter-rater reliability of the measure of complexity of explanation in both pilot studies was satisfactory (intraclass correlation coefficient = 0.78 and 0.72). The measure correlated with expert opinion as to what constitutes a complex explanation, and the responses of psychologists, GPs, and lay people differed in measured complexity. GPs with higher complexity scores had greater interest, more training in mental health, and more positive attitudes to depression.
Results suggest that the complexity of GPs' psychosocial explanations about common mental health problems can be reliably and validly assessed by this new standardised measure.
Full-text · Article · Jul 2008 · British Journal of General Practice
[Show abstract][Hide abstract] ABSTRACT: Patients with psychosocial problems may benefit from a variety of community, educational, recreational and voluntary sector resources, but GPs often under-refer to these through lack of knowledge and time. This study evaluated the acceptability and effectiveness of graduate primary care mental health workers (GPCMHWs) facilitating access to voluntary and community sector services for patients with psychosocial problems.
Patients with psychosocial problems from 13 general practices in London were referred to a GPCMHW Community Link scheme providing information and support to access voluntary and community resources. Patient satisfaction, mental health and social outcomes, and use of primary care resources, were evaluated.
108 patients consented to take part in the study. At three-month follow-up, 63 (58%) had made contact with a community service identified as suitable for their needs. Most were satisfied with the help provided by the GPCMHW in identifying and supporting access to a suitable service. There was a reduction in the number of patients with a probable mental health problem on the GHQ-12 from 83% to 52% (difference 31% (95% CI, 17% - 44%). Social adjustment improved and frequencies of primary care consultations and of prescription of psychotropic medications were reduced.
Graduates with limited training in mental health and no prior knowledge of local community resources can help patients with psychosocial problems access voluntary and community services, and patients value such a scheme. There was some evidence of effectiveness in reducing psychosocial and mental health problems.
Full-text · Article · Feb 2008 · BMC Family Practice
[Show abstract][Hide abstract] ABSTRACT: The vast majority of patients with psychological problems are seen solely by their GP, but little is known about patients' perspectives regarding the variety of consultation skills that may be used in routine GP consultations with these patients.
To identify which aspects of GP consultations patients presenting with psychological problems experience as helpful or unhelpful.
Nine general practices in north central London.
Twenty patients, who had discussed psychological problems as a significant part of their index GP consultation, were asked in detail using the tape-assisted recall (TAR) method, about aspects of the consultation they had experienced as helpful or unhelpful.
All patients described how the relationship with the GP helped or hindered them in discussing their problems; this was central to their experience of the consultation. An underlying attitude of genuine interest and empathy, within a continuing relationship, was highly valued. Patients also described how the GP helped them make sense of, or resolve their problems, and supported their efforts to change.
These patient accounts suggest that routine GP consultations for psychological problems can have a powerful impact, at least short-term. The GP role in providing a safe place where patients feel they are listened to and understood should not be underestimated, particularly in the mental health context. Further research is required to investigate the longer-term impact of different GP behaviours on patient health outcomes. The TAR method has potential applications in primary care research and in the training of GPs and other health professionals.
No preview · Article · Aug 2006 · British Journal of General Practice
[Show abstract][Hide abstract] ABSTRACT: Background The NHS Plan proposed that 1000 graduate primary care mental health workers (GPCMHWs) be employed by 2004. Recruitment of GPCMHWs and their enrolment on university training courses has begun; however, the specific roles to be carried out by GPCMHWs are still in the process of being defined, and there is a limited evidence base to underpin this.Aims The current paper discusses a pilot study of GPCMHWs facilitating access to voluntary and community services, via a 'Community Link Service'. The rationale behind the facilitator role and its application to primary care are provided, and vignettes are employed to help clarify and illustrate the service within the context of primary care.Results People supported by the GPCMHW service were most likely to have experienced depression, anxiety, isolation or difficulties around relationships and work, and tended to fall within typical ranges of clinically affected populations (as measured on the General Health Questionnaire-12, Clinical Outcomes in Routine Evaluation, and Work and Social Adjustment Scale). Perceptions of primary care staff about the project were generally favourable.Conclusions It is feasible for GPCMHWs, with relevant training and support, to set up and run a primary care-based service facilitating access for patients to voluntary and community sector organisations.
No preview · Article · Aug 2005 · Primary Care Mental Health
[Show abstract][Hide abstract] ABSTRACT: Older people with psychological morbidity generally first present to health services in primary care, where they are increasingly seen by primary care nurses. In order to evaluate primary care nurses' identification of psychological morbidity, 190 older patients attending eight practice nurses completed the General Health Questionnaire (GHQ) and the practice nurses made an assessment as to the presence or absence of psychological problems. The practice nurses identified only 26% of probable cases of psychological morbidity identified by the GHQ. Their threshold for identification was high, rating only 12% of patients as experiencing psychological problems compared to 29% probable cases identified by the GHQ, and their accuracy was low (kappa for agreement between GHQ and nurse ratings = 0.23). Likelihood of identification depended on length and type of visit. The findings suggest that it may be unrealistic to expect practice nurses, without additional training and reorganisation of their work, to identify more than a minority of older patients with psychological morbidity in the course of their routine work.
No preview · Article · Nov 2003 · Aging and Mental Health