Social work effectiveness in the management of depressed women: a clinical trial

Counselling for mental health and psychosocial problems in primary care

BACKGROUND

The prevalence of mental health and psychosocial problems in primary care is high. Counselling is a potential treatment for these patients, but there is a lack of consensus over the effectiveness of this treatment in primary care.

OBJECTIVES

To assess the effectiveness and cost effectiveness of counselling for patients with mental health and psychosocial problems in primary care.

SEARCH STRATEGY

To update the review, the following electronic databases were searched: the Cochrane Collaboration Depression, Anxiety and Neurosis (CCDAN) trials registers (to December 2010), MEDLINE, EMBASE, PsycINFO and the Cochrane Central Register of Controlled Trials (to May 2011).

SELECTION CRITERIA

Randomised controlled trials of counselling for mental health and psychosocial problems in primary care.

DATA COLLECTION AND ANALYSIS

Data were extracted using a standardised data extraction sheet by two reviewers. Trials were rated for quality by two reviewers using Cochrane risk of bias criteria, to assess the extent to which their design and conduct were likely to have prevented systematic error. Continuous measures of outcome were combined using standardised mean differences. An overall effect size was calculated for each outcome with 95% confidence intervals (CI). Continuous data from different measuring instruments were transformed into a standard effect size by dividing mean values by standard deviations. Sensitivity analyses were undertaken to test the robustness of the results. Economic analyses were summarised in narrative form. There was no assessment of adverse events.

MAIN RESULTS

Nine trials were included in the review, involving 1384 randomised participants. Studies varied in risk of bias, although two studies were identified as being at high risk of selection bias because of problems with concealment of allocation. All studies were from primary care in the United Kingdom and thus comparability was high. The analysis found significantly greater clinical effectiveness in the counselling group compared with usual care in terms of mental health outcomes in the short-term (standardised mean difference -0.28, 95% CI -0.43 to -0.13, n = 772, 6 trials) but not in the long-term (standardised mean difference -0.09, 95% CI -0.27 to 0.10, n = 475, 4 trials), nor on measures of social function (standardised mean difference -0.09, 95% CI -0.29 to 0.11, n = 386, 3 trials). Levels of satisfaction with counselling were high. There was some evidence that the overall costs of counselling and usual care were similar. There were limited comparisons between counselling and other psychological therapies, medication, or other psychosocial interventions.

AUTHORS' CONCLUSIONS

Counselling is associated with significantly greater clinical effectiveness in short-term mental health outcomes compared to usual care, but provides no additional advantages in the long-term. Participants were satisfied with counselling. Although some types of health care utilisation may be reduced, counselling does not seem to reduce overall healthcare costs. The generalisability of these findings to settings outside the United Kingdom is unclear.

On-site mental health workers delivering psychological therapy and psychosocial interventions to patients in primary care: effects on the professional practice of primary care providers

BACKGROUND

Mental health problems are common in primary care and mental health workers (MHWs) are increasingly working in this setting delivering psychological therapy and psychosocial interventions to patients. In addition to treating patients directly, the introduction of on-site MHWs represents an organisational change that may lead to changes in the clinical behaviour of primary care providers (PCPs).

OBJECTIVES

To assess the effects of on-site MHWs delivering psychological therapy and psychosocial interventions in primary care on the clinical behaviour of primary care providers (PCPs).

SEARCH STRATEGY

The following sources were searched in 1998: the Cochrane Effective Practice and Organisation of Care Group Specialised Register, the Cochrane Controlled Trials Register, MEDLINE, EMBASE, PsycINFO, CounselLit, NPCRDC skill-mix in primary care bibliography, and reference lists of articles. Additional searches were conducted in February 2007 using the following sources: MEDLINE, EMBASE, PsycINFO, CINAHL, and Cochrane Central Register of Clinical Trials (CENTRAL) (The Cochrane Library).

SELECTION CRITERIA

Randomised trials, controlled before and after studies, and interrupted time series analyses of MHWs working alongside PCPs in primary care settings. The outcomes included objective measures of PCP behaviours such as consultation rates, prescribing, and referral.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed study quality.

MAIN RESULTS

Forty-two studies were included in the review. There was evidence that MHWs caused significant reductions in PCP consultations (standardised mean difference -0.17, 95% CI -0.30 to -0.05), psychotropic prescribing (relative risk 0.67, 95% CI 0.56 to 0.79), prescribing costs (standardised mean difference -0.22, 95% CI -0.38 to -0.07), and rates of mental health referral (relative risk 0.13, 95% CI 0.09 to 0.20) for the patients they were seeing. In controlled before and after studies, the addition of MHWs to a practice did not affect prescribing behaviour towards the wider practice population and there was no consistent pattern to the impact on referrals in the wider patient population.

AUTHORS' CONCLUSIONS

This review provides some evidence that MHWs working in primary care to deliver psychological therapy and psychosocial interventions cause a significant reduction in PCP behaviours such as consultations, prescribing, and referrals to specialist care. However, the changes are modest in magnitude, inconsistent, do not generalise to the wider patient population, and their clinical or economic significance is unclear.

Effectiveness and cost effectiveness of counselling in primary care

BACKGROUND

The prevalence of mental health and psychosocial problems in primary care is high. This review examines the clinical and cost-effectiveness of psychological therapies provided in primary care by counsellors.

OBJECTIVES

To assess the effectiveness and cost effectiveness of counselling in primary care by reviewing cost and outcome data in randomised controlled trials for patients with psychological and psychosocial problems considered suitable for counselling.

SEARCH STRATEGY

To update the review, the following electronic databases were searched on 25-10-2005: MEDLINE, EMBASE, PsycLIT, CINAHL, the Cochrane Controlled Trials register and the Cochrane Collaboration Depression, Anxiety and Neurosis (CCDAN) trials registers.

SELECTION CRITERIA

All controlled trials comparing counselling in primary care with other treatments for patients with psychological and psychosocial problems considered suitable for counselling. Trials completed before the end of June 2005 were included in the review.

DATA COLLECTION AND ANALYSIS

Data were extracted using a standardised data extraction sheet. Trials were rated for quality using CCDAN criteria, to assess the extent to which their design and conduct were likely to have prevented systematic error. Continuous measures of outcome were combined using standardised mean differences. An overall effect size was calculated for each outcome with 95% confidence intervals (CI). Continuous data from different measuring instruments were transformed into a standard effect size by dividing mean values by standard deviations. Sensitivity analyses were undertaken to test the robustness of the results. Economic analyses were summarised in narrative form.

MAIN RESULTS

Eight trials were included in the review. The analysis found significantly greater clinical effectiveness in the counselling group compared with usual care in the short-term (standardised mean difference -0.28, 95% CI -0.43 to -0.13, n = 772, 6 trials) but not the long-term (standardised mean difference -0.09, 95% CI -0.27 to 0.10, n = 475, 4 trials). Levels of satisfaction with counselling were high. There was some evidence that the overall costs of counselling and usual care were similar.

AUTHORS' CONCLUSIONS

Counselling is associated with modest improvement in short-term outcome compared to usual care, but provides no additional advantages in the long-term. Patients are satisfied with counselling. Although some types of health care utilisation may be reduced, counselling does not seem to reduce overall healthcare costs.

Effectiveness and cost effectiveness of counselling in primary care

BACKGROUND

Counsellors are prevalent in primary care settings. However, there are concerns about the clinical and cost-effectiveness of the treatments they provide, compared with alternatives such as usual care from the general practitioner, medication or other psychological therapies.

OBJECTIVES

To assess the effectiveness and cost effectiveness of counselling in primary care by reviewing cost and outcome data in randomised controlled trials, controlled clinical trials and controlled patient preference trials of counselling interventions in primary care, for patients with psychological and psychosocial problems considered suitable for counselling.

SEARCH STRATEGY

The original search strategy included electronic searching of databases (including the CCDAN Register of RCTs and CCTs) along with handsearching of a specialist journal. Published and unpublished sources (clinical trials, books, dissertations, agency reports etc.) were searched, and their reference lists scanned to uncover further controlled trials. Contact was made with subject experts and CCDAN members in order to uncover further trials. For the updated review, searches were restricted to those databases judged to be high yield in the first version of the review: MEDLINE, EMBASE, PSYCLIT and CINAHL, the Cochrane Controlled Trials register and the CCDAN trials register.

SELECTION CRITERIA

All controlled trials comparing counselling in primary care with other treatments for patients with psychological and psychosocial problems considered suitable for counselling. Trials completed before the end of June 2001 were included in the review.

DATA COLLECTION AND ANALYSIS

Data were extracted using a standardised data extraction sheet. The relevant data were entered into the Review Manager software. Trials were quality rated, using CCDAN criteria, to assess the extent to which their design and conduct were likely to have prevented systematic error. Continuous measures of outcome were combined using standardised mean differences. An overall effect size was calculated for each outcome with 95% confidence intervals. Continuous data from different measuring instruments were transformed into a standard effect size by dividing mean values by standard deviations. In view of the diversity of counselling services in primary care (the range of treatments, patients and practitioners) tests of heterogeneity were done to assess the feasibility of aggregating measures of outcome from trials. Sensitivity analyses were undertaken to test the robustness of the results.

MAIN RESULTS

Seven trials were included in the review. The main analyses showed significantly greater clinical effectiveness in the counselling group compared with 'usual care' in the short-term (standardised mean difference -0.28, 95% CI -0.43 to -0.13, n=772, 6 trials) but not the long-term (standardised mean difference -0.09, 95% CI -0.27 to 0.10, n=475, 4 trials). Levels of satisfaction with counselling were high. Four studies reported similar total costs associated with counselling and usual care over the long-term. However, the economic analyses were likely to be underpowered.

REVIEWER'S CONCLUSIONS

Counselling is associated with modest improvement in short-term outcome compared to 'usual care', but provides no additional advantages in the long-term. Patients are satisfied with counselling, and it may not be associated with increased costs.

On-site mental health workers in primary care: effects on professional practice

BACKGROUND

Mental health problems are common in primary care and mental health workers (MHWs) are increasingly working in this setting. In addition to treating patients, the introduction of on-site MHWs may lead to changes in the clinical behaviour of primary care providers (PCPs).

OBJECTIVES

To assess the effects of on-site MHWs in primary care on the clinical behaviour of primary care providers (PCPs).

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group specialised register (18-22 June 1998), the Cochrane Controlled Trials Register (18-22 June 1998), MEDLINE (1966 to 1998), EMBASE (1980 to 1998), PsychInfo (1984 to 1998), CounselLit (18-22 June 1998), NPCRDC skill-mix in primary care bibliography, and reference lists of articles.

SELECTION CRITERIA

Randomised trials, controlled before and after studies and interrupted time series analyses of MHWs either replacing PCPs as providers of mental health care ('replacement' models) or providing collaborative care/support to PCPs in managing patients' mental health problems ('consultation-liaison' models). The participants were primary care providers. The outcomes included objective PCP behaviours such as diagnosis, prescribing and referral.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality.

MAIN RESULTS

Thirty-eight studies were included involving more than 460 PCPs and more than 3880 patients. There was some evidence that 'replacement' model MHWs achieved significant short-term reductions in PCP psychotropic prescribing and mental health referral, but the effects were not reliable. Consultation rates were also reduced, but with even less evidence of a consistent effect. There were no indirect effects in prescribing behaviour on the wider population and no consistent pattern to the impact on referrals. 'Indirect' effects on PCP consultation rates were not assessed. There was some evidence that 'consultation-liaison' model MHWs had a direct effect on PCP prescribing behaviour when used as part of complex, multifaceted interventions. Few studies examined the 'indirect' effects of such interventions, and those that did failed to provide evidence that 'direct' effects were generalisable to the wider population or endured once the 'consultation-liaison' intervention was removed.

REVIEWER'S CONCLUSIONS

This review does not support the hypothesis that adding MHWs to primary care provider organisations in 'replacement' models causes a significant or enduring change in PCP behaviour. 'Consultation-liaison' interventions may cause changes in psychotropic prescribing, but these seem short-term and limited to patients under the direct care of the MHW. Longer-term studies are needed to assess the degree to which demonstrated effects endure over time.

Outcome of anxiety and depressive disorders in primary care

BACKGROUND

Factors related to the outcome of depression and anxiety in primary care are not fully understood.

METHOD

Adult patients in general practice with depressive, anxiety or panic disorder (n = 148; DSM-III-R criteria) were studied prospectively for six months to determine the factors most closely associated with outcome. The Psychiatric Assessment Schedule, Hamilton Depression Rating Scale, Clinical Anxiety Scale and Life Events and Difficulties Schedule interviews were performed at index consultations and repeated six months later. Variables associated with outcome were assessed by multiple regression analysis.

RESULTS

Good outcome was predicted by mild depression at initial assessment, high educational level, and being in employment. At follow-up the most important predictor of improvement was reduction in marked difficulties over the six months. Recognition and management by the GP was most frequent in patients with severe disorder; such patients were least likely to improve because of the severity of their depression and marked social difficulties.

CONCLUSIONS

This naturalistic study helps to provide a framework for further studies with more precisely defined groups of people with depression. An effective treatment strategy for people with marked depression and ongoing social difficulties is especially needed.

Acute and one-year outcome of a randomised controlled trial of brief cognitive therapy for major depressive disorder in primary care

BACKGROUND

The consensus statement on the treatment of depression (Paykel & Priest, 1992) advocates the use of cognitive therapy techniques as an adjunct to medication.

METHOD

This paper describes a randomised controlled trial of brief cognitive therapy (BCT) plus 'treatment as usual' versus treatment as usual in the management of 48 patients with major depressive disorder presenting in primary care.

RESULTS

At the end of the acute phase, significantly more subjects (P < 0.05) met recovery criteria in the intervention group (n = 15) compared with the control group (n = 8). When initial neuroticism scores were controlled for, reductions in Beck Depression Inventory and Hamilton Rating Scale for Depression scores favoured the BCT group throughout the 12 months of follow-up.

CONCLUSIONS

BCT may be beneficial, but given the time constraints, therapists need to be more rather than less skilled in cognitive therapy. This, plus methodological limitations, leads us to advise caution before applying this approach more widely in primary care.

Randomised controlled trial comparing problem solving treatment with amitriptyline and placebo for major depression in primary care

OBJECTIVE

To determine whether, in the treatment of major depression in primary care, a brief psychological treatment (problem solving) was (a) as effective as antidepressant drugs and more effective than placebo; (b) feasible in practice; and (c) acceptable to patients.

DESIGN

Randomised controlled trial of problem solving treatment, amitriptyline plus standard clinical management, and drug placebo plus standard clinical management. Each treatment was delivered in six sessions over 12 weeks.

SETTING

Primary care in Oxfordshire.

SUBJECTS

91 patients in primary care who had major depression.

MAIN OUTCOME MEASURES

Observer and self reported measures of severity of depression, self reported measure of social outcome, and observer measure of psychological symptoms at six and 12 weeks; self reported measure of patient satisfaction at 12 weeks. Numbers of patients recovered at six and 12 weeks.

RESULTS

At six and 12 weeks the difference in score on the Hamilton rating scale for depression between problem solving and placebo treatments was significant (5.3 (95% confidence interval 1.6 to 9.0) and 4.7 (0.4 to 9.0) respectively), but the difference between problem solving and amitriptyline was not significant (1.8 (-1.8 to 5.5) and 0.9 (-3.3 to 5.2) respectively). At 12 weeks 60% (18/30) of patients given problem solving treatment had recovered on the Hamilton scale compared with 52% (16/31) given amitriptyline and 27% (8/30) given placebo. Patients were satisfied with problem solving treatment; all patients who completed treatment (28/30) rated the treatment as helpful or very helpful. The six sessions of problem solving treatment totalled a mean therapy time of 3 1/2 hours.

CONCLUSIONS

As a treatment for major depression in primary care, problem solving treatment is effective, feasible, and acceptable to patients.

Referrals from general practitioners to psychiatrists and paramedical mental health professionals

The literature on referral of patients by GPs to psychiatrists and mental health specialists is examined. Referrals to psychiatrists account for 3% of all those made by GPs, but the individual rates vary widely. The proportion of patients referred to psychiatrists and paramedical mental health workers in general practice is unknown, but probably substantial.

Specialist mental health treatment in general practice: a meta-analysis

A meta-analysis of studies was carried out to compare treatment by specialist mental health professionals in the general practice setting and 'usual GP treatment'. Overall, treatment by specialist mental health professionals had a 10% greater success rate.

The effectiveness of mental health consultation and referral in ambulatory primary care: a research lacuna

This article reviews the research literature on referral to and consultation with mental health specialists for patients in ambulatory medical settings. Very few controlled trials measuring the efficacy of such liaison could be located. They were mainly from the British literature, usually involved psychologists, and (with the exception of one study) tested only the model of referral to the mental health specialist for treatment. More research needs to be done in this important area. Methodologic issues and topics for further study are discussed.

The treatment of emotional disorders in general practice: psychological methods versus medication

This paper describes three recent trials in which psychological methods were evaluated in the treatment of emotional disorders in general practice. In the first trial, brief counselling by the general practitioner was found to be as effective as anxiolytic medication, was welcomed by patients and did not increase demands on doctors' time. In the second trial (still in progress), in which treatment is aimed at emotional disorders of poor prognosis, problem solving treatment by a psychiatrist is being compared with control treatment by the G.P. The third trial evaluated an anxiety management programme provided by clinical psychologists in health centres; substantial reductions in anxiety occurred rapidly and were maintained at follow-up.

The effects of non-prescribing of anxiolytics in general practice. II. Factors associated with outcome

Factors associated with psychiatric outcome were examined in a series of 87 patients who had presented in general practice with new episodes of minor affective disorder. Two outcome measures were used: (i) Status on Present State Examination (PSE) seven months after initial consultation; (ii) prescribing of psychotropic medication between one-month and seven-month follow-up assessments. Outcome according to the PSE was significantly associated with: worse measures of psychiatric state (General Health Questionnaire, Profile of Mood states) and of social functioning (SAS-M) at initial consultation and one month later; and with persistent anxious or depressed mood during the follow-up period; but not with life events. During the follow-up period 20 patients received at least one psychotropic prescription; they were significantly associated with worse initial GHQ scores, consumption of tobacco and non-prescribed medication, and initial anxiety. A sub-group of 11 patients received multiple psychotropic prescriptions; they were significantly associated with the same initial measures, and also with poor outcome measures (psychiatric and social).

Cognitive therapy for major depressive disorder in primary care

Cognitive therapy for depression is a psychological treatment designed to train patients to identify and correct the negative depressive thinking which, it has been hypothesised, contributes to the maintenance of depression. General practice patients meeting Research Diagnostic Criteria for primary major depressive disorder were randomly allocated either to continue with the treatment they would normally receive (which in the majority of cases included antidepressant medication) or to receive, in addition, sessions of cognitive therapy. At completion of treatment, patients receiving cognitive therapy were significantly less depressed than the comparison group, both on blind ratings of symptom severity made by psychiatric assessors and on a self-report measure of severity of depression. At three-month follow-up cognitive therapy patients no longer differed from patients receiving treatment-as-usual, but this was mainly as a result of continuing improvement in the comparison group.

Social support and post hospital outcome for depressed women

In a larger follow-up study of discharged patients, a subgroup of 87 women with non-psychotic disorders had an unexpectedly poor outcome at six months with regard to readmissions, symptoms and social adjustment. The only factor which distinguished those who had been readmitted was lack of social support. Lack of social support was also related to poor symptom and social adjustment outcomes. There were considerable difficulties with social functioning independent of high symptoms. The adequacy of aftercare services is questioned in the light of these findings.