Practice nurse-led proactive care for chronic depression in primary care: a randomised controlled trial

Incidence of Major Depressive Disorder Relapse and Effectiveness of Pharmacologic and Psychological Interventions in Primary Care: A Systematic Review and Meta-Analysis: Incidence de la rechute du trouble dépressif majeur et efficacité des interventions pharmacologiques et psychologiques en soins primaires : revue systématique et méta-analyse

ObjectiveThis research aims to investigate the relapse rates of major depressive disorder (MDD) within primary care and evaluate the efficacy of relapse prevention therapies. Despite primary care being the common point of contact for MDD patients, there are limited studies around this.MethodsWe included randomized controlled trials and observational studies examining MDD relapse incidence and the effect of pharmacological and non-pharmacological interventions in preventing relapse in primary care. Databases; Medline via Ovid, EMBASE, The Cochrane Library, PsycInfo (ebsco), and Clinical Trials.gov were searched from their inception until September 7, 2022. Joanna Briggs Institute (JBI) appraisal instrument for methodological quality assessment was used. A proportional data analysis estimated the MDD relapse incidence. Therapy effectiveness results were shown as odds ratios with 95% confidence intervals, with heterogeneity explored via subgroup analysis.ResultsOut of the reviewed studies, 35 met the eligibility criteria. Quality appraisal scores varied between 73% and 96%. MDD relapse incidence was divided into subgroups, revealing that both pharmacotherapy and non-pharmacotherapy led to a similar decrease in relapse rates with combination therapies showing further reduction in relapse. Subgroup analyses by study design, follow-up length, date of study and quality of study also yielded noteworthy findings.ConclusionOur findings showed that MDD relapse rates in primary care settings can be effectively reduced by pharmacotherapy, non-pharmacotherapy, or combination therapy. Some psychological interventions might also reduce relapse likelihood. More studies are needed on individual and combined treatments over longer periods to understand their long-term impacts on MDD relapse in primary care.

Undertaking multi-centre randomised controlled trials in primary care: learnings and recommendations from the PULsE-AI trial researchers

BACKGROUND

Conducting effective and translational research can be challenging and few trials undertake formal reflection exercises and disseminate learnings from them. Following completion of our multicentre randomised controlled trial, which was impacted by the COVID-19 pandemic, we sought to reflect on our experiences and share our thoughts on challenges, lessons learned, and recommendations for researchers undertaking or considering research in primary care.

METHODS

Researchers involved in the Prediction of Undiagnosed atriaL fibrillation using a machinE learning AlgorIthm (PULsE-AI) trial, conducted in England from June 2019 to February 2021 were invited to participate in a qualitative reflection exercise. Members of the Trial Steering Committee (TSC) were invited to attend a semi-structured focus group session, Principal Investigators and their research teams at practices involved in the trial were invited to participate in a semi-structured interview. Following transcription, reflexive thematic analysis was undertaken based on pre-specified themes of recruitment, challenges, lessons learned, and recommendations that formed the structure of the focus group/interview sessions, whilst also allowing the exploration of new themes that emerged from the data.

RESULTS

Eight of 14 members of the TSC, and one of six practices involved in the trial participated in the reflection exercise. Recruitment was highlighted as a major challenge encountered by trial researchers, even prior to disruption due to the COVID-19 pandemic. Researchers also commented on themes such as the need to consider incentivisation, and challenges associated with using technology in trials, especially in older age groups.

CONCLUSIONS

Undertaking a formal reflection exercise following the completion of the PULsE-AI trial enabled us to review experiences encountered whilst undertaking a prospective randomised trial in primary care. In sharing our learnings, we hope to support other clinicians undertaking research in primary care to ensure that future trials are of optimal value for furthering knowledge, streamlining pathways, and benefitting patients.

Nurse-led task-shifting strategies to substitute for mental health specialists in primary care: A systematic review

AIM

The study aimed to synthesize evidence comparing task-shifting interventions led by general practice nurses and mental health specialists in improving mental health outcomes of adults in primary care.

DESIGN

This study used a systematic review of randomized controlled trials.

DATA SOURCES

Articles from the databases CINAHL, MEDLINE, APA PsycInfo, PubMed, EMBASE, Cochrane EBM Reviews, Web of Science Core Collection, and ProQuest Dissertation and Thesis published between 2000 and 2020 were included.

REVIEW METHODS

The review was arranged based on the Cochrane Collaboration guidelines and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

RESULTS

Twelve articles met the eligibility criteria. Eight studies revealed that nurse-led intervention was significantly superior to its comparator. The review identified three major themes: training and supervision, single and collaborative care and psychosocial treatments.

CONCLUSION

Nurses could be temporarily employed to provide mental health services in the absence of mental health specialists as long as appropriate training and supervision was provided. This finding should be interpreted with caution due to the high risk of bias in the studies reviewed and the limited generalisability of their findings.

Personalized care planning and shared decision making in collaborative care programs for depression and anxiety disorders: A systematic review

BACKGROUND

Collaborative care is an evidence-based approach to improving outcomes for common mental disorders in primary care. Efforts are underway to broadly implement the collaborative care model, yet the extent to which this model promotes person-centered mental health care has been little studied. The aim of this study was to describe practices related to two patient and family engagement strategies-personalized care planning and shared decision making-within collaborative care programs for depression and anxiety disorders in primary care.

METHODS

We conducted an update of a 2012 Cochrane review, which involved searches in Cochrane CCDAN and CINAHL databases, complemented by additional database, trial registry, and cluster searches. We included programs evaluated in a clinical trials targeting adults or youth diagnosed with depressive or anxiety disorders, as well as sibling reports related to these trials. Pairs of reviewers working independently selected the studies and data extraction for engagement strategies was guided by a codebook. We used narrative synthesis to report on findings.

RESULTS

In total, 150 collaborative care programs were analyzed. The synthesis showed that personalized care planning or shared decision making were practiced in fewer than half of programs. Practices related to personalized care planning, and to a lesser extent shared decision making, involved multiple members of the collaborative care team, with care managers playing a pivotal role in supporting patient and family engagement. Opportunities for quality improvement were identified, including fostering greater patient involvement in collaborative goal setting and integrating training and decision aids to promote shared decision making.

CONCLUSION

This review suggests that personalized care planning and shared decision making could be more fully integrated within collaborative care programs for depression and anxiety disorders. Their absence in some programs is a missed opportunity to spread person-centered mental health practices in primary care.

The role of relapse prevention for depression in collaborative care: A systematic review

BACKGROUND

Relapse (the re-emergence of depression symptoms before full recovery) is common in depression and relapse prevention strategies are not well researched in primary care settings. Collaborative care is effective for treating acute phase depression but little is known about the use of relapse prevention strategies in collaborative care. We undertook a systematic review to identify and characterise relapse prevention strategies in the context of collaborative care.

METHODS

We searched for Randomised Controlled Trials (RCTs) of collaborative care for depression. In addition to published material, we obtained provider and patient manuals from authors to provide more detail on intervention content. We reported the extent to which collaborative care interventions addressed four relapse prevention components.

RESULTS

93 RCTs were identified. 31 included a formal relapse prevention plan; 42 had proactive monitoring and follow-up after the acute phase; 39 reported strategies for optimising sustained medication adherence; and 20 of the trials reported psychological or psycho-educational treatments persisting beyond the acute phase or focussing on long-term health/relapse prevention. 30 (32.3%) did not report relapse prevention approaches.

LIMITATIONS

We did not receive trial materials for approximately half of the trials, which limited our ability to identify relevant features of intervention content.

CONCLUSION

Relapse is a significant risk amongst people treated for depression and interventions are needed that specifically address and minimise this risk. Given the advantages of collaborative care as a delivery system for depression care, there is scope for more consistency and increased effort to implement and evaluate relapse prevention strategies.

Nurse-delivered interventions for mental health in primary care: a systematic review of randomized controlled trials

BACKGROUND

Mental health issues are increasingly prevalent within the community. Many people experiencing mental health issues have established relationships with primary care providers, including general practice nurses (GPNs). With the recent growth of general practice nursing, it is timely to explore the evidence for GPNs to provide mental health interventions for adults with mental illness within their scope of practice.

OBJECTIVE

To synthesize the evidence about nurse-delivered interventions in primary care for adults with mental illness.

METHODS

A systematic review of randomized control trials (RCTs) retrieved from the CINAHL, Ovid MEDLINE and EBSCO electronic databases between 1998 and 2017.

RESULTS

Nine randomized controlled trials were identified, which reported nurse-delivered interventions in primary care for the management of mental health in adults with mental illness. The heterogeneity of interventions and outcomes made comparison of studies difficult. Seven studies demonstrated significant improvement in at least one outcome following the intervention. In some studies, these improvements were sustained well beyond the intervention. Additionally, consumers were satisfied with the interventions and the role of the GPN.

CONCLUSION

There is currently limited evidence of the impact of nurse-delivered interventions in primary care for adults with mental illness. Given the significant improvements in symptoms and the acceptability of interventions seen in included studies, there is a need for further robust research exploring the role of the GPN both individually and within the multidisciplinary team. Such research will enable stronger conclusions to be drawn about the impact of nurse-delivered interventions in primary care for adults with mental illness.