OBJECTIVE\nThe authors evaluated the incremental cost-effectiveness of stepped collaborative care for patients with persistent depressive symptoms after usual primary care management.\n\n\nMETHOD\nPrimary care patients initiating antidepressant treatment completed a standardized telephone assessment 6-8 weeks after the initial prescription. Those with persistent major depression or significant subthreshold depressive symptoms were randomly assigned to continued usual care or collaborative care. The collaborative care included systematic patient education, an initial visit with a consulting psychiatrist, 2-4 months of shared care by the psychiatrist and primary care physician, and monitoring of follow-up visits and adherence to medication regimen. Clinical outcomes were assessed through blinded telephone assessments at 1, 3, and 6 months. Health services utilization and costs were assessed through health plan claims and accounting data.\n\n\nRESULTS\nPatients receiving collaborative care experienced a mean of 16.7 additional depression-free days over 6 months. The mean incremental cost of depression treatment in this program was $357. The additional cost was attributable to greater expenditures for antidepressant prescriptions and outpatient visits. No offsetting decrease in use of other health services was observed. The incremental cost-effectiveness was $21.44 per depression-free day.\n\n\nCONCLUSIONS\nA stepped collaborative care program for depressed primary care patients led to substantial increases in treatment effectiveness and moderate increases in costs. These findings are consistent with those of other randomized trials. Improving outcomes of depression treatment in primary care requires investment of additional resources, but the return on this investment is comparable to that of many other widely accepted medical interventions.

Cost-effectiveness of a collaborative care program for primary care patients with persistent depression

Objective: Assessing stereotypes towards people with mental illness among mental health professionals, comparing their view to the Swiss general population and analysing the influence of demographic factors, profession and work place variables (type of ward, employment time and professional experience).

Method:  Conducting a representative telephone survey (n = 1073). Factor analysis was used to achieve one-dimensional scales, which were analysed by regression analysis.

Results:  Most positive depictions were regarded as less characterizing people with mental illness, whereas most negative descriptions were viewed as more typifying these people. Compared with the Swiss general population, mental health professionals have not consistently less negative or more positive stereotypes against mentally ill people. Of the 22 stereotypes five factors were detected: ‘social disturbance’, ‘dangerousness’, ‘normal healthy’, ‘skills’ and ‘sympathy’. Stereotypes about people with mental illness are influenced by the professional background and if at all only slightly affected by gender, age, ward type, participation rate of the hospital, weekly working hours or years of professional experience.

Conclusion:  Mental health professionals must improve their attitudes towards people with mental illness. Different ways, e.g. improving their professional education or their quality of professional contacts by regular supervision to prevent burn-out, are discussed.

Do mental health professionals stigmatize their patients

For 16 years, the Hamilton Family Health Team Mental Health Program has successfully integrated mental health counselors, addiction specialists, child mental health professionals, and psychiatrists into 81 offices of 150 family physicians in Hamilton, Ontario. Maximising the potential of a "shared care" model requires changes within the primary care setting, to support the addition of mental health and addiction professionals, active involvement of primary care staff in managing mental health problems of patients, and collaborative practice. This coordinated effort allow mental health treatment through onsite support from a mental health team and supplants the need to refer most patients to the mental health setting. This article reviews the evolution of the program and the changes made by practices with key lessons learnt.

Integrating mental health services within primary care settings: the Hamilton Family Health Team.

Background: Primary care services have not generally been effective in meeting mental health care needs. There is evidence that collaboration between primary care and specialist mental health services can improve clinical and organisational outcomes. It is not clear however what factors enable or hinder effective collaboration. The objective of this study was to examine the factors that enable effective collaboration between specialist mental health services and primary mental health care. Methods: A narrative and thematic review of English language papers published between 1998 and 2009. An expert reference group helped formulate strategies for policy makers. Studies of descriptive and qualitative design from Australia, New Zealand, UK, Europe, USA and Canada were included. Data were extracted on factors reported as enablers or barriers to development of service linkages. These were tabulated by theme at clinical and organisational levels and the inter-relationship between themes was explored. Results: A thematic analysis of 30 papers found the most frequently cited group of factors was “partnership formation”, specifically role clarity between health care workers. Other factor groups supporting clinical partnership formation were staff support, clinician attributes, clinic physical features and evaluation and feedback. At the organisational level a supportive institutional environment of leadership and change management was important. The expert reference group then proposed strategies for collaboration that would be seen as important, acceptable and feasible. Because of the variability of study types we did not exclude on quality and findings are weighted by the number of studies. Variability in local service contexts limits the generalisation of findings. Conclusion: The findings provide a framework for health planners to develop effective service linkages in primary mental health care. Our expert reference group proposed five areas of strategy for policy makers that address organisational level support, joint clinical problem solving, local joint care guidelines, staff training and supervision and feedback.

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Building effective service linkages in primary mental health care: A narrative review part 2

Evaluation of a mental health training intervention for multidisciplinary teams in primary care in Brazil: a pre- and posttest study.

Purpose: This study involved the conduct of a descriptive and process evaluation to examine the implementation and maintenance of an existing local shared care program: The Hamilton Health Service Organization Mental Health and Nutrition Program located in the Hamilton, Ontario, Canada. The program was organized to strengthen links between mental health, nutrition, and primary care services, to improve access to mental health and nutrition care, and to realize the benefits of improved communication, collaboration and mutual support among multiple practitioners, increased continuity of care, and increased family physicians’ comfort and skill in handling more complex problems. Method: A mixed-method, multi-measures evaluation design was used. Data were gathered from the program’s central patient database and by conducting focus groups. Results: Teams of practitioners provide comprehensive primary mental health and nutrition care. Collaboration and education opportunities are extensive although time constraints are an issue. Patients with a range of problems were assessed, treated, and referred among team members. There appears to be a decreased burden on external services. Conclusions & Discussion: This evaluation suggests that implementation and maintenance of shared care programs are possible within community practices.

/pdf/descriptive-and-process-evaluation-of-a-shared-primary-care-2hhuf2td2j.pdf

Descriptive and Process Evaluation of a Shared Primary Care Program

Recent changes in Royal College training requirements have highlighted the need for residency programs to be able to offer challenging and worthwhile experiences to their trainees in caring for the chronically mentally ill. This training should bring them into contact with patients at each stage of their illness and recovery and expose them to the different settings in which treatment or management takes place. Postgraduate programs face many problems in organizing this teaching that arise from the nature and course of long-term psychiatric illnesses, the organization of residency training programs, attitudes and preconceptions of residents and teachers and competing time demands. The authors review these problems, identify specific goals for the training and suggest strategies for achieving these goals. Expectations of postgraduate programs, clinical placements, supervisors and residents themselves are outlined.

Training residents to care for the mentally ill.

Purpose: This study involved the conduct of a descriptive and process evaluation to examine the implementation and maintenance of an existing local shared care program: The Hamilton Health Service Organization Mental Health and Nutrition Program located in Hamilton, Ontario, Canada. The program was organized to strengthen links between mental health, nutrition, and primary care services, to improve access to mental health and nutrition care, and to realize the benefits of improved communication, collaboration and mutual support among multiple practitioners, increased continuity of care, and increased family physicians’ comfort and skill in handling more complex problems. Method: A mixed-method, multi-measures evaluation design was used. Data were gathered from the program’s central patient database and by conducting focus groups. Results: Teams of practitioners provide comprehensive primary mental health and nutrition care. Collaboration and education opportunities are extensive although time constraints are an issue. Patients with a range of problems were assessed, treated, and referred among team members. There appears to be a decreased burden on external services. Conclusions & Discussion: This evaluation suggests that implementation and maintenance of shared care programs are possible within community practices.

Nick Kates

Papers

Descriptive and Process Evaluation of a Shared Primary Care Program

Training residents to care for the mentally ill.

Descriptive and a process evaluation of a shared care program