Sunday, 6 March 2011

Collaberative care

Finally managed to find some time for a “proper” post, came across this whilst trawling the web.

From Pulse

Depressed? You will be after you have read this, first we had Cognitive Behaviour Therapy (CBT), then they tacked on Computer Cognitive Behaviour Therapy (CCBT or CBBC as I like to call it), now we have “Collaborative Care” which I suppose you could call CCCBT, it was developed in the US – a form of enhanced consultation liaison, whereby input into general practice by mental health experts is facilitated through specially trained case managers.

Essential elements of these programmes are the use of evidence-based protocols for treatment, structured collaboration between primary care providers and mental health specialists, active monitoring of adherence to treatment and of outcomes, and in some cases structured programmes of psychotherapy delivered in primary care.

Collaborative care involves trained and competent workers who manage high volumes of patients, are supervised by mental health specialists and link with GPs to provide regular feedback on the progress of an individual patient.

A great deal of evidence has been amassed in the US on this quality improvement method and recently three small trials have shown that positive results could also be achieved here in the UK.

Great, you may think, but look at the reasoning behind this Telephone Therapy-Despite the proven efficacy of pharmacological and talking treatments, patient compliance with both is poor. One of the problems with talking treatments is that they tend to be offered in very traditional ways, mainly face to face with therapists using weekly ‘golden hour’ sessions. This limits the numbers of patient’s counsellors and therapists can treat and many patients find the need to take time off work every week an insurmountable barrier.

According to Professor David Richards GPs have very limited options available when faced with patients consulting about common mental health problems such as depression and anxiety. NICE guidelines state that cognitive behaviour therapy is as effective as some drug treatments and recommend all suitable patients be offered such treatment.

But best estimates are that overall GPs are able to access talking treatments for only 9% of their patients, with fewer than 2% receiving CBT.

In a recent clinical research protocol developed by a team funded through the Medical Research Council, case managers supported patients with depression in primary care using a 6:1 ratio of telephone versus face-to-face contacts. The workers delivered a mixture of medication support – mainly regarding antidepressants – and a form of low-intensity CBT for depression called behavioural activation.(5)

On average, patients in the case-managed group showed twice the improvement compared with a control group. The total additional time spent treating each patient was very modest – on average slightly more than three hours per patient in total over a 12-week period.

Interviews with patients were extremely positive, particularly regarding the use of the phone, providing they had at least one initial face-to-face appointment.

With PCTs now focused very much on patient choice and access, GPs and practice teams may find the arguments easy to make.

Most patients value the flexibility of telephone working – indeed, in one classic recent case study, a mental health worker was able to treat a patient over the telephone during his lunch break while the patient sat in his JCB, allowing him to undergo a full treatment programme without disturbing his very real need to function undisturbed at his workplace.

Although telephone working will not suit all patients, current evidence and experience is indicating that telephone support and treatment is effective, acceptable and a cost-effective way of redressing the parlous state of access to non-drug treatments for the majority of people with anxiety and depression.


A bit like the Swine Flu helpline then, let your fingers do the walking and some invisible “therapist” do the talking.



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