Mental health policy and practice across Europe: an overview

222 Mental health policy and practice
relate to the amount of specialist time required per patient, and the seniority
(and cost) of the specialist involved.
It should be noted that these impacts are theoretical, as there is very little
empirical work on levels of access to mental health care, compared to the
amount of research on effectiveness (see below).
Effectiveness
Effectiveness has traditionally been conceptualized as clinical effectiveness; that
is, changes in health status, such as reductions in depression symptoms. However,
as noted earlier and in line with WHO definitions of health, there is
increasing interest in wider outcomes such as social function and quality of life
and issues of efficiency mean that issues of cost are also increasingly important.
Compared with issues of access, the effectiveness of treatments has received
much greater scientific evaluation.
The next section summarizes the evidence for each of the models described
above, based on a number of systematic overviews or reviews completed by the
authors of organizational and educational interventions to improve the management
of common mental health problems in primary care (Bower and
Sibbald 2000a, 2000b; Bower 2002; Bower et al. 2003a, 2003b; Gilbody et al.
2003; Bower and Gilbody 2005). Systematic reviews represent the highest form
of evidence relating to clinical and cost-effectiveness data, and these reviews
have been conducted under the auspices of the Cochrane Collaboration and the
United Kingdom NHS Centre for Reviews and Dissemination. The methodological
details of this important approach to synthesizing clinical and costeffectiveness
data are elaborated in Box 9.1. Most of the data relates to the
management of depression, but the broad principles are likely to apply to all
common mental health disorders. The data focuses on randomized controlled
trials (RCTs), given the advantages associated with this design, but other designs
of relevance are considered where applicable (Gilbody et al. 2003). For example,
reviews of educational and organizational interventions look beyond the conventional
RCT, and consider evidence from non-randomized and observational
designs (Black 1996; Gilbody and Whitty 2002).
Box 9.1 A systematic review of the clinical and cost-effectiveness of
strategies to improve the management of depression in primary care
conducted by the Cochrane Effective Practice and Organization of Care
(EPOC) group
Context
Depression is common in primary care settings, yet is often missed or suboptimally
managed. A number of organizational and educational strategies
to improve the management of depression have been proposed. The
clinical and cost-effectiveness of these strategies have not yet been subject
to systematic review.