Mental health policy and practice across Europe: an overview

224 Mental health policy and practice
Evidence concerning the effectiveness of the models
Training
Although this model is theoretically one of the most attractive, and has been
the subject of large-scale interventions in both Europe and the United States,
the evidence is generally unconvincing that training alone can improve the
effectiveness of primary care for depression. Simple passive dissemination of
guidelines is ineffective, as are the sort of short-term, pragmatic training courses
that can be delivered within current educational systems (certainly in the
United Kingdom) (Kendrick 2000). Although there is evidence that more intensive
and complex training packages can influence primary care clinician
behaviour (Gask et al. 1987, 1995), it may not always impact on patient outcome
when delivered alone (King et al. 2002). The training model may be
limited by the paradox that feasible training is not effective, while effective
training may be unfeasible. An additional problem is that, although the training
model has the greatest theoretical impact on access, training courses which
rely on voluntary attendance may only attract those clinicians with an interest
in mental health problems, who may be least likely to benefit. Therefore,
advantages in access may be unrealized, and inequities may occur.
Consultation-liaison
The current evidence concerning consultation-liaison is sparse, and the studies
that do exist do not provide evidence of effectiveness. Given the theoretical
possibility that this model could be highly efficient, the lack of empirical
evidence is surprising. One of the problems may relate to the fact that the evaluation
of this model has important methodological considerations which makes
evaluation problematic (Gask et al. 1987). One reason for the lack of effectiveness
may be that the presumed causal mechanisms underlying consultationliaison
are themselves ineffective in changing professional behaviour (Bower
and Gask 2002).
Collaborative care
Although the exact nature of the interventions varies from study to study, there
is a large amount of high quality evidence for the general approach of collaborative
care (Gilbody et al. 2003). Several issues remain. The key ‘mechanisms of
change’ in these interventions are unclear, and it may be the case that the
effectiveness of this approach derives in part from the large number of components
(e.g. patient and clinician education; enhanced physician support;
compliance monitoring; structured patient follow-up; audit and feedback).
Importantly, almost all the studies emanate from the United States, and it is not
clear whether they will generalize to different populations or European health
care settings; for instance, collaborative care interventions in the United
Kingdom have not been as uniformly successful (Wilkinson et al. 1993; Mann