Common Mental Disorders Depression - New Zealand Doctor

The models are not mutually exclusive and a combined approach to service provision
was the norm. Variants of the collaborative care model (including stepped care) were
the most widely researched. There was a trend towards multidisciplinary collaborative
care showing short-term, modest benefits for people with depression, compared with
usual care. The collaborative models incorporated a care management approach
using the services of a care manager or primary mental health care worker. This
approach was most effective for individuals with persistent or recurrent disorders, and
for older adults with depression. The approach was less effective for those with milder
or subthreshold disorders.
Telephone care management interventions were effective for people with mild to
moderate mental disorders, especially in combination with other interventions such
as cognitive behavioural therapy (CBT).
There were two studies favouring a consultation-liaison approach, but overall,
evidence was lacking on the effectiveness of approaches other than collaborative care
and there was insufficient evidence to determine the effectiveness of individual models
or to compare models. Moreover, most of the relevant studies were conducted in the
US and may not be applicable in other health care systems. 339 Relevant New Zealand
initiatives are underway, due to report back in 2008. 543
Barriers to the adoption of collaborative care models could include financial or time
costs to anyone involved, including patients and their families, and the need for
substantial changes to clinical practice (eg, protocols for follow-up or referral between
services). Incentives for engagement may increase uptake by providers. Collaboration
between primary and secondary services can be helped by processes such as mapping
pathways to care, and linking of stepped care models to treatment guidelines. 544
An Australian study 545 describes a modelling exercise that found that with the number
of people needing treatment held constant, evidence-based care using a stepped
care approach was no more expensive and was more effective than the traditional
model (ie, allocating resources top-down, according to the needs and demands of
stakeholder groups). Increased coverage was also possible because the additional
cases tended to be of disorders that were easier and less expensive to treat. The model
assumed a sequence of stepped care from the less intensive, lower-cost interventions
(ie, GP advice plus patient self-management), through to more intensive higher-cost
interventions (ie, active GP treatment, involvement of allied mental health staff and on
to psychiatric and inpatient care).
A retrospective service audit of the provision of stepped care for common mental
health disorders in the UK found this model clinically effective, with a high rate of
patient satisfication. 546 There was a high use of psychological interventions (eg, brief
psychological/behavioural interventions in primary care). These were rated by patients
as the most helpful intervention. Psychological interventions were complemented by
a range of other approaches, including computerised CBT (CCBT), social support
(eg, with housing), exercise and other activities, information and support with training,
educational and job opportunities. Waiting times for specialist psychological therapies
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Identification of Common Mental Disorders and Management of Depression in Primary Care