The effects of a shared decision-making intervention in primary care of depression: a cluster-randomized controlled trial

OBJECTIVE: Patient-centred depression care approaches should better address barriers of insufficient patient information and involvement in the treatment decision process. Additional research is needed to test the effect of increased patient participation on outcomes. The aim of this study was to assess, if patient participation in decision-making via a shared decision-making intervention leads to improved treatment adherence, satisfaction, and clinical outcome without increasing consultation time. METHODS: Cluster-randomized controlled intervention study based on physician training and patient-centered decision aid compared to usual care in primary care settings in Südbaden region of Germany. Twenty-three primary care physicians treating 405 patients with newly diagnosed depression were enrolled. Patient involvement was measured with the patient perceived involvement in care scale (PICS) and a patient participation scale (MSH-scale). Patient satisfaction was measured by the CSQ-8 questionnaire. Treatment adherence was evaluated by patient and provider self-report. Depression severity and remission outcomes were assessed with the Brief PHQ-D. RESULTS: Physician facilitation of patient participation improved significantly and to a greater extent in the intervention compared to the control group. There was no intervention effect for depression severity reduction. Doctor facilitation of patient participation, patient-rated involvement, and physician assessment of adherence improved only in the intervention group. Patient satisfaction at post-intervention was higher in the intervention group compared to the control group. The consultation time did not differ between groups. CONCLUSION: A shared decision-making intervention was better than usual care for improving patient participation in treatment decision-making, and patient satisfaction without increasing consultation time. Additional research is needed to model causal linkages in the decision-making process in regard to outcomes. PRACTICE IMPLICATIONS: The study results encourage the implementation of patient participation in primary care of depression.     

Learning social determinants of health through a home visiting course in the clinical years

ObjectiveThe purpose of this study was to assess the impact of a new experience-based educational program aiming to teach social determinants of health (SDH) and health disparities, through a post-discharge home-visit conducted with patients recruited in hospital.Methods105 clinical-year students visited 177 patients living in disadvantaged circumstances. Their home-visit reports were analyzed employing mixed methodology. Content analysis was conducted for classifying issues raised by students, and quantitative analysis to compare reports by level of elaboration, gender and class.ResultsFifteen taxonomy items were identified. Social support and patients' medical conditions were most prevalent, followed by personal-related and community-related issues. Analysis demonstrated students' understanding of the relationship between SDH and patient health, and challenges patients face following discharge. Women and mixed couples provided more elaborate reports, which contained significantly greater critique of medical care.ConclusionsMeeting patients both in hospital and at home enhanced awareness of SDH. Students learned to view the patient comprehensively, and to understand the diverse factors affecting their health. Students, who had essentially sole responsibility for the home-visit, successfully integrated their skills to take action when needed.Practice implicationsThe ETGAR experience provided a means for effective learning about how social determinants impact on health.     

Hero/heroine modeling for Puerto Rican adolescents: a preventive mental health intervention

Culturally sensitive treatments of the special mental health needs of high-risk Puerto Rican adolescents are lacking. The hero/heroine intervention was based on adult Puerto Rican role models to foster ethnic identity, self-concept, and adaptive coping behavior. 90 nonclinical Puerto Rican 8th and 9th graders were screened for presenting behavior problems in school and randomly assigned to an intervention and a control group. After 19 sessions, the intervention significantly increased adolescents' ethnic identity and self-concept and reduced anxiety. Treatment outcomes varied as a function of grade level, sex, and household composition. Self-concept was negatively affected among girls from intact families. The study supports the effectiveness of the culturally sensitive modality as a preventive mental health intervention for high-risk Puerto Rican adolescents, especially from single-parent families.     

Self-harm in postpartum depression and referrals to a perinatal mental health team: an audit study

There is a paucity of research on self-harm during pregnancy and the postpartum period despite suicide being a leading cause of death and high rates of mental disorder during this time. This audit describes a cohort of women referred to a new perinatal mental health team (PMHT) based in a large maternity hospital in the UK over a 12-month period. The audit was conducted in two stages. Stage one describes the clinical and socio-demographic characteristics of 225 pregnant women referred to the team after screening positive for a significant mental health history. Stage two determines the veracity of data on a subgroup of 73 pregnant women referred for previous postpartum depression (PPD), 58 % of whom disclosed an episode of self-harm with the ‘intent to kill themselves’ to the maternity staff when they first booked in for antenatal care. Previous PPD accounted for the largest majority of referrals (32 %) to the PMHT followed by depression (27 %) and self-harm (10 %). The majority of women (85 %) referred to the PMHT were engaged. Eight percent were so unwell at the point of referral they required an admission to the hospital. Attempted suicide in the subgroup of 73 women with previous PPD ranged from 24–49 %. The findings from this audit suggest that self-harm in PPD warrants further investigation.     

Analysis of clinical uncertainties by health professionals and patients: an example from mental health

Background  

The first step in practising Evidence Based Medicine (EBM) has been described as translating clinical uncertainty into a structured and focused clinical question that can be used to search the literature to ascertain or refute that uncertainty. In this study we focus on questions about treatments for schizophrenia posed by mental health professionals and patients to gain a deeper understanding about types of questions asked naturally, and whether they can be reformulated into structured and focused clinical questions.     

A study on the feasibility of delivering a psychologically informed ward-based intervention on an acute mental health ward

Acute mental health inpatient wards have been criticized for being nontherapeutic. The study aimed to test the feasibility of delivering a psychologically informed intervention in these settings. This single-arm study evaluated the feasibility of clinical psychologists delivering a ward-based psychological service model over a 6-month period on two acute mental health wards. Data were gathered to assess trial design parameters and the feasibility of gathering patient/staff outcome data. Psychologists were able to deliver key elements of the intervention. Baseline staff and patient participant recruitment targets were met. However, there was significant patient attrition at follow-up, with incorrect contact details on discharge being the primary reason. Implementation of a ward-based psychological intervention appears feasible when implemented flexibly. It is feasible to recruit staff and patient participants and to collect staff outcome measures over a 6-month period. However, greater efforts need to be taken to trace patient movement following discharge.     

Comparing the acceptability of a positive psychology intervention versus a cognitive behavioural therapy for clinical depression

There is growing evidence on the efficacy of positive psychology interventions (PPI) to treat clinical disorders. However, very few studies have addressed their acceptability. The present study aimed to analyse 2 key components of acceptability (i.e., client satisfaction and adherence to treatment) of a new PPI programme, the Integrative Positive Psychological Intervention for Depression (IPPI‐D), in comparison to a standard cognitive behavioural therapy (CBT) programme in the treatment of clinical depression. One hundred twenty‐eight women with a DSM‐IV diagnosis of major depression or dysthymia were allocated to a 10‐session IPPI‐D or CBT group intervention condition. Results showed that both interventions were highly acceptable for participants. Attendance rates were high, and there were no significant differences between conditions. However, the IPPI‐D condition showed significantly higher client satisfaction than the CBT condition. Moreover, acceptability did not differ based on participants' severity of symptoms, regardless of condition. These findings encourage further investigations of the applicability of PPI in clinical settings in order to broaden the range of acceptable and suitable therapies for depressed patients. Key Practitioner Message

• This study sheds light on the client satisfaction and adherence to a positive intervention.
• For participants, positive psychology interventions (PPI) may be more satisfactory than CBT as PPI are framed within a positive mental health model and, consequently, may reduce the risk of stigmatization
• Because acceptability of treatments and preferences may affect the efficacy of treatments, this study provides an excellent opportunity to offer professionals more therapeutic options to tailor treatments to clients' needs and expectations

     

Attitudes of mental health professionals about mental illness: a review of the recent literature

A large body of research has documented public attitudes toward people with mental illness. The current attitudes of the people who provide services to those with psychiatric disorders are important to understand, as well. The authors review what studies over the past 5 years reveal about the attitudes of psychiatric professionals. Empirical studies of the attitudes of mental health professionals, published since 2004, were identified and reviewed. Only 19 such studies were found. Most of these studies revealed overall positive attitudes among mental health professionals. However, evidence of negative attitudes and expectations was also found, particularly with respect to social acceptance of people with mental illness. Results indicate a need for greater research attention to mental health professionals' views and for improved attitudes among caregivers. © 2009 Wiley Periodicals, Inc.     

A randomized trial of a brief mental health intervention for primary care patients

This randomized trial is a first evaluation of a brief psychotherapeutic intervention for primary care patients. Sixty-two participants were randomly assigned to the intervention or to treatment as usual. As compared with treatment as usual, the intervention led to significant reductions in symptoms of anxiety and depression. The reduction was maintained for 3 months after the end of treatment, but some return of symptoms occurred by 6 months after treatment. The treatment was well accepted by patients. This study provides good preliminary evidence for the effectiveness of this intervention.     

Cluster randomised controlled trial of the effectiveness of primary care mental health workers

BACKGROUND: Mental health issues are a core part of the work of primary care and are the second most common reason for consultations. There is some evidence that the quality of primary care mental health provision is variable. AIM: To evaluate the effectiveness of primary care mental health workers with regards to satisfaction with care, mental health symptoms, use of the voluntary sector, and cost effectiveness of care. DESIGN OF STUDY: Cluster randomised controlled trial. SETTING: Practices in the Heart of Birmingham Primary Care Trust, Birmingham, England. METHOD: Nineteen practices and 368 patients (18 to 65 years of age) with a diagnosis of a new or ongoing common mental health problem were recruited. Sixteen practices and 284 patients completed the trial. RESULTS: Patients in intervention practices had a higher mean level of general satisfaction than those in control practices (difference between group scores of 8.3, 95% confidence interval = 1.3 to 15.3, P = 0.023). The two groups did not differ in mental health symptom scores or use of the voluntary sector. CONCLUSION: For patients with common mental health problems, primary care mental health workers may be effective at increasing satisfaction with an episode of care.     

Use of a time series design to test effectiveness of a theory‐based intervention targeting adherence of health professionals to a clinical guideline

Objectives . The aim of this study was to test the effectiveness of a theory of planned behaviour intervention to increase adherence of community mental health professionals to a national suicide prevention guideline. Design . Routinely collected audit adherence data from an intervention and control site were collected and analysed using time series analysis to test whether the intervention significantly increased adherence. The effects of a local and national event on adherence were also examined. Method . A Theory of Planned Behaviour (TPB) questionnaire, developed from interview findings, was administered to the health professionals. Subjective norms were found to be the most significant predictor of intention to adhere to the guideline, and were targeted with an interactive educational intervention. Time series analysis applied to routinely collected audit adherence data was used to test intervention effectiveness. Results . The TPB accounted for 58% of the variance in intention to adhere, with subjective norms the only significant predictor. The intervention did not significantly increase adherence; however, the national and local events were found to have significantly increased adherence. Conclusions . The TPB was a useful framework for exploring barriers to adherence; however, this did not translate into an effective intervention. Future research should seek collaboration with local experts, and use this information in combination with the TPB, to develop interventions. Collaborative research with experts in pedagogy may also help to develop more effective interventions, particularly education‐based interventions that require adult learning.     

A randomized clinical trial of a brief, mailed intervention for symptoms of depression

This research evaluated the efficacy of a brief, mailed personalized feedback intervention designed to alleviate depressed mood and antecedents (ineffective coping and hopelessness). College students (N = 177) were randomly assigned to intervention or control group following a baseline assessment. A week after completing the baseline assessment, participants in the intervention condition were mailed feedback and information detailing their mood, coping strategies, as well as suggestions for enhancing mood. Results indicated that feedback was effective in reducing depressive symptoms, hopelessness, and among men, increasing willingness to use coping strategies at the 1-month follow-up. Hopelessness mediated reductions in depressive symptoms. Results support the use of personalized feedback as a low-cost, initial intervention for college students suffering from symptoms of depression.     

Primary care patients with mental health problems: outcome of a randomised clinical trial.

BACKGROUND: The prevalence of patients with mental health problems in general practice is high, and at least one-third of these problems last for 6 months or longer. Patients with these problems take up more time during a consultation and attend more frequently. AIM: This study investigated the effectiveness of problem-solving treatment for primary care patients with mental health problems. The hypothesis was that patients receiving problem-solving treatment from a nurse would have fewer symptoms after 3 months, or a lower attendance rate, compared with patients receiving the usual care from the GP. DESIGN OF THE STUDY: Randomised clinical trial. SETTING: Twelve general practices in Amsterdam and 12 nurses from a mental healthcare institution. METHOD: A sample of patients aged >or=18 years were screened for mental health problems with the general health questionnaire (GHQ-12) in the waiting room of the general practices, and were randomised. Patients receiving the problem-solving treatment were required to complete four to six treatment sessions, while patients in the control group were treated as usual by the GP. RESULTS: No significant difference was found between the groups in terms of improved psychopathology or a decrease in attendance rate. Post-hoc analyses showed a sub-group of patients with more severe pathology who may benefit from problem-solving treatment. CONCLUSION: The main results show that problem-solving treatment provided by a nurse adds little to the usual care from the GP for frequent attenders with mental health problems. Post-hoc analyses show that there may be a sub-group of more severely depressed patients who could benefit from problem-solving treatment.     

Strategic intervention: a mental health program for the Hispanic community

Over the past three years the Worcester Youth Guidance Center has developed a series of mental health programs directed to the Hispanic community of Worcester, Massachusetts. The model for these programs has been that of strategic intervention. This approach was based upon knowledge gained from the literature and extensive exploratory contacts with key Hispanic leaders. The Center's Hispanic Program consists of five components: (1) community education and training. (2) clinical consultation, (3) program consultation, (4) research, and (5) clinical intervention and case management. This article describes these components in detail and presents a rationale for strategic intervention.     

Exploring the effectiveness of an integrated exercise/CBT intervention for young men's mental health

Objective. This pilot study investigated the effectiveness of a team‐based sport/psychosocial intervention (Back of the Net, BTN) with an individual exercise (IE) and a control condition for the mental health of young men. Design. Ten‐week randomized control trial and eight‐week post‐intervention follow‐up. Methods. A total of 104 sedentary males aged between 18 and 40 years were recruited and randomly assigned to the BTN, IE, or a control condition. The BTN programme integrated team sport (i.e., football) and cognitive‐behavioural techniques. IE sessions included aerobic and resistance training. The control group refrained from exercise. Participants completed the Beck Depression Inventory – 2nd Edition (BDI‐II), the Social Provisions Scale (SPS) and a short qualitative questionnaire at pre‐intervention, week 5, post‐intervention and at 8‐week follow‐up. Results. Participants in both the BTN and the IE condition demonstrated a significant decrease in BDI‐II scores compared to the control condition at post‐intervention and at 8‐week follow‐up. The IE condition demonstrated significantly greater perceived social support than the BTN condition at week 5 and the control group at 8‐week follow‐up. Qualitative data support the main empirical findings. Conclusion. Exercise‐based interventions were effective in reducing symptoms of depression in a non‐clinical community sample of young men. The BTN programme demonstrated potential for improving the mental health of young men however larger scale community‐based research is warranted to further examine the effectiveness of this type of intervention.