Implementing the role of the primary care mental health worker: a qualitative study

BACKGROUND: Primary care mental health workers are a new role recently introduced into primary care in England to help manage patients with common mental health problems. AIM: To explore the views of GPs, primary care teams and patients on the value and development of the new role of primary care mental health workers in practice. DESIGN OF STUDY: Qualitative study. SETTING: The Heart of Birmingham Primary Care Teaching Trust in the West Midlands, UK. METHOD: Thirty-seven semi-structured interviews involving seven primary care mental health workers, 21 patients and 11 focus groups involving 38 members of primary care teams were held with six teams with a worker. Two teams asked for the worker to be removed. Six practice managers also took part in the study. RESULTS: A number of different approaches were used to implement this new role. Strategies that incorporated the views of primary care trust senior management, primary care teams and workers' views appeared most successful. Rapid access to a healthcare professional at times of stress and the befriending role of the worker were also highly valued. Workers felt that their role left them professionally isolated at times. A number of workers described tension around ownership of the role. CONCLUSION: Primary care mental health workers appear to provide a range of skills valued by patients and the primary care teams and can increase patient access and choice in this area of health care. Successful implementation strategies highlighted in this study may be generalisable to other new roles in primary care.     

Graduate mental health worker case management of depression in UK primary care: a pilot study.

BACKGROUND: Based on data from large multicentre US trials, the National Institute for Health and Clinical Excellence (NICE) is advocating a stepped-care model for the management of depression, with 'case management' or 'collaborative care' for selected patients in primary care. AIM: To conduct a pilot study examining the use of graduate mental health workers case managing depressed primary care NHS patients. DESIGN OF STUDY: A randomised controlled trial comparing usual GP care with or without case management over 16 weeks of acute antidepressant drug treatment. SETTING: Three primary care practices in the North East of England. METHOD: Patients with depression, aged 18-65 years, who had failed to adequately respond to antidepressant treatment, were randomised to the two treatments. Assessments were made at baseline, 12, and 24 weeks using a combination of observer and self ratings. RESULTS: Randomisation of 62 patients required screening of 1073 potential patients. There was little difference in outcome between the two treatment arms but a gradual improvement in symptoms over time was seen. Client satisfaction was assessed as high across both treatments. CONCLUSION: While this pilot study confirmed the integrity of the study protocol and the suitability of the outcome measures and randomisation procedure, it raises questions regarding the practicality of recruitment and feasibility of the intervention. It would be crucial to address these issues prior to the implementation of a large multi-centre randomised controlled trial.     

Exploratory cluster randomised controlled trial of shared care development for long-term mental illness.

BACKGROUND: Primary care clinicians have a considerable amount of contact with patients suffering from long-term mental illness. The United Kingdom's National Health Service now requires general practices to contribute more systematically to care for this group of patients. AIMS: To determine the effects of Mental Health Link, a facilitation-based quality improvement programme designed to improve communication between the teams and systems of care within general practice. Design of study: Exploratory cluster randomised controlled trial. SETTING: Twenty-three urban general practices and associated community mental health teams. METHOD: Practices were randomised to service development as usual or to the Mental Health Link programme. Questionnaires and an audit of notes assessed 335 patients' satisfaction, unmet need, mental health status, processes of mental and physical care, and general practitioners' satisfaction with services and beliefs about service development. Service use and intervention costs were also measured. RESULTS: There were no significant differences in patients' perception of their unmet need, satisfaction or general health. Intervention patients had fewer psychiatric relapses than control patients (mean = 0.39 versus 0.71, respectively, P = 0.02) but there were no differences in documented processes of care. Intervention practitioners were more satisfied and services improved significantly for intervention practices. There was an additional mean direct cost of pound 63 per patient with long-term mental illness for the intervention compared with the control. CONCLUSION: Significant differences were seen in relapse rates and practitioner satisfaction. Improvements in service development did not translate into documented improvements in care. This could be explained by the intervention working via the improvements in informal shared care developed through better link working. This type of facilitated intervention tailored to context has the potential to improve care and interface working.     

A cluster randomised controlled trial of patient-held medical records for people with schizophrenia receiving shared care.

BACKGROUND: Patient-held records can improve communication across the primary-secondary interface. There has been no previous rigorous assessment of the utility of patient-held records for people with schizophrenia from a primary care perspective and their value for this population is unclear. AIM: To evaluate the effectiveness of a patient-held record for patients with schizophrenia receiving shared care. DESIGN OF STUDY: Cluster randomised controlled trial. SETTING: Seventy-four general practices and six community mental health localities in Birmingham, England between June 1998 and June 1999. METHOD: A sample of 201 patients with schizophrenia (ICD-10 classification F20) was recruited; of these, 100 were intervention and 101 were control. Patient-held records were given to the intervention patients. At 12-month follow-up, all patients were accounted for and 191 (95%) were revisited. Primary outcomes were the Verona Service Satisfaction Scale-54 (VSSS-54) and the Krawiecka and Goldberg (K & G) rating scale of psychopathology at 12-month follow-up. Secondary outcomes were use of primary and secondary care services. RESULTS: A total of 63/92 (68.5%) patients still had the patient-held record, 64/92 (69.6%) had used it, and 39 (60.9%) of the 64 who had used it said the patient-held record was regularly used by their keyworker. However the patient-held record had no significant effect on primary outcomes (VSSS-54: F1,116 = 0.06, P = 0.801, K & G: F1,116 = 0.6, P = 0.439) or on use of services. A higher symptom score was associated with not using the patient-held record. CONCLUSIONS: The trial provides no good evidence to suggest that patient-held records should be introduced as part of routine shared care for all patients with schizophrenia. However, the patient-held record was acceptable to patients with schizophrenia and acted as a communication tool, particularly between patients and keyworkers.     

汶川地震受灾地区灾后社区、乡镇卫生院工作者精神卫生服务能力评估

目的:了解汶川受灾地区社区、乡镇卫生院工作者的精神卫生知识掌握情况及精神卫生服务能力,为精神卫生培训提供依据,为我国精神卫生服务体系建设提供科学参考。方法:选取灾后社区、乡镇卫生工作者心理卫生服务技能培训班学员353名为研究样本,回收有效问卷313份。使用自编精神卫生知识评估问卷和精神卫生服务调查表进行评估。自编精神卫生知识评估问卷包含抑郁症、酒精依赖、精神分裂症(阳性症状为主)、创伤后应激障碍和躯体形式障碍5种精神障碍。结果:受灾地区乡镇、社区卫生院工作者对于社区5种精神障碍准确诊断率最高的案例为抑郁症(77.0%),药物处理中位数得分最高的为酒依赖;非药物处理中位数得分最高的是酒依赖和创伤后应激障碍。培训前1月内报告未接诊过精神障碍患者的社区、乡镇卫生院工作者占53.4%。不知道任何1所精神卫生服务机构的卫生院工作者占35.1%;不知道精神科专科会诊的占37.7%;不能邀请精神科专科会诊的占39.6%。结论:汶川地震后,受灾地区的乡镇、社区卫生院工作者精神卫生知识和技能掌握较少,精神卫生服务能力相对弱。     

Computerised patient-specific guidelines for management of common mental disorders in primary care: a randomised controlled trial.

BACKGROUND: A large proportion of people with depression and anxiety go unrecognised by their general practitioner (GP). Case-finding does not appear to be effective on its own. AIM: To compare the effectiveness of case-finding followed by computer-generated patient-specific guidelines with usual care for the management of common mental disorders in primary care.Design of study: Individual patient randomised controlled trial. SETTING: Five general practices in Bristol and Cardiff.METHOD: 762 individuals aged >/= 16 years scoring >/= 12 on the Clinical Interview Schedule Revised were randomised. The experimental intervention required participants to complete a computerised psychosocial assessment that generated a report for the GP including patient-specific treatment recommendations. The control patients were treated as usual with access to locally agreed guidelines.RESULTS: Participants' 12-item General Health Questionnaire (GHQ) score dropped irrespective of treatment allocation. The experimental group had a significantly lower GHQ score at 6 weeks, but not at 6 months. Recovery at 6 months was 3% greater among those receiving the experimental intervention (95% confidence interval [CI] = -4 to 10). Treatment was not significantly associated with quality of life or patient satisfaction.CONCLUSION: Only small benefits are likely from using case-finding followed by patient-specific guidelines to improve clinical management of common mental disorders in primary care. However, depression and anxiety are important public health problems so the utility of such systems should be further investigated.     

Chronic fatigue in general practice: is counselling as good as cognitive behaviour therapy? A UK randomised trial.

BACKGROUND: Fatigue is a common symptom for which patients consult their doctors in primary care. With usual medical management the majority of patients report that their symptoms persist and become chronic. There is little evidence for the effectiveness of any fatigue management in primary care. AIM: To compare the effectiveness of cognitive behaviour therapy (CBT) with counselling for patients with chronic fatigue and to describe satisfaction with care. DESIGN OF STUDY: Randomised trial with parallel group design. SETTING: Ten general practices located in London and the South Thames region of the United Kingdom recruited patients to the trial between 1996 and 1998. Patients came from a wide range of socioeconomic backgrounds and lived in urban, suburban, and rural areas. METHOD: Data were collected before randomisation, after treatment, and six months later. Patients were offered six sessions of up to one hour each of either CBT or counselling. Outcomes include: self-report of fatigue symptoms six months later, anxiety and depression, symptom attributions, social adjustment and patients' satisfaction with care. RESULTS: One hundred and sixty patients with chronic fatigue entered the trial, 45 (28%) met research criteria for chronic fatigue syndrome; 129 completed follow-up. All patients met Chalder et al's standard criteria for fatigue. Mean fatigue scores were 23 on entry (at baseline) and 15 at six months' follow-up. Sixty-one (47%) patients no longer met standard criteria for fatigue after six months. There was no significant difference in effect between the two therapies on fatigue (1.04 [95% CI = -1.7 to 3.7]), anxiety and depression or social adjustment outcomes for all patients and for the subgroup with chronic fatigue syndrome. Use of antidepressants and consultations with the doctor decreased after therapy but there were no differences between groups. CONCLUSION: Counselling and CBT were equivalent in effect for patients with chronic fatigue in primary care. The choice between therapies can therefore depend on other considerations, such as cost and accessibility.     

Case finding of lifestyle and mental health disorders in primary care: validation of the 'CHAT' tool.

BACKGROUND: Primary care is accessible and ideally placed for case finding of patients with lifestyle and mental health risk factors and subsequent intervention. The short self-administered Case-finding and Help Assessment Tool (CHAT) was developed for lifestyle and mental health assessment of adult patients in primary health care. This tool checks for tobacco use, alcohol and other drug misuse, problem gambling, depression, anxiety and stress, abuse, anger problems, inactivity, and eating disorders. It is well accepted by patients, GPs and nurses. AIM: To assess criterion-based validity of CHAT against a composite gold standard. DESIGN OF STUDY: Conducted according to the Standards for Reporting of Diagnostic Accuracy statement for diagnostic tests. SETTING: Primary care practices in Auckland, New Zealand. METHOD: One thousand consecutive adult patients completed CHAT and a composite gold standard. Sensitivities, specificities, positive and negative predictive values, and likelihood ratios were calculated. RESULTS: Response rates for each item ranged from 79.6 to 99.8%. CHAT was sensitive and specific for almost all issues screened, except exercise and eating disorders. Sensitivity ranged from 96% (95% confidence interval [CI] = 87 to 99%) for major depression to 26% (95% CI = 22 to 30%) for exercise. Specificity ranged from 97% (95% CI = 96 to 98%) for problem gambling and problem drug use to 40% (95% CI = 36 to 45%) for exercise. All had high likelihood ratios (3-30), except exercise and eating disorders. CONCLUSION: CHAT is a valid and acceptable case-finding tool for most common lifestyle and mental health conditions.     

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.     

徐州煤矿伤工心理健康及社会支持研究

目的研究煤矿受伤工人的心理健康和社会支持状况,为开展针对性心理健康教育提供依据。方法抽取住院井下受伤工人自愿参与的115名作为研究对象,同期在体检中心另选煤矿井下作业工人作对照组,采用症状自评量表(SCL-90)和社会支持评定量表(SSRS)进行问卷调查。结果与对照组比较115名煤矿井下伤工SCL-90各因子分、总分、总均分、阳性项目数、阳性症状均分具有显著差异。社会主客观支持、支持利用度水平具有非常显著差异。结论煤矿伤工心理健康水平较差,应该有针对性地开展健康教育,以便能促进伤工尽快地恢复健康和保持健康的心理。     

Psychology in primary health care: effects of brief targeted therapy on children's medical care utilization

Evaluated the impact of psychological treatment for 93 children (ages 1-15) with common behavior, toilet, school, and psychosomatic problems. Children and parents, who were members of a health maintenance organization, had 1-6 visits to a primary care-based psychological consultation service. Individualized treatment was guided by problem-specific behavioral protocols. Parent outcome and behavior checklist ratings indicated improvement or resolution for 74% of children and high satisfaction with the psychological service. Children's use of medical services, especially acute primary care visits, was reduced during the year after treatment; a matched comparison group's use was unchanged. Addressing children's unmet mental health needs reduces medical care utilization. A primary health care model of psychological services provides an integrated system for serving the health and mental health needs of children.     

Patient costs in anticoagulation management: a comparison of primary and secondary care.

BACKGROUND: The demand for anticoagulation management is increasing. This has led to care being provided in non-hospital settings. While clinical studies have similarly demonstrated good clinical care in these settings, it is still unclear as to which alternative is the most efficient. AIM: To determine the costs borne by patients when attending an anticoagulation management clinic in either primary or secondary care and to use this information to consider the cost-effectiveness of anticoagulation management in primary and secondary care, both from the National Health Service and patient perspectives. DESIGN OF STUDY: Observational study comparing two cohorts of patients currently attending anticoagulation management clinics. SETTING: Four primary care clinics in Birmingham and one in Warwickshire, and the haematology clinics at the University of Birmingham Hospitals Trust and the City Hospital NHS Trust. METHOD: The survey of patients attending the clinics was used to ascertain patient costs. This information was then used in conjunction with the findings of a recent randomised controlled trial to establish cost-effectiveness. RESULTS: Patient costs were lower in primary care than in secondary care settings; the mean (standard deviation) costs per visit were Pound Sterling6.78 (Pound Sterling5.04) versus Pound Sterling14.58 (Pound Sterling9.08). While a previous cost-effectiveness analysis from a health sector perspective alone found a higher cost for primary care, the adoption of the societal perspective lead to a marked change in the result: a similar total cost per patient in both sectors. CONCLUSION: There are significantly higher costs borne by patients attending secondary care anticoagulation management clinics than similar patients attending primary care clinics. This study also demonstrates that the perspective adopted in an economic evaluation can influence the final result.     

Does the Birmingham model of oral anticoagulation management in primary care work outside trial conditions?

The effectiveness of the Birmingham model of primary care oral anticoagulation management has previously been demonstrated within a randomised controlled trial. The aim of this study was to assess the effectiveness of the Birmingham model in routine care. All patients from 12 primary care centres attending either practice-based or hospital-based anticoagulation clinics were retrospectively followed up from October 1996 to March 1998. Outcome measures were therapeutic International Normalised Ratio (INR) control, haemorrhagic and thrombotic episodes, and recall frequency; 452 patients who had two or more INR results during the follow-up period were investigated. There were no significant differences between practice-based and hospital-based populations in terms of the percentage time in range, (69% and 64% respectively). The proportion of tests in range was significantly higher in the practice-based group (61% practice-based, 57% hospital-based; P = 0.015). There was no difference between the two populations in terms of mean follow-up time (36 days in each group). There were no significant differences between groups for the number of clinical outcomes per patient. This study confirmed that, within these practices, oral anticoagulation management is safe and effective using the Birmingham model.     

A randomized controlled trial to evaluate the effectiveness and cost-effectiveness of psychodynamic counselling for general practice patients with chronic depression

BACKGROUND: Counsellors have been employed in general practice with little evidence of effectiveness. This study examined the effectiveness and cost-effectiveness of short-term counselling in general practice for patients with chronic depression either alone or combined with anxiety. METHOD: A randomized controlled trial with an economic evaluation was carried out in Derbyshire. One hundred and forty-five patients were recruited at seven GP practices by screening using the Beck Depression Inventory. Both the experimental and control group received routine GP treatment but the experimental group were also referred to the practice counsellor. Depression, anxiety and other mental health symptoms, social and interpersonal functioning and social support were measured at baseline, 6 months and 12 months. Comprehensive costs were also estimated. RESULTS: There was an overall significant improvement in the actual scores over time, but there were no significant differences between the two groups on any of the measures at either 6 or 12 months. However fewer experimental group patients were still 'cases' on the BDI than controls at 12 months. There were no significant differences in the mean total costs, aggregate costs of services, or any service-group costs except for primary care, between the experimental and control groups over time. CONCLUSIONS: This trial demonstrates only very limited evidence of improved outcomes in those referred to counselling and increased primary care treatment costs in the short-term. Stricter referral criteria to exclude the more severely depressed in the group (BDI > or = 24) might have yielded more conclusive results.     

Primary care mental health workers: models of working and evidence of effectiveness.

The NHS Plan proposed the creation of a new role in primary care to assist with the management of common mental health problems: the primary care mental health worker (PCMHW). However, it is not clear how PCMHWs should be employed to be most effective. Current literature concerning different models of mental health care is reviewed. This suggests that four key dimensions are of relevance: the types of patients that PCMHWs will manage; the degree to which PCMHWs will work autonomously, or as part of a system of care; at what stage in patients' illness trajectory they will intervene; and whether the role of PCMHWs will be related to clinical interventions, or whether they will have a wider, non-clinical role in the organisation and monitoring of care. Finally, published data concerning relevant interventions are presented. Experimental studies reporting the empirical outcomes associated with these models are reviewed in relation to four different outcomes: clinical effectiveness, cost effectiveness, patient satisfaction, and access to care. The data suggest that problem-solving therapy, group psycho-education, self-help, and some models of 'collaborative care' may be highly relevant to PCMHWs. Each model provides different advantages and disadvantages in terms of the four dimensions of outcome.     

A pragmatic randomized controlled trial of a guided self-help intervention versus a waiting list control in a routine primary care mental health service

OBJECTIVES. To evaluate the effectiveness of a two session guided self-help (GSH) intervention provided by primary care graduate mental health workers (PCGMHWs) in a primary care mental health service. DESIGN. Pragmatic randomized trial, with a wait list control design. METHOD. Patients presenting with significant anxiety and depression problems were given one or more self-help booklets at screening and randomly allocated to an immediate (ITG) or delayed treatment group (DTG). Following this, a two-session GSH intervention was provided by one of two PCGMHWs, with a review session to decide on the need for further intervention. The DTG began the intervention 8 weeks after the screening and the primary outcome was Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM) scores after 8 weeks. RESULTS. A total of 63 patients were allocated to the ITG, 59 to the DTG. Analysis of covariance, carried out on an intention to treat basis, showed a significant treatment effect, F(1,98) = 15, p < .001, and a comparison of means at 8 weeks showed a significant difference, t(116) = 2.1 (95% CI [1.1, 5.9]), p= .042 with an effect size, d= 0.375. Taking the two groups together, CORE-OM scores for patients who completed the intervention reduced between screening and the review session by an average of 7.9 (95% CI [6.3, 9.5]), effect size of 1.2. Between screening and the review session, 47% showed a reliable and clinically significant improvement. CONCLUSIONS. The study provides some support for the effectiveness of a two-session GSH intervention and a stepped-care service model.     

A randomized controlled trial and economic evaluation of counselling in primary care.

BACKGROUND: Counselling in primary care settings remains largely unevaluated. Such evaluation has been strongly recommended. AIM: To determine the relative effectiveness and cost-effectiveness of generic counselling and usual general practitioner (GP) care for patients with minor mental health problems. METHOD: A randomized controlled trial and health economic evaluation were carried out in nine general practices. Access to generic counselling (brief counselling, generally involving up to six 50-minute sessions) was compared with usual GP care. A total of 162 patients aged 16 years and over with diverse mental health problems (excluding phobic conditions and psychoses) were randomized. The Hospital Anxiety and Depression (HAD) scale, COOP/WONCA (World Organization of Family Doctors) functional health assessment charts, and the delighted-terrible faces scale were used to assess outcome four months after randomization. RESULTS: The two groups were similar at baseline. There were significant improvements in both groups between randomization and follow-up for most outcome measures, but no significant differences between the study arms. The 95% confidence limits were narrow and excluded clinically significant effects. Under various assumptions concerning the cost of secondary care referrals and of counselling time, no clear cost advantage was associated with either intervention. CONCLUSIONS: This pragmatic trial demonstrates no difference in functional or mental health outcome at four months between subjects offered access to counselling and those given usual care by their GP. There is no clear difference in the cost-effectiveness of the two interventions. Purchasers should take account of these findings in allocating resources within primary care.     

Breast and cervical cancer screening for women with mental illness: patient and provider perspectives on improving linkages between primary care and mental health

Summary Objective: Previous research suggests that women with mental illness may be at increased risk for breast and cervical cancer. This qualitative study of patients and primary care and mental health providers explored challenges to accessing and providing breast and cervical cancer screening for women with mental illness. Method: Key informant patient and provider participants were recruited from a community health setting and teaching hospital. Narrative data from 1) interviews with women in a community primary care setting (n = 16); 2) telephone interviews with women with mental illness (n = 16); and 3) focus groups with primary care providers (n = 9) and mental health providers (n = 26) were collected. Results: Patient, provider, and system factors that may contribute to suboptimal cancer screening among women with mental illness were identified. Communication between primary care and mental health providers was noted as a key area for intervention to enhance screening. Barriers to and possibilities for a more proactive role for mental health providers were also considered. Conclusions: Both patient and provider study participants emphasized the need to address communication gaps between primary care and mental health providers and to promote the active collaboration of mental health providers in preventive cancer screening for women with mental illness.     

What depressive symptoms are associated with the use of care services? Results from the Netherlands Mental Health Survey and Incidence Study (NEMESIS)

Background: Depression is generally regarded as a serious, incapacitating illness. Although effective treatment strategies are available, timely recognition remains a stumbling block. We investigated the rates of health service uptake among depressed people and the specific depressive symptoms associated with service use, after adjustment for other illness characteristics and sociodemographic variables. Methods: In a representative sample (n=7076) of the Dutch adult population, we identified 1572 subjects with lifetime major or minor depression, using the Composite International Diagnostic Interview. Results: The majority (73%) of subjects with depression had sought specialised mental health care, or to a lesser extent primary care. As expected, those with more severe (vegetative), complex (anxiety-comorbid) or dangerous symptoms (suicidal ideation) were more likely to be treated in the specialised mental health sector. However, subjects with comorbid substance use dependence were less likely to receive care, especially primary care, and those with more education were more likely to receive specialised care, even after adjustment for illness characteristics. Limitations: The use of lifetime measures of depression and service use may have introduced slight recall bias, but it made the assessments less vulnerable to selection bias for chronic cases and to misclassification of subjects with some lifetime treatment experience. Conclusions: Although care for people with depression is readily accessible in the Netherlands, people with less education and people with comorbid substance use dependence remain unnecessarily out of reach of the care services. Primary care services need to be strengthened to enable the broad-scale application of stepped-care strategies.