Managing Depression in Primary Care - Emerging Evidence
Depression is the most common mental disorder in community settings, and a major cause of disease burden.4Research has indicated that the prognosis of many depressive disorders is poor, and rates of relapse and recurrence are high.
Given the burden associated with depression, it is important that the care provided in primary care is of the highest quality, because this is where the bulk of the problems present and are currently managed. However, studies have indicated a number of significant problems in the provision of care for depression, including under-recognition by GPs, and inadequate treatment. 5-7
Efforts have been made to overcome some of these problems, using educational methods such as the large scale Defeat Depression campaign8 and smaller scale practice-based educational meetings,9 largely aimed at improving the skills, confidence and attitudes of GPs. However, the impact of these initiatives has been relatively modest. It has been recognised that improving the care of depression is a very complex task, which requires changes to the way care is provided and additional resources to develop the appropriate systems to enable primary care professionals to deliver high quality care. 6,10,11
The new GMS contract includes payments for National Enhanced Services (NES), and one of these NES relates to depression.
Although the initial description of enhanced services for depression included some detail as to the type of service that would attract the incentive, the initial specification did not reflect current evidence concerning the optimal methods of providing depression care. This handbook seeks to provide guidance on a model of care for depression in line with the current evidence. 11-13
One important point to note is that the model presented here does not significantly differ from the way in which most GPs implicitly deal with depression. The main difference is the focus on the systematic organisation of care.
KEY THEMES FROM THE LATEST RESEARCH ON INTERVENTIONS
There are a number of key themes that have come out of recent work in depression that are relevant to the NES for depression.
1. Depression as a chronic disease
Traditionally, primary care services have been structured around acute care. However, studies of the natural history of depression have indicated that depression may be better viewed as a chronic disease, characterised by high levels of relapse and recurrence. This means that depression may be best treated through the use of specific chronic disease management methods, 14 similar to the methods adopted in relation to other chronic diseases like asthma and diabetes. 15
Taking the chronic disease management perspective on depression means that primary care organisations will have to shift their perspective on depression from the care of the individual patient, to the care of the entire population of depressed individuals. Population-based care is aimed at restructuring service delivery to provide a strategy for the care of all patients within a defined population with a recurrent or chronic illness. 6
What are the practical implications of these findings? Broadly speaking, there is a shift away from simple quality improvement strategies, such as dissemination of guidelines, practice education and stand alone screening programmes. Instead, the whole process of depression care needs to be improved. Research has indicated that effective programmes can include a variety of different approaches (including education, screening and guidelines), but that a necessary ingredient of an effective intervention is case management. 13
Case management involves one professional in the practice taking responsibility for:
- Proactively following up patients
- Assessing patient adherence to psychological and pharmacological treatments
- Monitoring patient progress
- Taking action when treatment is unsuccessful
- Delivering psychological support
Case managers may be thought of as physician extenders, who work under the supervision of the GP to improve quality of care for patients with depression. They do not work alone, but receive support from a specialist professional, and share information with the GP. A variety of professionals may be able to take up the case management role, including practice nurses, CPNs, and the new graduate workers.
2. Improving access to psychological therapy through self-help
Research has indicated that psychological therapy is both effective for depression 16 and popular with patients. 17 However, almost all services have problems with access, with long waiting lists resulting from limited numbers of trained therapists.
One major development over the last few years is the development of self-help interventions. These interventions are usually based on cognitive behavioural therapy, which is one of the most effective treatments for depression.16 Self-help treatments can use books, computer programmes and websites to teach patients key CBT sklls.18 There is encouraging evidence that such approaches are effective in the management of some depressive disorders. Because these treatments are generally not dependent on the availability of a specialist psychological therapist, they provide one method of overcoming problems with access to psychological therapy.19
Although self-help is often based on health technologies such as books, computer programmes and websites, patients are not left to deal with their problems alone. Instead, in the guided self-help model, patients see a health professional during their treatment, who explains how to use the appropriate materials, encourages the patient, and monitors progress over time.
3. Stepped care
Stepped care is a model of healthcare delivery with its origins in the US, which has been applied to a range of disorders, particularly those of a chronic nature. 20-22
There are two key features of a stepped care system.
- The recommended treatment should be the least intensive of those currently available, but still likely to provide significant health gain. In stepped care, more intensive treatments are reserved for patients who do not benefit from simpler first line treatments. For example, CBT may be provided through self-help materials with minimal support from a graduate worker in the first instance, before it is provided by a trained CBT therapist.
- Secondly, stepped care is self-correcting, in that the results of treatments and decisions about treatment provision are monitored systematically, and changes are made (so-called stepping up) if current treatments are not achieving significant health gain.
This is similar to the way many clinicians implicitly operate, but stepped care standardises systems and procedures with an explicit aim of improving effectiveness and efficiency.
Summary
This section has discussed three key themes in current models of depression care: chronic disease management, self-help, and stepped care. The enhanced service for depression in this guide is an amalgamation of these three themes. The model can be broken down into three main stages (see Figure 1).
(Figure 1)