IMPROVING CARE FOR PATIENTS WITH DEPRESSIVE AND ANXIETY DISORDERS: A CONSULTATION-LIAISON INTERVENTION IN PRIMARY CARE (COLIPRI)
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W E N N B E R G I N T E R N AT I O N A L C O L L A B O R AT I V E SPRING POLICY MEETING 2018 Improving Care for Patients with Depressive and Anxiety Disorders: A Consultation-Liaison Intervention in Primary Care (CoLiPri) A l e x a n d r a W ü e s t , M a r k u s Wo l f , B i r g i t Wa t z k e Psychologisches Institut, Universität Zürich
Mental health care: treatment pathways
(primary) access treatment(s),
e.g. psychotherapy follow-up care
Project NRP 74: Project SNF:
CoLiPri / NaTel
Fachstelle Mental
Health
wennberg-zurich.org 12.04.18Depressive & Anxiety Disorders and the role
of primary care
- More than 10% of the population suffer from depression or/and anxiety (Baer et al., 2013; Grandes
et al., 2011; Kroenke et al., 2007)
- 30% of patients consulting a general practitioner (GP) have a mental disorder, but only 1
out of 3 patients are properly treated; i.e. diagnosed and treated correctly and promptly
according to treatment guidelines (Baer et al., 2013)
- GP – first and only contact (SAMW, 2014)?
- Referral to specialized care is low (e.g. Switzerland: 13%) (Baer et al., 2013)
- Underuse and inadequate treatment increase the risk for: prolonged suffering, poor
individual health outcomes, chronic courses; increased health care expenditures and
societal costs (Bachmann et al., 2015; Gustavsson et al., 2011; Tomonaga et al., 2013)
- Low-threshold, multidisciplinary collaboration in primary care could improve the
identification and uptake of evidence-based treatments in patients with depression and
anxiety disorders (Archer et al., 2012; Härter et al., 2015; Watzke et al., 2014, 2017)
wennberg-zurich.org 12.04.18Own previous research I (W a tz k e e t a l . 2 0 1 7 )
- Telephone intervention for depression (TIDe Study)
- Telephone consultations have the potential to
overcome barriers people face with mental health
problems (e.g., stigma) and can increase access to
evidence-based treatment
- Based on the principles of guided self-help and
telephone-based CBT (e.g., Mohr et al., 2008)
- Target group:
Primary care patients with mild to moderate
depressive symptoms (PHQ-9≤15)
- Aims:
To develop and test a novel low-threshold, tailored,
low intensity, and flexible psychotherapeutic service
for the treatment of depressive symptoms
wennberg-zurich.org 12.04.18TIDe-Study - Patient feedback (Haller et al., in prep) - “Ich mache das lieber so, ich glaube, dadurch konnte ich auch offener sein, ich musste mich... also ich musste das ja alles verbalisieren, es hat mich auch gezwungen, dadurch dass jemand ja meine Mimik nicht sehen kann, musste ich... also, das in Worte fassen und das ist auch... gut gewesen.“ - “Es ist nicht so „ah ich gehe in die Therapie“, sondern man geht ein Telefon machen und durch das habe ich gemerkt, es ist ja gar nicht so schlimm, wenn man diese Dinge ein bisschen anschaut. Es ist auch Türöffner gewesen… also die Bereitschaft, das mit jemanden anzuschauen.“ - “[...] nein, es ist nicht das Gleiche, nicht ganz (wie bei anderen Therapieformen). Es hat einen anderen Zugang versucht oder eine andere Herangehensweise, die ich geschätzt habe. Eben ein wenig niederschwelliger, einfacher, direkter.“ wennberg-zurich.org 12.04.18
Own previous research II (W a tz k e e t a l . 2 0 1 4 ; H ä rte r e t a l .,
2015)
- Collaborative and Stepped Care in Depressive Disorders:
Development of a Model Project in the Hamburg Network
Netzwerk Ambulante Behandler Teilstationäre Behandler
for Mental Health (psychenet.de)
Step IV - Multidisciplinary collaboration: family doctors,
Psychotherapie und
Psychopharmakotherapie
Abb. 1 9 psychotherapists,
Das Konzept des
Stepped-Care-Modells in-
psychiatrists, clinics
(ggf. stationär)
Step III
- vier
tegriert Implementation
verschiede-
ne Steps mit insgesamt
of a graduated depression diagnosis and
Psychotherapie oder
Psychopharmakotherapie
treatment in accordance with guidelines, including low-
sechs leitlinienbasierten
Behandlungsoptionen und
threshold
eine begleiten- interventions
Screening
Primärärztliche (ambulant) Stationäre wird durch
Behandler Behandler de wissenschaftliche Stu-
die-evaluiert.
Step II+
PT-Telefonunterstützung
Target group: Patients with mild, moderate or severe
Die Interven-
Step II depression
tionen werden im Rahmen
eines multiprofessionellen
Bibliotherapie
E-Selbsthilfe - Primary outcome:
Netzwerks aus Hausärzten,
Psychotherapeuten, Psy-
Step I chiaternImprovement
und (teil)stationä- in depressive symptoms at 12-month follow-
Aktiv-abwartendes Begleiten ren Behandlern durchge-
führt, dieup (PHQ-9)
u. a. über eine In-
Monitoring ternetplattform miteinan-
-vernetzt
der Main conclusions:
sind. Poten-
Vernetzung via E-Plattform zielle Über- oder Unterver-
à Successful
sorgung wird durch das be- implementation of a stepped / collaborative care model
gleitende Monitoring früh-
à Effectiveness comparable to international
zeitig erkannt und die Be-
meta-analyses (e.g.,
Begleitevaluation: Effektivität und Effizienz
handlung Firth
in ihreret al., 2015; Thota et al., 2012)
Intensität
angepasst
à Larger and faster reduction of depressive symptoms in patients
wennberg-zurich.org
sion [5] durch. Erstmals wird darüber treated in the network 12.04.18
Risikopatient-Checkliste hinaus in Deutschland der kombinier- krankung) bei Patienten zutrifft, prüft der
te Einsatz innovativer niedrigschwelli- Hausarzt, ob eine depressive ErkrankungImproving Care for Patients with Depression
and Anxiety Disorders in Primary Care:
The CoLiPri Study
- Study objectives: Improving the early detection, diagnosis, treatment planning and efficient
treatment of common mental disorders in primary care
- Aims: To develop and test a complex intervention (Consultation-Liaison intervention in
Primary Care) for patients with elevated depressive and/or anxiety symptoms
- Implementation of a Fachstelle «Mental Health»
- Project duration: 2018-2022
- Funded by the SNSF National Research Programme 74 «Smarter Health Care»
- Project collaborators:
1. Institute of Primary Care, University of Zurich (Thomas Rosemann)
2. Epidemiology, Biostatistics and Prevention Institute, University of Zurich (Matthias Schwenkglenks)
3. Center for Psychotherapy Research, University of Heidelberg (Stephanie Bauer)
4. International Advisory Board: Prof. S. Gilbody (Univ. York; GB), Prof. R. Lieb (Univ. Basel; CH), Prof. R. Muche
(Univ. Ulm; DE), Prof. S. Riedel-Heller (Univ. Hospital Leipzig; DE)
wennberg-zurich.org 12.04.18Design of the CoLiPri Study Assessed for eligibility (No of clusters)
Excluded (No of clusters):
Enrolment
Not meeting inclusion criteria (No of clusters)
Refused to participate (No of clusters)
Other reasons (No of clusters)
- Two-group, cluster-randomized clinical trial
- Complex intervention: Fachstelle «Mental Health»
GPs trained (No of clusters)
- Target sample size: 420 patients recruited by 40 Randomised (No of clusters)
GP practices in the greater Zurich area
Allocation
- Primary outcome:
Allocated to TAU+ Allocated to intervention +
(No of clusters): TAU+ (No of clusters):
Recruited patients: (N=) Recruited patients: (N=)
Improvement in depressive and/or anxiety
symptoms at 12-month follow-up Patient baseline (N=) Patient baseline (N=)
- Secondary outcomes:
Intervention
Cost-effectiveness; service acceptability; 3-month follow-up (N=) 3-month follow-up (N=)
Follow-up
translational and implementation processes 6-month follow-up (N=) 6-month follow-up (N=)
12-month follow-up (N=) 12-month follow-up (N=)
Analysis
Analysed (No of clusters, Analysed (No of clsuters,
average cluster size, range of average cluster size, range of
cluster size) cluster size)
Primary outcome available Primary outcome available
(N=) (N=)
wennberg-zurich.org 12.04.18Department of Psychology
CoLiPri Study – Treatment Rationale
Department of Psychology
Fachstelle „Mental Health“:
Screening: Enhanced screening and diagnosis algorithm
Consultation: On-demand expert consultation of mental-health professionals
Treatment: Low-threshold walk-in service offered to patients based on GP referral
wennberg-zurich.org 12.04.18Fachstelle „Mental Health“
- General aims:
a) Providing an efficient interface between primary and secondary care through improved
communication and information flow, facilitated inter-professional collaboration, and accelerated
decision making processes
b) Relief of GP work load through efficient resource allocation
c) Improved quality of care for patients with common mental disorders
- Organisational structure:
Modular system offering a low-threshold, inter-professional collaboration between primary health
care and mental health specialists based on the principles of a consultation-liaison service
- Team:
Multi-professional, consisting of clinical psychologists, licensed psychotherapists and psychiatrists,
located at the UZH Psychotherapy Outpatient Center (Attenhoferstr. 9, 8032 Zürich)
- Services offered:
- Undelayed full diagnostic clarification
- Individual, guideline-concordant treatment planning and recommendation
- Initiation of, or further referral to, psychotherapy, counseling, and/or psychiatric treatment
wennberg-zurich.org 12.04.18wennberg-zurich.org 12.04.18
Conclusions - The CoLiPri Study aims to improve the (early) detection, diagnosis and treatment pathways of patients with common mental disorders seen in primary care. - The complex intervention aims to impact the treatment process as early as possible, to reduce the burden for patients, and decrease the risk for chronic courses of the illness. - If feasible and effective translating the consultation-liaison service can be used as a model and translated to other medical areas as well as other mental disorders and chronic conditions. wennberg-zurich.org 12.04.18
T h an k yo u f o r yo u r at t en t i o n ! References - Archer J, Bower P, Gilbody S et al. Collaborative care for depression and anxiety problems. Cochrane Database Syst Rev 2012; 10:CD006525. - Bachmann N, Burl Laila, Kohler D. Gesundheit in der Schweiz - Fokus chronische Erkrankungen: Nationaler Gesundheitsbericht 2015. 1., Aufl. Bern: Verlag Hans Huber; 2015. - Baer N. Depressionen in der Schweizer Bevolkerung: Daten zur Epidemiologie, Behandlung und sozialberuflichen Integration. Neuchatel: Schweizerisches Gesundheitsobservatorium; 2013. - Firth, N., Barkham, M., & Kellett, S. (2015). The clinical effectiveness of stepped care systems for depression in working age adults: A systematic review. Journal of Affective Disorders, 170, 119-130. - Grandes G, Montoya I, Arietaleanizbeaskoa MS et al. The burden of mental disorders in primary care. Eur Psychiatry 2011; 26(7):428–35. - Gustavsson A, Svensson M, Jacobi F et al. Cost of disorders of the brain in Europe 2010. Eur Neuropsychopharmacol 2011; 21(10):718–79. - Härter M, Heddaeus D, Steinmann M et al. Collaborative and stepped care for depression: Development of a model project within the Hamburg Network for Mental Health (psychenet.de). Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2015; 58(4-5):420– 9. - Kroenke K, Spitzer RL, Williams JBW et al. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med 2007; 146(5):317–25. - Mohr DC, Vella L, Hart S, Heckman T, Simon G. The effect of telephone-administered psychotherapy on symptoms of depression and attrition: a meta-analysis. Clin Psychol. 2008;15:243–53. - Schweizerische Akademie der Medizinischen Wissenschaften (2014). Stärkung der Versorgungsforschung in der Schweiz. Swiss Academies Reports 9 (1). - Thota AB, Sipe TA, Byard GJ et al (2012) Collaborative care to improve the management of depressive disorders: a community guide systematic review and meta-analysis. Am J Prev Med 42:525–538. - Tomonaga Y, Haettenschwiler J, Hatzinger M et al. The economic burden of depression in Switzerland. Pharmacoeconomics 2013; 31(3):237– 50. - Watzke B, Heddaeus D, Steinmann M et al. Effectiveness and cost-effectiveness of a guideline-based stepped care model for patients with depression: study protocol of a cluster-randomized controlled trial in routine care. BMC Psychiatry 2014; 14:230. - Watzke B, Haller E, Steinmann M, Heddaeus D et al. Effectiveness and cost-effectiveness of telephone-based cognitive-behavioural therapy in primary care: study protocol of TIDe – telephone intervention for depression. BMC Psychiatry 2017; 17:263.
Fachstelle „Mental Health“
Screening & diagnostic support:
Guideline-based enhanced screening algorithm on
depressive disorders and anxiety disorders
Consultation services:
1. Telephone hotline: On-demand telephone
expert consultation for GPs for diagnostic
clarification & treatment planning
2. Low-threshold Walk-in service: Face-to-
face consultation with patients based on
GPs referral for full diagnostic clarification
and treatment recommendation
3. Upon request: Triage & treatment initiation
Specialist treatment:
1. Psychosocial counselling
2. Brief psychotherapeutic interventions
wennberg-zurich.org
3. Psychiatric consultation and treatment 12.04.18You can also read
