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A faulty production line

Every patient with depression to have a 'care manager', under model being considered by NICE

GPs will have the option of referring patients with depression to a ‘care manager’ to oversee their medication and provide behavioural support, under a ‘US-style’ care model being considered by NICE.

The move comes after a study in UK primary care showed using care managers led to improvements in depression symptoms and recovery that lasted up to a year, compared with usual GP care.

The UK’s clinical regulatory body strongly hinted it could give the model the green light for new guidance after it said the latest research showed ‘it could be successfully replicated in the UK’.

The collaborative care model was tested out in nearly 600 patients diagnosed with depression at over 50 practices, and involved specially trained care managers assessing patient symptoms, giving them advice on medications and preventing relapses.

Care managers alerted GPs to adherence or tolerance problems, so that the dose could be amended, whilst offering ‘behavioural activation’ support - in a similar way to stop smoking advisers.

Researchers led by Professor David Richards at the University of Exeter randomly assigned 276 patients to receive the collaborative care model, involving between six and 12 contacts with care manager over 14 weeks, and 305 patients to receive usual care from the GP, which included treatment with antidepressants and referral for other treatments.

They reported in the BMJ that after four months, the mean depression score was 1.33 points lower on the Patient Health Questionnaire (PHQ)-9 in patients receiving collaborative than usual care, after adjusting for their baseline score.

The difference was maintained at 12 months, with the average score 1.36 points lower with collaborative care, albeit at lower statistical significance.

As well as the overall improvement in symptoms, patients were almost twice as likely to recover with the collaborative care approach, with 1.88 times the odds of recovery (score of nine or less on PHQ-9) at 12 months, relative to those in the usual care group.

Patients also preferred collaborative care, giving it better satisfaction ratings than usual care.

The authors conceded the treatment response was lower than they had expected, but highlighted that 15% more patients receiving collaborative than usual care had recovered at 12 months (55.7% versus 40.3%), meaning health services would need to treat 6.5 additional patients using collaborative care to enable one additional patient to achieve ‘sustained’ recovery.

The team is now conducting economic analysis of the findings and will continue to follow up participants for a further two years. They said that the programme could be incorporated into the IAPT scheme.

Professor Richards said: ‘This is one of the largest studies of collaborative care internationally, and demonstrates that it is as effective in the UK as it is in the US, and could reliably be imported. Importantly, patients also told us that they preferred the approach to their usual care.

‘This study was carried out in response to a plea for evidence from NICE, which we have now provided. We are now working on a full economic evaluation, and it will be for NICE to decide how to take this forward.’

Dr Ian Walton, a GPSI in mental health in Dudley, said it was an ‘important and well produced trial’ and that the authors ‘imply that it looks at least as cost effective as IAPT if not better’.  

He added: ‘Link workers who support patients with mental health problems have proved their worth in other trials, so it is no surprise to me that they have proved effective here.’

Co-author of the paper, Professor Carolyn Chew-Graham, Professor of General Practice Research at Keele University and a GP in central Manchester, told Pulse that the collaborative care model could be fairly easily integrated with existing IAPT services to enhance their effectiveness for the management of people with depression.

She said: ‘The care manager talks to the GP and gives them formal feedback, which doesn’t happen at the moment – there may be little liaison. That would require IAPT workers to have their training slightly modified to include the liaison aspect.

‘Also, GPs would need to have time freed up to have those discussions, which would need to be reimbursed, perhaps though a Local Enhanced Service.’

Professor Tony Kendrick, professor of primary care at University of Southampton, said the model appears more effective than IAPT, but questioned how many patients in primary care with depression could benefit, even with improved uptake rates.

He said: ‘As a model for treatment I think it’s good – but you’re going to need a lot more staff to take the referrals.

‘Unless there is a massive investment in resources, it is only ever going to be available for a minority of our patients with depression and we’ve still got to think about how we improve the care of people who can’t have it.’

Readers' comments (12)

  • Haha bankrupt NHS on the way...

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  • All these services sound fantastic but GP's cannot manage their current workload let alone have to provide additional services at extra cost.

    We appear to have become a nation of wimps where we expect GP's to have a solution for our own shortcomings!

    At the end of the day, GP's are only human beings too, they don't have super powers or the ability to work 24/7.

    It is time folk took a great deal more responsibility for their own health. there isn't a tablet that solves all
    problems and GP's do not have magical powers!

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  • Well said, Shurleea Harding. Are the care managers medical or will they be well-meaning individuals with little medical background and potentially offer dangerous advice like some RMN's I have encountered in the past?

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  • Where is the role of the relative, the parent, the son or daughter in all of this? When are we going to stop spoonfeeding and nannying patients, letting their relatives off the hook and able to abandon their relative taking no responsibility at all for their social well being? Society is becoming more and more selfish because we are allowing people to live with no responsibility at all. Taxes are not meant to be there for public services to fill the gap that relatives should be providing. The NHS was never meant to fill in the gap that the family and relatives of the patient should be providing. I really despair where we are going with all of this, it is impossible to individually take care of every vulnerable patient.

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  • With unhelpful attitudes such as those expressed above, it’s not surprising that in 2011 there were 4,552 male suicides (18.2 suicides per 100,000 population) and 1,493 female suicides (5.6 per 100,000 population) [ONS]. What a nation of wimps! Does killing yourself count as taking responsibility for your own health? Access to mental health services needs to improve; although, agree with anon 10.55 that someone with no medical background is unlikely to be useful . . . rope anyone?

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  • I'm already the care manager for my patients with mental health issues. I have given up my own time to initiate behavioural activation sessions due to the 6-8 week waiting list for IAPTS! I get fed up with CPN's or Psychology workers telling my patients to come back and get their medication changed, without giving me the professional curtesy of a phone call to discuss my plan of care or find out the past history!

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  • With unhelpful attitudes such as those expressed above, it’s not surprising that in 2011 there were 4,552 male suicides

    The comments before yours simply refer to how financially unworkable this "solution" is, and how unlikely it is to make a difference.

    You seem to be suggesting a link between attitudes like those and suicide rate. Do you have any evidence for this? If so you should present it.

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  • We're just need awareness

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  • lets summarise this: throwing money and resource at a problem and it gets better versus existing care.
    Is ANYONE surprised by this?
    Almost any patient I look after could be looked after better if I didnt have only 10 mins and 55 other people to see the same day.
    Where is the money coming from to fund this? If its out of the global sum - who is going to suffer - i suggest another patient with a non trendy illness.

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