Special report Depression: Telephone consultations to improve access to therapy
Last week health secretary Alan Johnson committed to give the NHS 3,600 new CBT therapists by 2010. Professor David Richards suggests how telephone consultations could play a key role until then
GPs have very limited options available when faced with patients consulting about common mental health problems such as depression and anxiety. Recent NICE guidelines identify that cognitive behaviour therapy is as effective as some drug treatments and recommend all suitable patients be offered such treatment. Sadly, best estimates are that GPs overall are able to access talking treatments for only 9% of their patients, with fewer than 2% receiving CBT.
Despite the proven efficacy of pharmacological and talking treatments, patient compliance with both is poor. One of the problems with talking treatments is that they tend to be offered in very traditional ways, mainly face to face with therapists using weekly ‘golden hour' sessions. This limits the numbers of patients counsellors and therapists can treat and many patients find the need to take time off work every week an insurmountable barrier.
These problems have led to research into both new forms of less burdensome psychological treatments – so-called ‘low-intensity treatments' – and new ways of delivering them, for example by using the phone.
As Professor Wayne Katon, professor of psychiatry at the University of Washington and a leading thinker in system redesign, said, ‘it is not a skills deficit but a systems deficit' that holds us back. With others, he has pioneered a system called ‘collaborative care', a form of enhanced consultation liaison, whereby input into general practice by mental health experts is facilitated through specially trained case managers.
Collaborative care involves trained and competent workers providing mental health education, medication support and low-intensity psychological treatments, mainly over the phone.
These workers can manage high volumes of patients, are supervised by mental health specialists and link with GPs to provide regular feedback on individual patient progress.
A great deal of evidence has been amassed in the US on this quality improvement method and recently three small trials have shown that positive results could also be achieved here in the UK.
Telephone vs face-to-face
In a recent clinical research protocol developed by a team funded through the Medical Research Council, case managers supported patients with depression in primary care using a 6:1 ratio of telephone versus face-to-face contacts. The workers delivered a mixture of medication support – mainly regarding antidepressants – and a form of low-intensity CBT for depression called behavioural activation.
On average, patients in the case-managed group showed twice the improvement compared with the group without additional case management. The total additional time spent treating each patient was very modest – on average just over three hours per patient in total during 12 weeks.
Interviews with patients were extremely positive, particularly regarding the use of the phone, providing they had at least one initial face-to-face appointment.
In this and other trials, the workers were a mixture of established mental health professionals – such as nurses and occupational therapists – and the newer para-professional group known as graduate primary care mental health workers.
There were no differences in outcomes between professional and para-professional workers. Nevertheless, even experienced professionals were given additional training and found the role rather different from the one they usually undertook.
Key to their success was regular supervision from experienced mental health clinicians in the trial team, which helped with clinical management and in keeping the workers to protocol. It may certainly be possible that practice nurses could be trained in the role, provided they were freed up to use their skills alongside their many other responsibilities.
Implementing a system that allows many more patients to receive advice and guidance for common mental health problems requires GPs and their associated mental health workers – such as counsellors – to embrace new ways of working.
Rather than commission counsellors to see just a few patients using traditional intense face-to-face methods, practices and PCTs should ensure that specifically trained primary care workers deliver telephone support to high volumes of patients. Graduate primary care mental health workers can function in this role very well if they receive supervision from experienced mental health workers – possibly delivered by workers in PCT provider services or through contracts with specialist mental health trusts.
While it is possible to use practice nurses, research does show that better results are obtained with specifically trained and supervised workers.
Graduate primary care mental health workers fit this bill very well since they are trained to support and treat high volumes of patients within collaborative care case management systems.
Such thinking requires GPs to consider an alternative to their traditional practice counsellor or attached CPN. The fact that these traditional systems have failed to deliver the level of access to psychological treatments demanded by increasingly knowledgeable and assertive patients is reason enough to look at alternative, more effective, systems of organisation.
With case managers treating two or three times more patients annually than traditional counsellors or other workers, the time has come to think about the possibility of retraining traditional workers or employing new ones to deliver mental health care to patients over the phone as part of routine primary care.
With PCTs now focused very much on patient choice and access, GPs and practice teams may find the arguments easy to make.
Most patients value the flexibility of telephone working – indeed, in one classic recent case study, a mental health worker was able to treat a patient over the telephone during his lunch break while the patient sat in his JCB, allowing him to undergo a full treatment programme without disturbing his very real need to function undisturbed at his workplace.
Although telephone working will not suit all patients, current evidence and experience is indicating that telephone support and treatment is effective, acceptable and a cost-effective way of redressing the parlous state of access to non-drug treatments for the majority of people with anxiety and depression.
Professor David Richards is professor of mental health at the University of York
Competing interests None declared
• Patients value the accessibility of telephone working
• The telephone can be a highly effective way of supporting and treating patients with anxiety and depression
• Collaborative care using the telephone improves concordance with both drug and talking treatments
• Patients do value at least one traditional face-to-face appointment to orient them to the case manager
• Specific training and expert supervision of case managers improves the effectiveness of collaborative care