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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.’