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Collaborative stepped care v. care as usual for common mental disorders: 8-month, cluster randomised controlled trial

  • Desiree B. Oosterbaan (a1), Marc J. P. M. Verbraak (a2), Berend Terluin (a3), Adriaan W. Hoogendoorn (a4), Wouter J. Peyrot (a4), Anna Muntingh (a4) and Anton J. L. M. van Balkom (a5)...

Extract

Background

Thus far collaborative stepped care (CSC) studies have not incorporated self-help as a first step.

Aims

To evaluate the effectiveness of CSC in the treatment of common mental disorders.

Method

An 8-month cluster randomised controlled trial comparing CSC to care as usual (CAU) (Dutch Trial Register identifier NTR1224). The CSC consisted of a stepped care approach guided by a psychiatric nurse in primary care with the addition of antidepressants dependent on the severity of the disorder, followed by cognitive–behavioural therapy in mental healthcare.

Results

Twenty general practitioners (GPs) and 8 psychiatric nurses were randomised to provide CSC or CAU. The GPs recruited 163 patients of whom 85% completed the post-test measurements. At 4-month mid-test CSC was superior to CAU: 74.7% (n = 68) v. 50.8% (n = 31) responders (P = 0.003). At 8-month post-test and 12-month follow-up no significant differences were found as the patients in the CAU group improved as well.

Conclusions

Treatment within a CSC model resulted in an earlier treatment response compared with CAU.

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Copyright

Corresponding author

D. B. Oosterbaan, Radboud University, Department of Psychiatry, PO Box 9101, 6500 HB Nijmegen, The Netherlands. Email: d.oosterbaan@psy.umcn.nl.

Footnotes

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See editorial, pp. 86–87, this issue.

Declaration of interest

None.

Footnotes

References

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Collaborative stepped care v. care as usual for common mental disorders: 8-month, cluster randomised controlled trial

  • Desiree B. Oosterbaan (a1), Marc J. P. M. Verbraak (a2), Berend Terluin (a3), Adriaan W. Hoogendoorn (a4), Wouter J. Peyrot (a4), Anna Muntingh (a4) and Anton J. L. M. van Balkom (a5)...
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eLetters

On Collaborative Care in treating depression.

Mark Agius, Visiting Research Associate
16 May 2014

Oosterbaan et al [1] discuss a complex collaborative care system for treating Depression and Anxiety disorders.Collaborative care has frequently been shown to be more effective than treatment as usual, both in the USA, with the work of Katon et al [2] and its positive effects have been seen to persist for up to 12 months in more recent studies in the UK [3].Oosterbaan discusses a system in which 'Stepped Care' is fitted within a system of collaborative care. It is, however necessary to define what a stepped care approach is, and also what Collaborative care is. Stepped care is in fact a protocol of treatment in which more difficult cases move from one step to another to enable more complex treatments to be brought to bear on more resistant cases[4] .Thus Stepped care may be applied without any working relationship between primary and secondary care.On the other hand Collaborative or Shared Care by definition is a system whereby the General Practitioner is supported within his practice by a case manager who works with the patients to give psychological therapy andimprove compliance, and a psychiatrist is available to the practice to help with difficult cases and to share his expertise with the Primary careteam. Thus, there is an active relationship between the psychiatrist and the primary care team.One consequence of this sharing of expertise is that the psychiatrist may well influence the treatment of patients in primary care who he may never see . Thus , theoretically at least, collaborative care may have a greatereffect on the outcomes of treatment of depression or anxiety in primary care than treatment as usual.It is important, when evaluating Collaborative care services that as well as data driven papers, narrative papers to describe the collaboration between primary and secondary care within the service.Thus far Collaborative care has been shown to be more effective than 'treatment as usual' [2] in the treatment of depression. However there have not been any direct comparisons between Collaborative care and Stepped care.Recently we have argued that Collaborative care is different from simply teaching general practitioners to identify and treat depression[5]. Also recently we have suggested a series of outcome measures for assessing the effectiveness of shared care services[6].There is need for large scale studies of Collaborative Care in order to further evaluate a most promising system for the treatment of depression and anxiety in primary care.

References.1.Desiree B. Oosterbaan, Marc J. P. M. Verbraak, Berend Terluin, Adriaan W. Hoogendoorn, Wouter J. Peyrot, Anna Muntingh, and Anton J. L. M. van Balkom.Collaborative stepped care v. care as usual for common mental disorders: 8-month, cluster randomised controlled trial BJP August 2013 203:132-139

2. Katon W, Von Korff M, Lin E, Walker E, Simon GE, Bush T, Robinson P, Russo J Collaborative management to achieve treatment guidelines. Impact on depression in primary care. JAMA. 1995 Apr 5;273(13):1026-31.3. Richards DA, Hill JJ, Gask L, Lovell K, Chew-Graham C, Bower P, Cape J,Pilling S, Araya R, Kessler D, Bland JM, Green C, Gilbody S, Lewis G, Manning C,Hughes-Morley A, Barkham M Clinical effectiveness of collaborative care for depression in UK primary care (CADET): cluster randomised controlled trial. BMJ. 2013 Aug 19;347:4. NICE Guideline Depression 20095. Agius M, Vyas V. Differences between training GPs to manage depression in primary care and issuing them with guidelines, and a system of collaborative care in the treatment of depression between primary and secondary care. Psychiatr Danub. 2011 Sep;23 Suppl 1:S79-82.

6. Hopwood J,Agius M. Establishing outcome measures for shared care in the treatment of depression. 2013 Psychiatria Danubina 25;supp2;291-294

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Conflict of interest: None declared

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