Taking a complex approach to depression and anxiety

If you’re making a trifle, you expect to put in lots of different ingredients, but opinion varies about what should go in. Are those vaguely stale-tasting sponge fingers vital for the optimal trifle or does Swiss roll provide a superior foundation? Some consider jelly to be a vital element, while others wouldn’t consider it. Fruit – tinned or fresh, and what sort? Cream or custard? Chocolate shavings (for the aspirational trifle), sugar strands or good old silver balls? The truth is, we don’t know which elements and which combinations work best, though every trifle maker will have their own ideas about that. The process may be standardized but the form of the thing will be adapted. A key question then is did it hit the spot and leave your consumers feeling much better for it?

The same is often true of  ‘complex interventions’ in healthcare, made up of several components. It can be difficult to establish which are the essential ingredients and how they work together. Then the elements may differ but be underpinned by the same behavioural change theory, for example. Collaborative care models are complex interventions that involve a number of different healthcare professionals working with people to help them manage chronicA health condition marked by long duration, by frequent recurrence over a long time, and often by slowly progressing seriousness. For example, rheumatoid arthritis. More conditions or recover from illness. For people with depression and anxiety, it often involves a medical doctor, a case manager (with training in those conditions) and a mental health specialist such as a psychiatrist.

The Depression, Anxiety and Neurosis Group has now published a review seeking to address the uncertainties surrounding the effectivenessThe ability of an intervention (for example a drug, surgery, or exercise) to produce a desired effect, such as reduce symptoms. More of this approach for people with depression and anxiety, providing an up-to-date assessment of the evidence in this rapidly developing area of research, to inform policy and practice. For the purposes of this review, collaborative care interventions had to have four key elements: involvement by a primary care provider (such as a GP) and at least one other health professional, a structured management plan, scheduled follow-ups and mechanisms to facilitate communication between professionals. The review includes 79 randomisedRandomization is the process of randomly dividing into groups the people taking part in a trial. One group (the intervention group) will be given the intervention being tested (for example a drug, surgery, or exercise) and compared with a group which does not receive the intervention (the control group).   More controlled trialsA trial in which a group (the ‘intervention group’) is given a intervention being tested (for example a drug, surgery, or exercise) is compared with a group which does not receive the intervention (the ‘control group’). More (RCTs) with 24,308 patients, comparing collaborative care with routine care or other interventions.

What did they find?

• For adults with depression: significantly greater improvement with collaborative care in the short-term, medium-term and long-term, but not the very long-term (after two years or more)
• For adults with anxiety: significantly greater improvement with collaborative care in the short-term, medium-term and long-term. There were no comparisons in the very long-term
• Some evidence that patients receiving collaborative care were more likely to take prescribed medication, were more satisfied with their care and had improved mental health-related quality of life

How good is the evidence?

This is a large body of evidence and the authors judge it to be ‘robust’ overall. They note some problems, for example in the methods of allocating patients to treatmentSomething done with the aim of improving health or relieving suffering. For example, medicines, surgery, psychological and physical therapies, diet and exercise changes. More groups, or patients and their doctors knowing which group they were in, leaving them open to biasAny factor, recognised or not, that distorts the findings of a study. For example, reporting bias is a type of bias that occurs when researchers, or others (e.g. drug companies) choose not report or publish the results of a study, or do not provide full information about a study. More.

The bottom line?

Collaborative care is associated with significant improvement in depression and anxiety in adults compared with usual care and represents a useful addition to clinical pathways.

The authors comment that their findings have important implications for current clinical guidelines for depression but, despite this evidence for the effectiveness of collaborative care, anticipate ongoing debate on the size of the benefits.

Links:

Archer J, Bower P, Gilbody S, Lovell K, Richards D, Gask L, Dickens C, Coventry P. Collaborative care for depression and anxiety problems. Cochrane Database of Systematic ReviewsIn systematic reviews we search for and summarize studies that answer a specific research question (e.g. is paracetamol effective and safe for treating back pain?). The studies are identified, assessed, and summarized by using a systematic and predefined approach. They inform recommendations for healthcare and research. More 2012, Issue 10. Art. No.: CD006525. DOI: 10.1002/14651858.CD006525.pub2.

Cochrane summary and podcast of this review http://summaries.cochrane.org/CD006525/collaborative-care-for-people-with-depression-and-anxiety

The Mental Elf blog. Collaborative care is effective for adults with depression and anxiety: new Cochrane systematic review.