Layard makes a strong economic case for investment in the treatment
of depression and anxiety in primary care settings. However, there are
many potential pitfalls in the outsourcing (for that is what it would be)
of psychological treatment.
Depression, as pointed out elsewhere in this issue, has many
characteristics of a chronic disorder. Kessler et al (1) showed that 72%
of patients had more than one episode. Judd et al (2) showed that
patients moved between levels of severity, and were ill for 59% of weeks.
These more disabled patients contribute disproportionately to overall
morbidity. They also tend to have needs other than psychological
treatment, eg social problems, the need for occupational rehabilitation,
and physical co-morbidities.
There is a substantial body of evidence which shows that these
patients are best managed using collaborative care and stepped care
models(3). A key factor is integration of care for depression
(psychological and pharmacological) with other aspects of care, both
physical and social. Therefore effective management of these patients
requires the co-ordination of multiple inputs.
Two models are of relevance. The outsourcing of business processes
is now commonplace, but works best with relatively uncomplicated tasks.
Returning to the field of health care, the chronic illness care model(4)
shows that such conditions are best managed in multidisciplinary teams
where there is clarity of role, high quality information and communication
and effective team leadership and management.
The outsourcing of one aspect of care is likely to lead to
preferential referral of less complex cases, and consequent dilution of
the potential health impact investment. .
New investment should instead go to create and strengthen
multidisciplinary primary care mental health teams, which are integrated
with general practice and with specialist mental health services. The
challenge here is to establish the effective team structures required.
This needs not just more trained cognitive therapists, but also effective
clinical leaders and managers.
Suresh Joseph
Consultant Psychiatrist,
Newcastle General Hospital
Newcastle upon Tyne
NE4 6BE
1 Kessler RC, Zhao S, Blazer DG, Swartz M. Prevalence, correlates
and course of minor depression in the national comorbidity survey.
Journal of Affective Disorders 45 (1997) 19 - 30.
2 Judd LL, Hagop SA, Maser JD, Zeller PJ, Endicott J, Coryell W et
al. A prospective 12 year study of subsyndromal and syndromal depressive
symptoms in unipolar major depressive disorders. Arch. Gen. Psychiatry;
55: 694 - 700.
3 Gilbody S, Whitty P, Grimshaw J, Thomas R. Educational and
organizational interventions to improve the management of depression in
primary care: a systematic review. JAMA 2003: 289 : 3145-51.
4 Wagner E, Austin B, Von Korff M. Organizing care for patients with
chronic illness. Millbank Q 1996: 74: 511 - 44.
Rapid Response:
The case against psychological treatment centres
The Editor
Layard makes a strong economic case for investment in the treatment
of depression and anxiety in primary care settings. However, there are
many potential pitfalls in the outsourcing (for that is what it would be)
of psychological treatment.
Depression, as pointed out elsewhere in this issue, has many
characteristics of a chronic disorder. Kessler et al (1) showed that 72%
of patients had more than one episode. Judd et al (2) showed that
patients moved between levels of severity, and were ill for 59% of weeks.
These more disabled patients contribute disproportionately to overall
morbidity. They also tend to have needs other than psychological
treatment, eg social problems, the need for occupational rehabilitation,
and physical co-morbidities.
There is a substantial body of evidence which shows that these
patients are best managed using collaborative care and stepped care
models(3). A key factor is integration of care for depression
(psychological and pharmacological) with other aspects of care, both
physical and social. Therefore effective management of these patients
requires the co-ordination of multiple inputs.
Two models are of relevance. The outsourcing of business processes
is now commonplace, but works best with relatively uncomplicated tasks.
Returning to the field of health care, the chronic illness care model(4)
shows that such conditions are best managed in multidisciplinary teams
where there is clarity of role, high quality information and communication
and effective team leadership and management.
The outsourcing of one aspect of care is likely to lead to
preferential referral of less complex cases, and consequent dilution of
the potential health impact investment. .
New investment should instead go to create and strengthen
multidisciplinary primary care mental health teams, which are integrated
with general practice and with specialist mental health services. The
challenge here is to establish the effective team structures required.
This needs not just more trained cognitive therapists, but also effective
clinical leaders and managers.
Suresh Joseph
Consultant Psychiatrist,
Newcastle General Hospital
Newcastle upon Tyne
NE4 6BE
suresh.joseph@ntw.nhs.uk
References:
1 Kessler RC, Zhao S, Blazer DG, Swartz M. Prevalence, correlates
and course of minor depression in the national comorbidity survey.
Journal of Affective Disorders 45 (1997) 19 - 30.
2 Judd LL, Hagop SA, Maser JD, Zeller PJ, Endicott J, Coryell W et
al. A prospective 12 year study of subsyndromal and syndromal depressive
symptoms in unipolar major depressive disorders. Arch. Gen. Psychiatry;
55: 694 - 700.
3 Gilbody S, Whitty P, Grimshaw J, Thomas R. Educational and
organizational interventions to improve the management of depression in
primary care: a systematic review. JAMA 2003: 289 : 3145-51.
4 Wagner E, Austin B, Von Korff M. Organizing care for patients with
chronic illness. Millbank Q 1996: 74: 511 - 44.
Competing interests:
None declared
Competing interests: No competing interests