DEPRESSION

Management Of Depression In Primary And Secondary Care



Management Of Depression In Primary And Secondary Care

Depression is predominantly treated in primary care, without referral to specialist mental health services , but research has identified a number of deficiencies in the diagnosis and management of depression in this setting . Overcoming these deficiencies has raised a number of questions about the optimal way to organize services to provide care that is accessible, effective, efficient and patient centered.

A number of different models of service delivery have been described . There was initially a great deal of interest in an 'education and training' model based on the use of guidelines and short training courses to educate primary care staff to deliver higher quality depression care (through improved antidepressant prescribing and psychosocial interventions). Like any service focused on primary care, this model has the potential to increase access to care in an efficient way. However, evaluations of effectiveness have been generally negative.

This has in turn led to a focus on models involving a greater role for specialist and quasi-specialist staff, either through the introduction of mental health professionals co-located in primary care settings, delivering treatments to patients directly (so-called attachments) , or through complex models involving system redesign, case management and structured collaborative working between primary care and specialist professionals (so-called collaborative care) .

There is developing evidence of the effectiveness of these models. However, implementation is problematic, because the addition of specialist staff means that improvements in effectiveness are routinely associated with increased costs. Such services may be formally cost-effective, because the health gains are obtained at a cost that decision makers are willing to pay. However, they may be less attractive to routine service providers who actually have to find the additional funds to implement the new services. This means that innovative models often do not endure once research funding disappears .

Therefore, despite the developing evidence base for collaborative care and attachment models, interest in more efficient models of delivery remains, especially in contexts with less resources available for mental health care.

Consultation-liaison is a model that is similar to 'education and training' in that it is fundamentally concerned with improving the skills of primary care professionals . However, rather than providing short courses to teach skills in dealing with depressed patients in general, specialists in the consultation-liaison model enter into an ongoing educational relationship with the primary care team, in order to support them in caring for specific patients currently undergoing care. The exact definition of consultation-liaison in primary care varies.

In the United Kingdom, the model reflects the gatekeeping role of the primary care professional and requires (a) regular face-to-face contact between specialist and primary care, (b) a focus on managing cases in primary care with appropriate support and (c) referral to specialist care only after direct discussion . Definitions in the United States reflect the more varied service structures in that setting, but most definitions include the fact that consultation-liaison involves an educational relationship between psychiatrist and primary care provider: consultation ...