Collaborative care for depression in European countries: A systematic review and meta-analysis

Highlights

• We investigate collaborative care for depression in European primary care.

• Collaborative care improved depression in the short, medium and medium-long term.

• Collaborative care did better in countries with higher strength of primary care system.

Abstract

Objectives

This is a systematic review and meta-analysis of randomized controlled trials (RCTs) investigating the effectiveness of collaborative care compared to Primary Care Physician's (PCP's) usual care in the treatment of depression, focusing on European countries.

Methods

A systematic review of English and non-English articles, from inception to March 2014, was performed using database PubMed, British Nursing Index and Archive, Ovid Medline (R), PsychINFO, Books@Ovid, PsycARTICLES Full Text, EMBASE Classic + Embase, DARE (Database of Abstract of Reviews of Effectiveness) and the Cochrane Library electronic database. Search term included depression, collaborative care, physician family and allied health professional. RCTs comparing collaborative care to usual care for depression in primary care were included. Titles and abstracts were independently examined by two reviewers, who extracted from the included trials information on participants' characteristics, type of intervention, features of collaborative care and type of outcome measure.

Results

The 17 papers included, regarding 15 RCTs, involved 3240 participants. Primary analyses showed that collaborative care models were associated with greater improvement in depression outcomes in the short term, within 3 months (standardized mean difference (SMD) − 0.19, 95% CI = − 0.33; − 0.05; p = 0.006), medium term, between 4 and 11 months (SMD − 0.24, 95% CI = − 0.39; − 0.09; p = 0.001) and medium–long term, from 12 months and over (SMD − 0.21, 95% CI = − 0.37; − 0.04; p = 0.01), compared to usual care.

Conclusions

The present review, specifically focusing on European countries, shows that collaborative care is more effective than treatment as usual in improving depression outcomes.

Introduction

Depression is highly prevalent in the general population [1] and is set to become one of the three leading causes of burden of disease by 2030 [2]. The majority of patients suffering from depressive disorders is managed within the primary care setting and despite the availability of effective treatments [3], the quality of care provided by GPs remains often suboptimal [4], [5]. Hence, the development of more efficient, structured and multifaceted integration programmes between primary care and mental health services was suggested to be a crucial factor for improving the depression outcomes in primary care [3], [6]. Past meta-analyses on this issue showed that collaborative care models were indeed more effective than treatment as usual, promoting better depression and health-related outcomes for patients suffering from depressive disorders [7], [8], [9].

Collaborative care was first developed in the early 90s in the US, from the Wagner's Chronic Care Model [10] and, since then, has been tested in different health care contexts and diseases [11]. Using a broad, widely accepted definition, a collaborative care intervention is a multifaceted approach to patient care provided by a primary care physician (PCP) and a psychiatrist, in the context of the primary care setting [12]. Several definitions have been developed to include a large number of “active ingredients”, that is a wide range of interventions of varying intensity [13]. Generally, the PCP assumes responsibility for the patient's care whilst the case manager supports the patient's needs, enhancing and facilitating the communication with the PCP. Bower et al. [13] underlined how problematic it is to develop precise inclusion criteria for such complex interventions as it is not clear which features have to be placed in order to define an intervention as collaborative care. Trying to overcome this issue, Gunn et al. [14] proposed a recent definition in which features of collaborative care intervention were highly specified. Collaborative care was then defined as an approach that should include a structured management plan, scheduled patients follow-up and enhanced inter-professional communication (such as written feedback, team meetings, individual consultation/supervision) [14]. The main aims of collaborative care programmes are, to improve the accessibility of the mental health service, the communication between the PCP and the psychiatrist and the quality and outcomes of psychiatric treatment delivered in primary care [15]. Further, an active case management has been suggested as a key element of collaborative care to achieve more positive outcomes [3].

Most of the available evidence emerged from studies that were conducted within the United States (US). A recent Cochrane meta-analysis [9], found that collaborative care was significantly more effective than usual care in the treatment of depressed patients with small to medium effect sizes. Since the vast majority (76%) of comparisons were conducted in the US, the authors underlined the need for interpreting with caution the positive outcome replicated in the European and other non-US countries. A sensitivity analysis about this issue was not performed [9]. Indeed, a previous meta-analysis found that collaborative care was not significantly more effective among non-US countries [7]. Further, results from non-US studies were subject to much larger degrees of between-study heterogeneity compared to US studies (I², 85.7% vs. 5.4%) [7]. It is likely that at least part of the heterogeneity could be explained in terms of differences in the health care organizations and/or in the degree of fidelity to the original collaborative care model, as described by Katon and colleagues [12], [16]. The US health care system has a longstanding history of promoting integration and continuity of care, with the presence of a professional other than the PCP acting as a case manager in the primary care context. In the US model, case management consists of: assessing and identifying patients in need of treatment, providing psychoeducation, actively following up patients, developing a treatment plan and monitoring patient adherence to psychological and/or pharmacological treatments, coordinating care and adjusting treatment plan when unsuccessful and delivering psychological support to improve treatment adherence.

In Europe, where the increasing integration has reduced differences between countries in a variety of economic sectors, the organization and provision of health care still tends to be relatively dissimilar: the level and type of professional training or background vary among primary care physicians, nursing and other disciplines in extended primary care have been developed to quite different degrees, and organizationally, primary care has been structured in a host of different arrangements. In almost half of the European countries, general practice is still solo practice and cooperation and coordination between PCPs and medical specialists are often problematic [17]. Nevertheless, the need for integration between primary care, hospitals, specialist care and social care is universal. Some changes have been made to adapt the collaborative care model to European countries, where often the role of the case manager appears less central. A number of interventions, in fact, aimed to potentiate PCPs' role without additional personnel [18], [19], [20] or to support them with professional figures other from nurse case manager [21], [22], [23].

The lack of evidences of effectiveness for the collaborative care model in countries other than the US, together with the increasing number of recent European studies comparing this models to usual care [7], [9], requires an up to date review and meta-analysis specifically focused on the European context. Therefore, the fist aim of this study was to assess whether the collaborative care models, developed and delivered in European countries, are more effective than the usual PCPs' care. The secondary aims, a priori planned, were: 1) to assess whether the collaborative care effectiveness varies according to the degree of fidelity to Gunn et al.'s [14] definition, as the studies included adhere to a broad definition of collaborative care [12]; 2) to evaluate whether differences in the strength of primary care – according to Kringos et al.'s [17] international comparative study – have an impact on the effectiveness of the collaborative care models delivered; and 3) to assess possible differences among UK vs. non-UK/European collaborative care models, considering the great emphasis given by the UK National Health Service on the organization of the primary care.