Heather Burroughs

A randomised controlled trial to test the feasibility of a collaborative care model for the management of depression in older people.

BACKGROUND Depression is the most common mental health disorder in people aged over 65 years. Late-life depression is associated with chronic illness and disability. AIM To investigate the feasibility of a collaborative care model for depression in older people in a primary care setting. DESIGN OF STUDY Randomised controlled trial with 16-weeks follow up. SETTING A primary care trust in Manchester. METHOD Participants were 105 people aged 60 years or older who scored 5 or more on the Geriatric Depression Scale; 53 were randomly allocated to an intervention group and 52 to a usual care group. The intervention group received care managed by a community psychiatric nurse who delivered an intervention comprising a facilitated self-help programme with close liaison with primary care professionals and old-age psychiatry according to a defined protocol. The usual care group received usual GP care. A nested qualitative study explored the views of the health professionals and patients regarding the acceptability and effectiveness of the intervention. RESULTS The main outcome measure was recovery from depression. Patients in the intervention group were less likely to suffer from major depressive disorder at follow up compared with usual care (0.32, 95% confidence = interval = 0.11 to 0.93, P = 0.036). The qualitative component of the study demonstrated the acceptability of the intervention to patients. CONCLUSION A model of collaborative care for older people with depression, used in a primary care setting with a facilitated self-help intervention is more effective than usual GP care. This study demonstrates that the implementation of a collaborative care model is feasible in UK primary care and that the intervention is effective and acceptable to patients.

Saturation in qualitative research: exploring its conceptualization and operationalization

Saturation has attained widespread acceptance as a methodological principle in qualitative research. It is commonly taken to indicate that, on the basis of the data that have been collected or analysed hitherto, further data collection and/or analysis are unnecessary. However, there appears to be uncertainty as to how saturation should be conceptualized, and inconsistencies in its use. In this paper, we look to clarify the nature, purposes and uses of saturation, and in doing so add to theoretical debate on the role of saturation across different methodologies. We identify four distinct approaches to saturation, which differ in terms of the extent to which an inductive or a deductive logic is adopted, and the relative emphasis on data collection, data analysis, and theorizing. We explore the purposes saturation might serve in relation to these different approaches, and the implications for how and when saturation will be sought. In examining these issues, we highlight the uncertain logic underlying saturation—as essentially a predictive statement about the unobserved based on the observed, a judgement that, we argue, results in equivocation, and may in part explain the confusion surrounding its use. We conclude that saturation should be operationalized in a way that is consistent with the research question(s), and the theoretical position and analytic framework adopted, but also that there should be some limit to its scope, so as not to risk saturation losing its coherence and potency if its conceptualization and uses are stretched too widely.

Researching the mental health needs of hard-to-reach groups: managing multiple sources of evidence.

BackgroundCommon mental health problems impose substantial challenges to patients, carers, and health care systems. A range of interventions have demonstrable efficacy in improving the lives of people experiencing such problems. However many people are disadvantaged, either because they are unable to access primary care, or because access does not lead to adequate help. New methods are needed to understand the problems of access and generate solutions. In this paper we describe our methodological approach to managing multiple and diverse sources of evidence, within a research programme to increase equity of access to high quality mental health services in primary care.MethodsWe began with a scoping review to identify the range and extent of relevant published material, and establish key concepts related to access. We then devised a strategy to collect - in parallel - evidence from six separate sources: a systematic review of published quantitative data on access-related studies; a meta-synthesis of published qualitative data on patient perspectives; dialogues with local stakeholders; a review of grey literature from statutory and voluntary service providers; secondary analysis of patient transcripts from previous qualitative studies; and primary data from interviews with service users and carers.We synthesised the findings from these diverse sources, made judgements on key emerging issues in relation to needs and services, and proposed a range of potential interventions. These proposals were debated and refined using iterative electronic and focus group consultation procedures involving international experts, local stakeholders and service users.ConclusionsOur methods break new ground by generating and synthesising multiple sources of evidence, connecting scientific understanding with the perspectives of users, in order to develop innovative ways to meet the mental health needs of under-served groups.

Improving access to psychosocial interventions for common mental health problems in the United Kingdom: narrative review and development of a conceptual model for complex interventions.

BackgroundIn the United Kingdom and worldwide, there is significant policy interest in improving the quality of care for patients with mental health disorders and distress. Improving quality of care means addressing not only the effectiveness of interventions but also the issue of limited access to care. Research to date into improving access to mental health care has not been strongly rooted within a conceptual model, nor has it systematically identified the different elements of the patient journey from identification of illness to receipt of care. This paper set out to review core concepts underlying patient access to mental health care, synthesise these to develop a conceptual model of access, and consider the implications of the model for the development and evaluation of interventions for groups with poor access to mental health care such as older people and ethnic minorities.MethodsNarrative review of the literature to identify concepts underlying patient access to mental health care, and synthesis into a conceptual model to support the delivery and evaluation of complex interventions to improve access to mental health care.ResultsThe narrative review adopted a process model of access to care, incorporating interventions at three levels. The levels comprise (a) community engagement (b) addressing the quality of interactions in primary care and (c) the development and delivery of tailored psychosocial interventions.ConclusionsThe model we propose can form the basis for the development and evaluation of complex interventions in access to mental health care. We highlight the key methodological challenges in evaluating the overall impact of access interventions, and assessing the relative contribution of the different elements of the model.

Community Engagement in a complex intervention to improve access to primary mental health care for hard‐to‐reach groups

Despite the availability of effective evidence‐based treatments for depression and anxiety, many ‘harder‐to‐reach’ social and patient groups experience difficulties accessing treatment. We developed a complex intervention, the AMP (Improving Access to Mental Health in Primary Care) programme, which combined community engagement (CE), tailored (individual and group) psychosocial interventions and primary care involvement.

Development and evaluation of culturally sensitive psychosocial interventions for under-served people in primary care

BackgroundPsychological therapy is effective for symptoms of mental distress, but many groups with high levels of mental distress face significant barriers in terms of access to care, as current interventions may not be sensitive to their needs or their understanding of mental health. There is a need to develop forms of psychological therapy that are acceptable to these groups, feasible to deliver in routine settings, and clinically and cost effective.MethodsWe developed a culturally sensitive wellbeing intervention with individual, group and sign-posting elements, and tested its feasibility and acceptability for patients from ethnic minorities and older people in an exploratory randomised trial.ResultsWe recruited 57 patients (57% of our target) from 4 disadvantaged localities in the NW of England. The results of the exploratory trial suggest that the group receiving the wellbeing interventions improved compared to the group receiving usual care. For elders, the largest effects were on CORE-OM and PHQ-9. For ethnic minority patients, the largest effect was on PHQ-9. Qualitative data suggested that patients found the intervention acceptable, both in terms of content and delivery.ConclusionsThis exploratory trial provides some evidence of the efficacy and acceptability of a wellbeing intervention for older and ethnic minority groups experiencing anxiety and depression, although challenges in recruitment and engagement remain. Evidence from our exploratory study of wellbeing interventions should inform new substantive trial designs.Trial registrationCurrent controlled trials ISRCTN68572159

Aiming to improve the quality of primary mental health care: developing an intervention for underserved communities.

BackgroundThe purpose of the study was to improve the quality of primary mental healthcare in underserved communities through involvement with the wider primary care team members and local community agencies.MethodsWe developed training intended for all GP practice staff which included elements of knowledge transfer, systems review and active linking. Seven GP Practices in four localities (North West England, UK) took part in the training. Qualitative evaluation was conducted using thirteen semi-structured interviews and two focus groups in six of the participating practices; analysis used principles of Framework Analysis.ResultsStaff who had engaged with the training programme reported increased awareness, recognition and respect for the needs of patients from under-served communities. We received reports of changes in style and content of interactions, particularly amongst receptionists, and evidence of system change. In addition, the training program increased awareness of – and encouraged signposting to - community agencies within the practice locality.ConclusionsThis study demonstrates how engaging with practices and delivering training in a changing health care system might best be attempted. The importance of engaging with community agencies is clear, as is the use of the AMP model as a template for further research.

Achieving target recruitment in a primary care trial: lessons from PRIDE

Background: Failure to reach recruitment targets is a widespread problem in RCTs (randomized controlled trials). This paper presents experience of recruiting patients into the PRIDE trial which was carried out in one Primary Care Trust (PCT) in the North West of England. Aim: The aim of this feasibility study was to test the effectiveness of a new model of care for the management of late-life depression. Method: GPs (general practitioners), PNs (practice nurses) and community nurses were invited to refer patients into the study. Over 100 patients were needed (at least 50 in each arm of the trial) for the study to be sufficiently powered. On-target recruitment of over 100 patients over 18 months was achieved. Findings: Data obtained from conversations and from semi-structured interviews with health professionals is presented to give possible explanations for this successful recruitment. Not all practices in the PCT engaged with the study, and the most common reasons given by GPs and their staff for non-participation was being single handed or already having a heavy work-load. All community nurses spoken to agreed to refer patients to the study but only five referrals were made by this group over the course of the study. The main reasons primary care professionals did agree to participate and continue to refer patients was that they felt the trial was offering a local and relevant service to an under-served patient group. The very simple referral process was also an important factor. In addition, the Trial Nurse was perceived to be responsive, responding quickly to referrals made and providing regular and detailed feedback which was perceived to help and support the health professionals in the future management of the patient.

Medically unexplained symptoms: continuing challenges for primary care.

Bodily symptoms are common in community samples, but not all people consult for medical advice about such symptoms. Medically unexplained symptoms (MUS) refer to persistent bodily complaints for which adequate examination (including investigation) does not reveal sufficiently explanatory structural or other specified pathology.1 MUS are common, with a spectrum of severity, and patients are found everywhere within the healthcare system.2 It has been estimated that MUS account for up to 45% of all general practice consultations,3 while a study based in secondary care indicated that about 50% of patients had no clear diagnosis at 3 months.2 The annual NHS cost for MUS in adults of working age in England was estimated to be £2.89 billion in 2008/2009 (approximately 10% of total NHS expenditure on these services for the working age population), while sickness absence and decreased quality of life for people with MUS was estimated as costing over £14 billion per annum to the UK economy.4 Although the costs to the NHS and the economy are important considerations, the personal cost to the patient can also be significant. Patients often experience stress, distress, and anxiety because of their unexplained symptoms. They report feeling that their concerns are not taken seriously by their doctor, which can exacerbate the presentation of somatic symptoms. The suggestion that ‘negative test results means that nothing is wrong’ is cited as the most common explanation given by doctors,5 but patients can feel that their symptoms are not believed, and may disengage from health care (including for other …

Lifetime and current costs of supporting young adults who deliberately poisoned themselves in childhood and adolescence

Background: Little is known about the long-term economic consequences of child and adolescent mental health problems, despite concerns that costs in later life may be significant. Aims: To evaluate current and lifetime costs of young adults who deliberately poisoned themselves in childhood. Method: Prospective cohort study of 129 young adults (mean age 21) who as teenagers had taken part in a randomized trial following deliberate self-poisoning. Lifetime and current costs of public sector services were calculated and compared to those of a matched general population control group. Results: The self-poisoning group incurred significantly greater lifetime costs than the controls. They used more service-provided accommodation, special education and hospital services, incurred greater criminal justice costs and received more social security benefits. Higher costs in the self-poisoning group were significantly associated with conduct disorder, hopelessness, previous suicide attempts, being male and being in care prior to the self-poisoning event. Conclusions: Child and adolescent mental health problems predict significant costs compared to general population controls. This study provides indications of those groups of young people who incur high costs and for whom early intervention should be considered.