PHASE: a randomised, controlled trial of supervised self-help cognitive behavioural therapy in primary care. Changes in psychological diagnosis and prescription in a practice employing a counsellor. Evaluation of a primary care counselling service in Dorset. Thirty-six month outcome data from a trial of counselling with chronically depressed patients in a general practice setting. Psychological treatment in general practice: its effect on patients and their families. Group therapy in a general practice setting for frequent attenders: a controlled study of mothers with pre-school children. Clinical psychologist in primary care: controlled clinical and economic evaluation. Evaluation of the short-term impact of counseling in general practice. Taking mental health services to the people: the effects of referral to traditional psychiatric facilities. Effectiveness of an intervention to reduce sickness absence in patients with emotional distress or minor mental disorders: a randomized controlled effectiveness trial. Clinical psychology in general practice: a controlled trial evaluation. Cost-effectiveness of treatments for major depression in primary care practice. Cluster randomised controlled trial of the effectiveness of primary care mental health workers. Dedicated psychiatric care within general practice: health outcome and service providers' views. A randomized controlled trial and economic evaluation of counselling in primary care. Randomized controlled trial of cognitive behaviour therapy for repeated consultations for medically unexplained complaints: a feasibility study in Sri Lanka. Cost-benefit analysis of a controlled trial of nurse therapy for neuroses in primary care. A randomised controlled trial and cost analysis of problem-solving treatment for emotional disorders given by community nurses in primary care. Assessing the impact of psychological intervention on family practice clinic visits. Referrals to the psychiatric services by general practitioners in relation to the introduction of sessions by psychiatrists in Health Centres. Randomised controlled trial of non-directive counselling, cognitive-behaviour therapy, and usual general practitioner care for patients with depression. II: cost effectiveness. A pragmatic, unblinded randomised controlled trial comparing an occupational therapy-led lifestyle approach and routine GP care for panic disorder treatment in primary care. Brief psychotherapy in family practice. A controlled prospective intervention trial. Cognitive therapy for major depressive disorder in primary care. Evaluation of a brief psychological treatment for emotional disorders in primary care.
Common mental health problems account for up to 40% of all general practitioner (GP) consultations. Patients have limited access to evidence-based psychological therapies. Cognitive behavioural therapy self-help strategies offer one potential solution.
                To determine differences in clinical outcome, patient satisfaction and costs, between a cognitive behavioural-based self-help package facilitated by practice nurses compared to ordinary care by GPs for mild to moderate anxiety and depression.
                Randomised controlled trial.
                Seventeen primary healthcare teams.
                Patients presenting to their GP with mild to moderate anxiety and/or depression were recruited to the study and randomised to receive either a self-help intervention facilitated by practice nurses or ordinary care. The self-help intervention consisted of up to three appointments: two 1 week apart and a third 3 months later. There were no restrictions on ordinary care.
                Intention-to-treat analysis showed that patients treated with practice nurse-supported cognitive behavioural therapy self-help attained similar clinical outcomes for similar costs and were more satisfied than patients treated by GPs with ordinary care. On-treatment analysis showed patients receiving the facilitated cognitive behavioural therapy self-help were more likely to be below clinical threshold at 1 month compared to the ordinary care group (odds ratio [OR] = 3.65, 95% confidence interval [CI] = 1.87 to 4.37). This difference was less well marked at 3 months (OR = 1.36, 95% CI = 0.52 to 3.56).
                Facilitated cognitive behavioural self-help may provide a short-term cost-effective clinical benefit for patients with mild to moderate anxiety and depression. This has the potential to help primary care provide a choice of effective psychological as well as pharmacological treatments for mental health problems. This study investigated the effect on consultation rates and psychotropic drug prescribing of employing a counsellor in a general practice. No major change was detected in the number of prescriptions for psychotropic drugs or the consultation rates during the years that counselling was available. An increase in the number of psychotropic drug prescriptions in the year after counselling was accounted for by a very small number of patients. Three years after counselling more than three-quarters of the patients who had been counselled were receiving no medical attention for psychiatric problems. This may either reflect the effect of counselling over a longer period or the natural history of the problems. Research into the effectiveness of counselling in primary care is rare. This study attempts to provide a thorough evaluation of the effects of a new counselling service introduced throughout Dorset.
                To evaluate the impact of counselling on client symptomatology, self-esteem, and quality of life. The effect of counselling on drug prescribing, referrals to other mental health professionals, and client and general practitioner (GP) satisfaction were also assessed.
                All new clients referred for counselling were asked to complete and return questionnaires before and after counselling. A total of 385 clients took part in the study. The first and second assessments were compared statistically. Clients were ascribed a psychiatric diagnosis using a simplified version of DSM-IIIR (Diagnostic and Statistical Manual of the American Psychiatric Association). GPs' views of the service were determined using a specially designed questionnaire. Drug data were obtained from the Prescription Pricing Authority and referral statistics from Dorset HealthCare National Health Service (NHS) Trust.
                The number of psychiatric symptoms and their severity were significantly reduced by counselling. There were no significant differences in the prescription of anxiolytic/hypnotic and anti-depressant medication between matched practices with and without counsellors. The presence of a counsellor did not affect the rate of referral to other mental health professionals. Clients and GPs valued the service highly.
                The Psychology Managed Counselling Service is an effective method of running a counselling service and is well received by both clients and GPs. Counselled clients improved significantly on several measures. Counsellors have been employed in general practice with little evidence of effectiveness in this setting. This randomized controlled trial examined long-term effectiveness of short-term counselling in general practice for patients with chronic depression, either alone or combined with anxiety. Participants were 181 patients recruited from nine general practitioners' (GP) practices in Derbyshire by screening consecutive attenders using the Beck Depression Inventory. Both the experimental and control group received routine GP treatment but the experimental group were also referred to the practice counsellor. Depression and social adjustment were measured at baseline, 6, 12, and 36 months. There was an overall significant improvement in the actual scores over time, but there were no significant differences between the two groups on any of the measures at either 6, 12, or 36 months. Although fewer experimental group patients were still 'cases' on the BDI than controls at 6 and 12 months, this difference disappeared at 36 months. There was no evidence to demonstrate a long-term effect of improved outcomes in those referred to counselling. Rates of consultations and prescriptions for patients referred to clinical psychologists, and for these patients' immediate families, were investigated for three-year periods both before and after referral. Patients and their children consulted more and had more medication prescribed before referral than control groups, this tendency being particularly prevalent in the year before referral. After the contact with the psychologist there was a decrease in all these indices in the short term, and there were long-term decreases in psychotropic drug prescriptions for patients and in both consultations and prescriptions for their children. The frequent attendance of women suffering from anxiety and depression is a common problem in general practice and the problems are often externalized through the women's children. A small controlled study was carried out in a general practice surgery to see whether demand for medical attention by mothers of pre-school children would decrease after they attended a discussion group. Twenty women who fulfilled the study criteria of more than double the national average consultation rate for their age group and of having at least one pre-school child, were sequentially allocated to a treatment or control group. The group therapy was held over two terms of 10 sessions, each of 90 minutes, and was led by a psychologist and a general practitioner. Consultation rates (including surgery visits, house calls and prescription requests) were recorded for five consecutive six-month periods before and after the intervention. At follow-up six months after the end of the treatment a significant reduction in consultation rate had been achieved and maintained by the treated group compared with the controls (P<0.01). This study shows the value of attending to the cause of frequent consultation as well as to the complaints presented. In a controlled, evaluated study of a behaviourally orientated clinical psychology service based in a health centre two randomised groups of patients were compared. Patients in the control group received usual primary care management; subject patients received the same, but in addition were able to consult a clinical psychologist in the health centre. Outcome was assessed by psychosocial and economic measures. These showed changes in favour of the subject condition, many of which were statistically significant. This paper describes the findings of a randomised controlled trial of the short-term impact of counseling in the general practice setting. Compared with patients who received usual advice from their general practitioner for acute problems such as relationship difficulties, anxiety and depression, those who received counseling from qualified counselors working within the primary health care context showed greater improvement in psychological health as measured by the General Health Questionnaire. Significantly fewer of those counselled were prescribed anti-depressant drugs by the general practitioners in the study, or were referred to psychiatrists or clinical psychologists for care. In addition those patients who attended sessions with the practice counselor were more likely to report that they were satisfied with their treatment and more expressed feelings of well-being. This study investigated the effects of establishing a locally integrated mental health team in a small New Zealand township (Mosgiel), by comparing it with a similar township (Port Chalmers) without such established services. The rate of referral for out-of-district public and private inpatient and outpatient care was taken as an inverse measure of the strength of community resources to cope with psychiatric problems at the local level. In terms of referrals for inpatient care it was found that increased locally available mental health services did not reduce the number of onward referrals. However, length of hospital stay was significantly less. The total number of referrals to Dunedin for outpatient care also showed no significant change over time. The effect in this instance seems to be qualitative in that the proportion of first time referrals decreased while referrals tended to increase. It was also found that the lack of community mental health teams resulted in more self referrals to private health care. The appropriateness of this development needs further investigation. The presence of such a team is associated with a refinement in general practitioner referring practices. The purpose of this study was to evaluate the effectiveness of an activating intervention designed to reduce sick leave duration in patients with emotional distress or minor mental disorders.
                In a 1.5-year randomized controlled trial, 194 patients with minor mental disorders received either an experimental intervention by social workers or general practitioners' usual care. The intervention focused on understanding causes, developing and implementing problem-solving strategies and promoting early work resumption. Outcome measures were sick leave duration, mental health and physical health (questionnaires included the Hospital Anxiety and Depression Scale, the Four-Dimensional Symptom Questionnaire and SF-36), all measured at baseline at and 3, 6 and 18 months later. Multilevel analyses were used to evaluate differences between groups.
                The groups did not differ significantly on any of the outcome measures, except that the experimental group reported higher satisfaction with treatment.
                Although the intervention has benefits, it was not successful at its primary goal (i.e., to reduce sick leave duration in patients with emotional distress or minor mental disorders). Programs aimed at the reduction of sick leave duration may yield better results if targeted at patients with more severe emotional problems than at those with exclusively emotional distress or minor mental disorders, or if delivered by caregivers who are closer to the work environment than are social workers, such as occupational physicians. A controlled trial study is described in which 50 consecutive potential referrals for psychological treatment from one general practice were randomly allocated either to behavioural treatment or no-treatment conditions. Treatment-group patients received treatment from a clinical psychologist working within the practice; the control-group patients continued to be managed by their general practitioner. The patients' use of NHS resources was assessed during the treatment period (or its equivalent for the control group) and at a follow-up comparison point, when the patients' subjective ratings of their progress were also obtained. Between referral and the end of treatment the treated group received significantly less psychotropic medication than the control group. This difference was not, however, maintained at the longer-term follow-up. No differences in general practice consultation rates, in the subjective ratings of psychological distress, in control orientation or life satisfaction were found between the two groups, but the level of patient satisfaction was high. Implications for the design of future studies and for psychological health care delivery systems are discussed. This study augments a randomized controlled trial to analyze the cost-effectiveness of 2 standardized treatments for major depression relative to each other and to the "usual care" provided by primary care physicians.
                A randomized controlled trial was conducted in which primary care patients meeting DSM-III-R criteria for current major depression were assigned to pharmacotherapy (where nortriptyline hydrochloride was given) or interpersonal psychotherapy provided in a standardized framework or a primary physician's usual care. Two outcome measures, depression-free days and quality-adjusted days, were developed using information on depressive symptoms over time. The costs of care were calculated. Cost-effectiveness ratios comparing the incremental outcomes with the incremental costs for the different treatments were estimated. Sensitivity analyses were performed.
                In terms of both economic costs and quality-of-life outcomes, patients assigned to the pharmacotherapy group did slightly better than those assigned to interpersonal psychotherapy. Both standardized therapies provided better outcomes than primary physician's usual care, but each consumed more resources. No meaningful cost-offsets were found. The incremental direct cost per additional depression-free day for pharmacotherapy relative to usual care ranges from $12.66 to $16.87 which translates to direct cost per quality-adjusted year gained from $11270 to $19510.
                Standardized treatments for depression lead to better outcomes than usual care but also lead to higher costs. However, the estimates of the cost per quality-of-life year gained for standardized pharmacotherapy are comparable with those found for other treatments provided in routine practice. Mental health issues are a core part of the work of primary care and are the second most common reason for consultations. There is some evidence that the quality of primary care mental health provision is variable.
                To evaluate the effectiveness of primary care mental health workers with regards to satisfaction with care, mental health symptoms, use of the voluntary sector, and cost effectiveness of care.
                Cluster randomised controlled trial.
                Practices in the Heart of Birmingham Primary Care Trust, Birmingham, England.
                Nineteen practices and 368 patients (18 to 65 years of age) with a diagnosis of a new or ongoing common mental health problem were recruited. Sixteen practices and 284 patients completed the trial.
                Patients in intervention practices had a higher mean level of general satisfaction than those in control practices (difference between group scores of 8.3, 95% confidence interval = 1.3 to 15.3, P = 0.023). The two groups did not differ in mental health symptom scores or use of the voluntary sector.
                For patients with common mental health problems, primary care mental health workers may be effective at increasing satisfaction with an episode of care. Health service reforms have led to relocation of care of the chronic mentally ill from institutions to the community, with subsequent demands on the primary health care team. Few studies have attempted to identify satisfactory models of care for this patient group. This study explores the impact of the employment of a community psychiatric nurse (CPN) by a general practice in Aberdeen city to co-ordinate care of discharged long-stay psychiatric patients resettled in hostels. A similar general practice with a comparable group of registered patients was selected as a control group. Patient health outcome was measured using the Health of the Nation Outcome Scales (HoNOS) and service providers' views on dedicated psychiatric care within general practice were explored using qualitative methods. Improvements in communication, liaison and drug management were reported in the intervention practice. A primary care-based CPN service dedicated to the care of the chronic mentally ill promoted a smooth transfer of care from long-term institutionalized care to the community setting. Counselling in primary care settings remains largely unevaluated. Such evaluation has been strongly recommended.
                To determine the relative effectiveness and cost-effectiveness of generic counselling and usual general practitioner (GP) care for patients with minor mental health problems.
                A randomized controlled trial and health economic evaluation were carried out in nine general practices. Access to generic counselling (brief counselling, generally involving up to six 50-minute sessions) was compared with usual GP care. A total of 162 patients aged 16 years and over with diverse mental health problems (excluding phobic conditions and psychoses) were randomized. The Hospital Anxiety and Depression (HAD) scale, COOP/WONCA (World Organization of Family Doctors) functional health assessment charts, and the delighted-terrible faces scale were used to assess outcome four months after randomization.
                The two groups were similar at baseline. There were significant improvements in both groups between randomization and follow-up for most outcome measures, but no significant differences between the study arms. The 95% confidence limits were narrow and excluded clinically significant effects. Under various assumptions concerning the cost of secondary care referrals and of counselling time, no clear cost advantage was associated with either intervention.
                This pragmatic trial demonstrates no difference in functional or mental health outcome at four months between subjects offered access to counselling and those given usual care by their GP. There is no clear difference in the cost-effectiveness of the two interventions. Purchasers should take account of these findings in allocating resources within primary care. Research on the management and the outcome of treatment of medically unexplained symptoms is very limited. Development of simple but effective techniques for treatment and demonstration of their effectiveness when applied in primary health care are needed.
                A randomized controlled trial was carried out with follow-up assessments at 3 months after baseline assessments using the Short Explanatory Model Interview (SEMI), General Health Questionnaire (GHQ-30), Bradford Somatic Inventory (BSI) and patient satisfaction on a visual analogue scale. The study was carried out in a general out-patient clinic in Sri Lanka. The intervention group received six, 30 min sessions based on the principles of cognitive behavioural therapy over a period of 3 months. The control group received standard clinical care.
                Eighty patients out of the 110 patients referred, were eligible. Sixty-eight were randomly allocated equally to the control and treatment groups. All 34 in the treatment group accepted the treatment offer and 22 completed between three and six sessions. At 3 months, 24 in the treatment and 21 in the control group completed follow-up assessments. Intention-to-treat analysis revealed significant differences in mean scores of outcome measures (adjusted for baseline scores) between control and intervention groups respectively--complaints 6.1 and 3.8 (P = 0.001), GHQ 10.4 and 6.3 (P = 0.04), BSI score 15.6 and 132 (P < 0-01), visits 7.9 and 3.1 (P = 0.004).
                Intervention based on cognitive behavioural therapy is feasible and acceptable to patients with medically unexplained symptoms from a general out-patients clinic in Sri Lanka. It had a significant effective in reducing symptoms, visits and distress, and in increasing patient satisfaction. In a randomized, controlled trial neurotic patients (mainly phobics and obsessive-compulsives) in primary care were assigned to behavioural psychotherapy from a nurse therapist or to routine care from their general practitioner. At the end of one year clinical outcome was significantly better in patients cared for by the nurse therapist. Economic outcome to one year, compared with the year before entering the trial, showed a slight decrease in the use of resources by the nurse therapist group (N = 22), and an increase in resource usage in the GP-treated group (N = 28), mainly due to the latter's increased absence from work and more hospital treatment and drugs. On the reasonable assumptions that nurse therapists treat 46 patients a year and that such patients treated behaviourally maintain their gains for 2 years, the economic benefits to society from nurse therapists treating such patients may outweigh the costs. This excludes any monetary value on the substantial clinical gains such as reduction in fear and anxiety. However, the numbers are small, few economic differences were significant, and many patients either did not complete the trial or waiting-list periods or they failed to return economic data. Conclusions must thus be tempered with caution, even though pre-treatment demographic and clinical data of non-returners were comparable with those of returners, and though the few drop-outs who could be rated at one year had not improved. The findings cannot be extrapolated to other types of clinical problem and treatment. We set out to investigate whether community nurses could be trained in problem-solving therapy and, once trained, how effective they would be in treating emotional disorders in primary care.
                Seventy patients with an emotional disorder in primary care were randomly allocated to receive either problem-solving therapy from a trained community nurse or treatment as usual from their general practitioner. Interview and self-rated assessments of clinical and economic outcome were made pretreatment, at eight weeks and at 26 weeks after treatment.
                There was no difference in clinical outcome between patients who received problem-solving treatment and patients who received the general practitioner's usual treatment. However, patients who received problem-solving treatment had fewer disability days and fewer days off work. The health care cost of problem-solving was greater than that of the general practitioner's usual treatment but this was more than offset by savings in the cost of days off work.
                Problem-solving treatment can be given by trained community nurses. The clinical effectiveness and cost-benefit of the treatment will depend on the selection of appropriate patients. The effects of brief psychological intervention on rates of medical utilization were investigated in a family practice clinic. Patients referred to the psychology service served as experimental subjects. These subjects underwent psychological assessment and treatment from supervised clinical psychology externs in joint working arrangements with family practice residents. Control subjects were other family practice patients, matching the experimental group in age, sex, and race. The number of medical visits to the family practice clinic, specialty clinics, and the emergency room were the dependent measures. The study period was two years. Results indicated that the experimental subjects were more likely than control subjects to decrease medical utilization of the family practice clinic. The findings are consistent with earlier work showing an association between brief psychosocial intervention and decreases in the frequency of clinic visits. However, this study suggests that preinternship-level clinical psychology trainees can be equally as effective in providing this intervention as mental health professionals who have completed their training. nan To compare the cost effectiveness of general practitioner care and two general practice based psychological therapies for depressed patients.
                Prospective, controlled trial with randomised and patient preference allocation arms.
                General practices in London and greater Manchester.
                464 of 627 patients presenting with depression or mixed anxiety and depression were suitable for inclusion.
                Usual general practitioner care or up to 12 sessions of non-directive counselling or cognitive-behaviour therapy provided by therapists.
                Beck depression inventory scores, EuroQol measure of health related quality of life, direct treatment and non-treatment costs, and cost of lost production.
                197 patients were randomly assigned to treatment, 137 chose their treatment, and 130 were randomised only between the two psychological therapies. At four months, both non-directive counselling and cognitive-behaviour therapy reduced depressive symptoms to a significantly greater extent than usual general practitioner care. There was no significant difference in outcome between treatments at 12 months. There were no significant differences in direct costs, production losses, or societal costs between the three treatments at either four or 12 months. Sensitivity analyses did not suggest that the results depended on particular assumptions in the statistical analysis.
                Within the constraints of available power, the data suggest that both brief psychological therapies may be significantly more cost effective than usual care in the short term, as benefit was gained with no significant difference in cost. There are no significant differences between treatments in either outcomes or costs at 12 months. Treated anxiety increased in the UK by over 30% since 1994. Medication and psychological treatment is most common, but outcomes are sometimes poor, with high relapse rates. Lifestyle has a potential role in treatment, but is not considered in clinical guidelines. Panic disorder is potentially influenced by lifestyle factors.
                16 week unblinded pragmatic randomised controlled trial in 15 East of England primary care practices (2 Primary Care Trusts). Participants met DSM-IV criteria for panic disorder with/without agoraphobia. Follow-up at 20 weeks and 10 months. Control arm, unrestricted routine GP care. Trial Arm, Occupational therapy-led lifestyle treatment comprising: lifestyle review of fluid intake, diet pattern, exercise, caffeine, alcohol and nicotine; negotiation of positive lifestyle changes; monitoring and review of impact of changes. Primary outcome measure: Beck Anxiety Inventory.
                Intention-to-treat analysis provided between-group comparisons using analysis of co-variance. Bonferroni method to adjust p-values.
                From 199 referrals, 36 GP care and 31 lifestyle arm patients completed to final follow-up. Significantly lower lifestyle arm BAI scores at 20 weeks (p<0.001), non-significant (p=0.167) at 10 months after Bonferroni correction. 63.6% lifestyle arm, and 40% GP arm patients (p=0.045) panic-free at 20 weeks; 67.7% and 48.5% (p=0.123) respectively at 10 months.
                Final study size/power calls for caution in interpreting findings.
                A lifestyle approach may provide a clinically effective intervention at least as effective as routine GP care, with significant improvements in anxiety compared with routine GP care at the end of treatment. Further study is required before suggesting practice changes. In a prospective (controlled) trial, the result in 18 patients receiving eight, weekly half-hour sessions of brief problem-oriented dynamic psychotherapy was compared with the result in an equal number receiving eight, weekly half-hour sessions of family practitioner therapy and in another 20 receiving no additional therapy. The subjects were drawn from patients at ten suburban family practices in Sydney. They had had psychological complaints for at least six months. No differences between the three treatment groups were found in the final outcome, either in a symptom severity and social dysfunction factor or in a physical disability and medication factor. Cognitive therapy for depression is a psychological treatment designed to train patients to identify and correct the negative depressive thinking which, it has been hypothesised, contributes to the maintenance of depression. General practice patients meeting Research Diagnostic Criteria for primary major depressive disorder were randomly allocated either to continue with the treatment they would normally receive (which in the majority of cases included antidepressant medication) or to receive, in addition, sessions of cognitive therapy. At completion of treatment, patients receiving cognitive therapy were significantly less depressed than the comparison group, both on blind ratings of symptom severity made by psychiatric assessors and on a self-report measure of severity of depression. At three-month follow-up cognitive therapy patients no longer differed from patients receiving treatment-as-usual, but this was mainly as a result of continuing improvement in the comparison group. A randomized trial in general practice compared: (i) a brief psychological treatment (problem-solving) given by a psychiatrist; (ii) any treatment of the GP's choice, whether psychological or pharmacological. The patients had recent onset emotional disorders of poor prognosis. Patients in the problem-solving group showed significantly greater reductions in symptoms. Problem-solving as given by a psychiatrist was feasible in primary care and acceptable to patients. Problem-solving is now being evaluated as given by general practitioners trained in the method.
This review provides some evidence that MHWs working in primary care to deliver psychological therapy and psychosocial interventions cause a significant reduction in PCP behaviours such as consultations, prescribing, and referrals to specialist care. However, the changes are modest in magnitude, inconsistent, do not generalise to the wider patient population, and their clinical or economic significance is unclear.