Collaborative care for depression and anxiety problems

280 Pages·2013·2.4 MB·English

Collaborative care for depression and anxiety problems
(Review)
Archer J, Bower P, Gilbody S, Lovell K, Richards D, Gask L, Dickens C, Coventry P
ThisisareprintofaCochranereview,preparedandmaintainedbyTheCochraneCollaborationandpublishedinTheCochraneLibrary
2012,Issue10
http://www.thecochranelibrary.com
Collaborativecarefordepressionandanxietyproblems(Review)
Copyright©2012TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
PLAINLANGUAGESUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Figure1. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Figure2. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Figure3. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Figure4. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
AUTHORS’CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
CHARACTERISTICSOFSTUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
DATAANDANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 224
Analysis1.1. Comparison 1Collaborative careversus’usualcare’(adults), Outcome1Improvementindepression
symptoms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 228
Analysis1.2.Comparison1Collaborativecareversus’usualcare’(adults),Outcome2Depressionresponse. . . . 236
Analysis1.3.Comparison1Collaborativecareversus’usualcare’(adults),Outcome3Antidepressantmedicationuse. 248
Analysis 1.4. Comparison 1 Collaborative care versus ’usual care’ (adults), Outcome 4 Improvement in anxiety
symptoms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 252
Analysis1.5.Comparison1Collaborativecareversus’usualcare’(adults),Outcome5Anxietyresponse. . . . . . 253
Analysis1.6.Comparison1Collaborativecareversus’usualcare’(adults),Outcome6Anxietymedicationuse. . . 254
Analysis1.7.Comparison1Collaborativecareversus’usualcare’(adults),Outcome7MentalQoL. . . . . . . 255
Analysis1.8.Comparison1Collaborativecareversus’usualcare’(adults),Outcome8PhysicalQoL. . . . . . . 257
Analysis1.9.Comparison1Collaborativecareversus’usualcare’(adults),Outcome9Patientsatisfaction. . . . . 259
Analysis1.10.Comparison1Collaborativecareversus’usualcare’(adults),Outcome10Patientsatisfaction. . . . 260
Analysis2.1.Comparison2Collaborativecareversus’usualcare’(adolescents),Outcome1Depressionsymptoms. . 261
Analysis2.2.Comparison2Collaborativecareversus’usualcare’(adolescents),Outcome2Depression. . . . . . 262
Analysis2.3.Comparison2Collaborativecareversus’usualcare’(adolescents),Outcome3Antidepressantmedication
use. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 263
Analysis2.4.Comparison2Collaborativecareversus’usualcare’(adolescents),Outcome4MentalQoL. . . . . 264
Analysis2.5.Comparison2Collaborativecareversus’usualcare’(adolescents),Outcome5PhysicalQoL. . . . . 265
Analysis2.6.Comparison2Collaborativecareversus’usualcare’(adolescents),Outcome6Patientsatisfaction. . . 265
Analysis3.1.Comparison3Collaborativecareversusfeedback(adults),Outcome1Depression. . . . . . . . 266
Analysis4.1.Comparison4Collaborativecareversusconsultationliaison(adults),Outcome1Depression. . . . . 266
Analysis5.1.Comparison5Collaborativecareplusconsultationliaisonversuscollaborativecare(adults),Outcome1
Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 267
Analysis6.1.Comparison6Collaborativecareversusenhancedreferral(adults),Outcome1Depressionsymptoms. . 267
Analysis7.1.Comparison7Collaborativecare(psychotherapy)versuscollaborativecare(medication)(adults),Outcome1
Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
Analysis8.1.Comparison8Collaborativecarepluspsychotherapyversuscollaborativecare(adults),Outcome1Depression
symptoms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 268
Analysis8.2. Comparison 8 Collaborative care pluspsychotherapy versuscollaborative care (adults), Outcome 2
Depression. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 269
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 275
CONTRIBUTIONSOFAUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276
DECLARATIONSOFINTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276
Collaborativecarefordepressionandanxietyproblems(Review) i
Copyright©2012TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
SOURCESOFSUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 276
DIFFERENCESBETWEENPROTOCOLANDREVIEW . . . . . . . . . . . . . . . . . . . . . 277
INDEXTERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 277
Collaborativecarefordepressionandanxietyproblems(Review) ii
Copyright©2012TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
[InterventionReview]
Collaborative care for depression and anxiety problems
JanineArcher1,PeterBower2,SimonGilbody3,KarinaLovell1,DavidRichards4,LindaGask5,ChrisDickens6,PeterCoventry7
1SchoolofNursing,MidwiferyandSocialWork,TheUniversityofManchester,Manchester,UK.2NIHRSchoolforPrimaryCare
Research,ManchesterAcademicHealthScienceCentre,InstituteofPopulationHealth,UniversityofManchester,Manchester,UK.
3Department of Health Sciences, University of York, York, UK. 4School of Psychology, University of Exeter,Exeter,UK. 5Health
Sciences Research Group, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK. 6Institute of
HealthServicesResearch,PeninsulaCollegeofMedicineandDentistry,Exeter,UK.7NIHRCollaborationforLeadershipinApplied
Health Research and Care for Greater Manchester, Manchester Academic Health Science Centre, Institute of Population Health,
UniversityofManchester,Manchester,UK
Contactaddress:JanineArcher,SchoolofNursing,MidwiferyandSocialWork,TheUniversityofManchester,JeanMcFarlaneBuilding
(Room6.304),OxfordRoad,Manchester,Manchester,M139PL,[email protected].
Editorialgroup:CochraneDepression,AnxietyandNeurosisGroup.
Publicationstatusanddate:New,publishedinIssue10,2012.
Reviewcontentassessedasup-to-date: 9February2012.
Citation: Archer J, Bower P, Gilbody S, Lovell K, Richards D, Gask L, Dickens C, Coventry P. Collaborative care
for depression and anxiety problems. Cochrane Database of Systematic Reviews 2012, Issue 10. Art. No.: CD006525. DOI:
10.1002/14651858.CD006525.pub2.
Copyright©2012TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
ABSTRACT
Background
Common mentalhealthproblems,suchasdepressionandanxiety, areestimatedtoaffectupto15% oftheUKpopulation atany
onetime,andhealthcaresystemsworldwideneedtoimplementinterventionstoreducetheimpactandburdenoftheseconditions.
Collaborativecareisacomplexinterventionbasedonchronicdiseasemanagementmodelsthatmaybeeffectiveinthemanagementof
thesecommonmentalhealthproblems.
Objectives
Toassesstheeffectivenessofcollaborativecareforpatientswithdepressionoranxiety.
Searchmethods
WesearchedthefollowingdatabasestoFebruary2012:TheCochraneCollaborationDepression,AnxietyandNeurosisGroup(CC-
DAN)trialsregisters(CCDANCTR-ReferencesandCCDANCTR-Studies)whichincluderelevantrandomisedcontrolledtrials(RCTs)
fromMEDLINE (1950 topresent),EMBASE(1974 topresent),PsycINFO (1967 topresent)andtheCochrane CentralRegister
ofControlledTrials(CENTRAL,allyears);theWorldHealthOrganization (WHO)trialsportal(ICTRP); ClinicalTrials.gov; and
CINAHL(toNovember2010only).Wescreenedthereferencelistsofreportsofallincludedstudiesandpublishedsystematicreviews
forreportsofadditionalstudies.
Selectioncriteria
Randomisedcontrolledtrials(RCTs)ofcollaborativecareforparticipantsofallageswithdepressionoranxiety.
Collaborativecarefordepressionandanxietyproblems(Review) 1
Copyright©2012TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Datacollectionandanalysis
Twoindependentresearchersextracteddatausingastandardiseddataextractionsheet.Twoindependentresearchersmade’Riskofbias’
assessmentsusingcriteriafromTheCochraneCollaboration.Wecombinedcontinuousmeasuresofoutcomeusingstandardisedmean
differences(SMDs)with95%confidenceintervals(CIs).Wecombineddichotomousmeasuresusingriskratios(RRs)with95%CIs.
Sensitivityanalysestestedtherobustnessoftheresults.
Mainresults
Weincludedseventy-nine RCTs (including90relevantcomparisons) involving 24,308 participants inthereview. Studiesvariedin
termsofriskofbias.
The resultsof primary analysesdemonstrated significantly greater improvementindepression outcomes for adultswith depression
treatedwiththecollaborativecaremodelintheshort-term(SMD-0.34,95%CI-0.41to-0.27;RR1.32, 95%CI1.22to1.43),
medium-term(SMD-0.28,95%CI-0.41to-0.15;RR1.31,95%CI1.17to1.48),andlong-term(SMD-0.35,95%CI-0.46to-
0.24;RR1.29,95%CI1.18to1.41).However,thesesignificantbenefitswerenotdemonstratedintotheverylong-term(RR1.12,
95%CI0.98to1.27).
Theresultsalsodemonstratedsignificantlygreaterimprovementinanxietyoutcomesforadultswithanxietytreatedwiththecollaborative
caremodelintheshort-term(SMD-0.30,95%CI-0.44to-0.17;RR1.50,95%CI1.21to1.87),medium-term(SMD-0.33,95%
CI-0.47to-0.19;RR1.41,95%CI1.18to1.69),andlong-term(SMD-0.20,95%CI-0.34to-0.06;RR1.26,95%CI1.11to
1.42).Nocomparisonsexaminedtheeffectsoftheinterventiononanxietyoutcomesintheverylong-term.
Therewasevidenceofbenefitinsecondaryoutcomesincludingmedicationuse,mentalhealthqualityoflife,andpatientsatisfaction,
althoughtherewaslessevidenceofbenefitinphysicalqualityoflife.
Authors’conclusions
Collaborative care is associated with significant improvement in depression and anxiety outcomes compared with usual care, and
representsausefuladditiontoclinicalpathwaysforadultpatientswithdepressionandanxiety.
PLAIN LANGUAGE SUMMARY
Collaborativecareforpeoplewithdepressionandanxiety
Manypeoplesufferfromdepressionandanxiety.Theseproblemscanmakepeoplefeelsad,scaredandevensuicidal,andcanaffect
theirwork,theirrelationshipsandtheirqualityoflife.Depressionandanxietycanoccurbecauseofpersonal,financial,socialorhealth
problems.
‘Collaborativecare’isaninnovativewayoftreatingdepressionandanxiety.Itinvolvesanumberofhealthprofessionalsworkingwith
apatienttohelpthemovercometheirproblems.Collaborativecareofteninvolvesamedicaldoctor,acasemanager(withtrainingin
depressionandanxiety),andamentalhealthspecialistsuchasapsychiatrist.Thecasemanagerhasregularcontactwiththeperson
andorganisescare,togetherwiththemedicaldoctorandspecialist.Thecasemanagermayofferhelpwithmedication,oraccesstoa
‘talkingtherapy’tohelpthepatientgetbetter.
Collaborativecarehasbeentestedwithpatientsinanumberofcountriesandhealthcaresystems,butitisnotclearwhetheritshould
berecommendedforpeoplewithdepressionoranxiety.
Inthisreviewwefound79randomisedcontrolledtrials(RCTs)(90comparisons)including24,308patientsworldwide,comparing
collaborative care with routine care or alternative treatments (such as consultation-liaison) for depression and anxiety. There were
problemswiththemethodsinsomeofthestudies.Forexample,themethodsusedtoallocatepatientstocollaborativecareorroutine
carewerenotalwaysfreefrombias,andmanypatientsdidnotcompletefollow-uporprovideinformationabouttheiroutcomes.Most
ofthestudiesfocusedondepressionandtheevidencesuggeststhatcollaborativecareisbetterthanroutinecareinimprovingdepression
foruptotwoyears.Asmallernumberofstudiesexaminedtheeffectofcollaborativecareonanxietyandtheevidencesuggeststhat
collaborativecareisalsobetterthanusualcareinimprovinganxietyforuptotwoyears.Collaborativecareincreasesthenumberof
patientsusingmedicationinlinewithcurrentguidance,andcanimprovementalhealthrelatedqualityoflife.Patientswithdepression
andanxietytreatedwithcollaborativecarearealsomoresatisfiedwiththeirtreatment.
Collaborativecarefordepressionandanxietyproblems(Review) 2
Copyright©2012TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
BACKGROUND Ithasbeenrecognisedthatimprovingthetreatmentofcommon
mental health problems is a very complex task which requires
changestothewaycareisprovided,togetherwithadditionalre-
sourcestodeveloptheappropriatesystemstoenableprimarycare
Descriptionofthecondition professionalstodeliverhighqualitycare(Gilbody2003a;Katon
1997;Katon2001).Fourdistinctmodelsofqualityimprovement
Commonmentalhealthproblems,suchasdepressionandanxi-
incommonmentalhealthproblemshavebeenidentified:training
ety,arehighlyprevalentwithestimatesofupto15%oftheUK
primarycarestaff,consultation-liaison,replacement/referral,and
population affectedatany onetime(NICE 2011a).Thepreva-
collaborativecare(Bower2005).
lenceofindividualcommonmentalhealthdisordersvariesconsid-
Thecollaborativecaremodelisbasedontheprinciplesofchronic
erably.Theone-weekprevalenceratesfromtheOfficeofNational
diseasemanagementappliedtoconditionssuchasdiabetes.The
Statistics2007nationalsurveywere4.4%forgeneralisedanxiety
modelcaninvolvealargenumberofdifferentinterventionsinclud-
disorder,3.0%forpost-traumatic stressdisorder (PTSD), 2.3%
ing:screening,educationofpatients,changesinpracticeroutines,
fordepression,1.4%forphobias,1.1%forobsessivecompulsive
and developments in information technology (Wagner 1996).
disorder(OCD),and1.1%forpanicdisorder(McManus2009).
Collaborativecaremodelsareexemplarsof’complexinterventions’
Worldwide,depressionaffectsabout154millionpeople,andan
whichconsistofanumberofseparateelements,wheretheparticu-
estimated5.8%ofmenand9.5%ofwomenwillexperienceade-
larelementsthatfunctionasthe‘activeingredient’canbedifficult
pressiveepisodeinanygivenyear(WHO2001a).
toidentify(MedicalResearchCouncil2008).
Depressionandanxietyareamajorcauseofdiseaseburdenand
Theterm’collaborativecare’wasfirstusedtodescribeaninterven-
disability(Ustun2004)withdepressionprojectedtobecomeone
tionwhichwasdeliveredbyaprimarycareproviderandapsychi-
ofthethreeleadingcausesofburdenofdiseaseby2030(Mathers
atrist(Katon1995a).However,therehavebeensignificantdevel-
2006).Symptomsofdepressioninclude:depressedmood;lossof
opmentsinthemodelsincethattime,andthusclearspecification
interestorpleasureinactivities;insomniaorsleepingtoomuch;
ofthemeaningof theterminlinewith currentthinking isim-
andfatigueorlossofenergy.Symptomsofanxietydifferbutcan
portant.Awidelyaccepteddefinitionofcollaborativecareusedin
include:excessiveworry;feelingtenseorrestless;significantten-
asystematicreviewofcomplexsysteminterventionsrequiresthat
sioninmuscles;andirritability(APA2000).Theimpactofboth
fourkeycriteriaaremet:amulti-professionalapproachtopatient
disordersonsocialandoccupationalfunctioning,physicalhealth
care,structuredmanagementplan,scheduledpatientfollow-ups,
and mortality is alsosubstantial (Ormel1999), and often anxi-
andenhancedinter-professionalcommunication(Gunn2006).
etyanddepressionpresenttogether,disablingthepersonfurther
(NICE2011a).Depressionalsoaccountsfortwo-thirdsofallsui-
cides(Sartorius2001).
Depressionandanxietyareoftenchronicinnature,characterised Howtheinterventionmightwork
byhighratesofrelapseandrecurrence.Followingtheirfirstepisode
Researchhassuggestedthatakeyaspectofeffectivecollaborative
of depression, atleast50% of peoplewillgo ontohaveone or
careis’casemanagement’(Gilbody2003a).Casemanagementhas
morefurtherepisode(s),withtheriskofrelapseincreasingto70%
beendescribedasahealthworkertakingresponsibilityforproac-
afterthesecondepisode,andashighas90%afterathirdepisode
tively following up patients, assessing patient adherence to psy-
(Kupfer1991).
chological and pharmacological treatments, monitoring patient
progress, taking action when treatmentis unsuccessful, and de-
liveringpsychologicalsupport(VonKorff2001).Casemanagers
workcloselywiththeprimarycareprovider(whoretainsoverall
Descriptionoftheintervention
clinicalresponsibility)andcanreceiveregularsupervisionfroma
Itisestimatedthatupto90%ofpatientsdiagnosedwithdepres- mentalhealthspecialist(Gilbody2003a;Katon2001).
sionandanxietyaretreatedsolelyinprimarycare(NICE2011a).
However,themanagementofthesedisordersisoftensuboptimal
(NHS2002).Themostcommonmethodoftreatmentforcom-
Whyitisimportanttodothisreview
monmentalhealthdisordersinprimarycareispsychotropicmed-
ication(NICE2011a).Thereareproblemswiththisapproach,as Collaborativecareisamodelofcareforcommonmentalhealth
patientsdonottakethemedicationasprescribedforavarietyof problemswhichhasgeneratedworldwideinterestinitseffective-
reasonsincludingfearsofaddiction,dependencyandsideeffects nessandcost-effectiveness.Althoughanumberofreviewsofcol-
(Lingam2002).Careforpatientswithchronicproblemslikede- laborativecarehavebeenpublished,significantuncertaintiesre-
pression is often not proactive; patients do not receive ongoing main.ManytrialsarefromtheUnitedStates,andtheirgeneralis-
monitoring and care designed to reduce the burden of disorder abilitytoothercontextsandhealthcaresystemsisunclear.Effec-
andthelikelihoodofrecurrenceandrelapse(Buszewicz2011). tivenessmayvarybypatientpopulation;collaborativecarewasnot
Collaborativecarefordepressionandanxietyproblems(Review) 3
Copyright©2012TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
recommended by the National Institute for Clinical Excellence Comorbidity: Trial participants could also have long-term con-
(NICE)fordepression(NICE2010)oranxiety(NICE2011b), ditions(i.e.asthma,diabetes,chronicobstructivepulmonarydis-
but was recommended for depression in patients with chronic ease),aswellasacommonmentalhealthproblem.
disease(NICE2009).Theevidencebaseforcollaborativecareis Setting:Trialparticipantscouldbeidentifiedinavarietyofhealth-
alsorapidlydeveloping.MentalhealthpolicyintheUKhighlights care settings (excluding in-patient/specialist mental health),but
theimportanceofpatientchoiceintreatmentsformentalhealth the intervention had to be predominantly delivered in primary
problems,andcollaborativecarecouldprovideanotheroptionfor careorcommunitysettings.
servicestocomplementotherproventreatments.Thisreviewwill
consolidatethedevelopingbodyofevidenceoncollaborativecare
Typesofinterventions
andprovideanup-to-dateandrigorousassessmenttoinformpol-
icyandpractice.
Experimentalintervention
Thisreviewhasadoptedfourkeycollaborativecarecriteria(Gunn
2006). We regarded studies as collaborative care studies if they
OBJECTIVES
fulfilledthefollowingcriteria.
Thisreviewaimstoevaluatetheeffectivenessofcollaborativecare 1. Amulti-professionalapproachtopatientcare.Aprimary
fordepressionandanxiety. careprovider(generalpractitioner,familyphysician,primary
carephysicianoraspecialistprovidingundifferentiatedmedical
care)andatleastoneotherhealthprofessional(e.g.nurse,
METHODS psychologist,psychiatrist,orpharmacist)orparaprofessionalis
involvedwithpatientcare.Forthepurposesofthecurrent
review,wecharacterisedprimarycareasmedicalcareinvolving
Criteriaforconsideringstudiesforthisreview firstcontactandongoingcaretopatients,regardlessofthe
patient’sage,genderorpresentingproblem(Boerma1999;
WHO2001b).
Typesofstudies 2. Astructuredmanagementplan.Introductionofan
We included all randomised controlledtrials (RCTs), including organisedapproachtopatientcareincludingaccesstoevidence
cluster-RCTs. basedmanagementinformationintheformofguidelinesor
protocols.Managementincludedeitherorbothpharmacological
(e.g.antidepressantmedication)andnon-pharmacological
Typesofparticipants
interventions(e.g.patientandprovidereducation,counselling,
Participantcharacteristics: Trial participantswereeithermaleor orcognitivebehaviourtherapy(CBT)).
femalepatientsofanyage. 3. Scheduledpatientfollow-ups.Anorganisedapproachto
Diagnosis:Trialparticipantshadaprimarydiagnosisofdepression patientfollow-updefinedasoneormorescheduledtelephoneor
(including:acute,chronic,persistent,remitted,subthresholdand in-personfollow-upappointmentstoprovidespecific
postnatal)oranxiety(including:generalisedanxiety,panic,post- interventions,facilitatetreatmentadherence,ormonitor
traumaticstressdisorder(PTSD),phobias,socialanxiety,health symptomsoradverseeffects.
anxietyandobsessivecompulsivedisorder(OCD)).Diagnosisof 4. Enhancedinter-professionalcommunication.Introduction
trialparticipantswasaccordingtooneofthefollowing:1)diagno- ofmechanismstofacilitatecommunicationbetween
sismadebyprimarycareprovider;2)ResearchDiagnosticCriteria professionalscaringforthepatient,includingteammeetings,
(RDC), Diagnostic and Statistical Manual (DSM) (APA 2000) caseconferences,individualconsultation/supervision,shared
or International Classification of Diseases (ICD) (WHO 1992) medicalrecords,andpatient-specificwrittenorverbalfeedback
criteria;or3)assessmentthroughself-ratedorclinician-ratedvali- betweencare-givers.
datedinstruments,e.g.PatientHealthQuestionnaire9(PHQ-9)
(Kroenke2001),BeckDepressionInventory(BDI)(Beck1987)
and/orBeckAnxietyInventory(BAI)(Beck1988).Somestudies Comparatorinterventions
included a mixed population, of which only a proportion were Weincludedstudiesthatcomparedcollaborativecarewith’usual
depressedoranxious(e.g.wherestudiesincludedamixofpatients care’(forexample,routineprimarycare,waitinglists,oruntreated
whowereat-riskdrinking,suicidalordepressed).Thesewerein- groups identified through screening) or collaborative care with
cludedonlyifthemajority(>=50%)ofparticipantsweredepressed otherinterventions.
and/oranxious, toensurethattheresultsofthestudyrelatedto Based on analysis of studies identified in the review, we distin-
ourtargetgroup. guishedthefollowingthreetypesofusualcare.
Collaborativecarefordepressionandanxietyproblems(Review) 4
Copyright©2012TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
1. Studiesthatprovidednoadditionalinterventioninthe • Qualityoflife,e.g.ShortFormHealthSurvey(SF-36,SF-
usualcaregroup,includingnonotificationofpatientdepression 12)(Ware1993).
status. • Patientsatisfaction,e.g.ClientSatisfactionQuestionnaire
2. Studiesthatprovidedadditionalinterventionsintheusual (CSQ)(Attkinson2003).
caregroup(suchaseducationofprimarycareproviders,or
notificationofpatientdepressionstatus),butwheretheseaspects
Timingofoutcomeassessment
oftheinterventionwereappliedtobotharms,andpotentially
Wecategorisedoutcomesasshort-term(0to6months),medium-
cancelledout.
term(7to12months),long-term(13to24months),andvery
3. Studiesthatenhancedusualcarebyprovidingan
long-term(25monthsormore).Weroundeddownstudiesthat
interventionthatthecollaborativecarearmdidnotreceivee.g.
reportedunconventionalfollow-uppoints(e.g.27weeks).
whereonlyprimarycarecliniciansintheusualcarearmreceived
trainingandeducationalmaterialsondepressionevaluationand
treatment(Asarnow2005).
Searchmethodsforidentificationofstudies
Based on analysis of studies identified in the review, we distin-
guishedthefollowingthreetypesof‘activecomparisons’.
1. ‘Alternativeinterventions’suchasfeedbackalone,
CCDAN’sSpecialisedRegister
consultation-liaisonandenhancedreferral,whichwerecompared
withcollaborativecare. TheCochrane Collaboration Depression, Anxiety andNeurosis
2. ’Enhancementsofcollaborativecare’suchascollaborative Group (CCDAN) maintain two clinical trials registers at their
careplusconsultation-liaison,andcollaborativecareplus editorial baseinBristol,UK;areferencesregister andastudies-
psychotherapy,whichwerecomparedwithcollaborativecare. based register. The CCDANCTR-References Register contains
3. ‘Modelsofcollaborativecareinterventions’suchas over29,500reportsoftrialsindepression,anxietyandneurosis.
collaborativecare(medication)versuscollaborativecare Approximately65%ofthesereferenceshavebeentaggedtoindi-
(psychotherapy),whichwerecompareddirectly. vidual,codedtrials.ThecodedtrialsareheldintheCCDANCTR-
StudiesRegisterandrecordsarelinkedbetweenthetworegisters
throughtheuseofuniqueStudyIDtags.Codingoftrialsisbased
Typesofoutcomemeasures
ontheEU-Psicodingmanual.Furtherdetailsareavailablefrom
Whererelevant(i.e.fortheeffectsofcollaborativecareondepres- theCCDANTrialsSearchCo-ordinator(TSC).Reportsoftrials
sion)wereportedbothcontinuous anddichotomous outcomes. for inclusion in the registers are collated from routine (weekly)
Fordichotomousoutcomes,studiesgenerallyreportedeither‘re- genericsearchesofMEDLINE(1950topresent),EMBASE(1974
sponse’outcomes(i.e.a≥50%reductioninsymptomscoresfrom topresent),andPsycINFO(1967topresent);quarterlysearchesof
baseline)or’remission’(patientsateachtimepointwithscoresun- theCochraneCentralRegisterofControlledTrials(CENTRAL);
deraparticularthreshold).Forconsistency,wereportedresponse andreviewspecificsearchesofadditionaldatabases.Reportsoftri-
outcomeswherepossible. alsarealsosourcedfrominternationaltrialsregistersc/otheWorld
Health Organization’s (WHO’s) trials portal (ICTRP) (http://
apps.who.int/trialsearch/),drugcompanies,thehandsearchingof
Primaryoutcomes
keyjournals,conferenceproceedings,andother(non-Cochrane)
Changeindepressionoranxiety,asmeasuredbyobserverorpatient
systematicreviewsandmeta-analyses.
self-report.
DetailsofCCDAN’sgenericsearchstrategiescanbefoundonthe
Group‘swebsite.
Secondaryoutcomes
• Medicationfordepressionand/oranxiety.Thiswas Electronicsearches
reportedastheproportionofpatientsusingmedication,
WesearchedtheCCDANregisters(to9thFebruary2012)using
proportionsmeetingpredefinedlevelsofuse,orproportionswith
thefollowingterms.
‘appropriate’useaccordingtoguidelinesorothermeasures.Such
1.CCDANCTR-Studies
datacouldbebasedonadministrativedataorpatientself-report.
Condition=(depress*ordysthymi*oranxietyoranxiousorpanic
Wepooleddatarelatingtoratesofuseandadherence,and
or*phobi*orobsessi*orcompulsi*orpost-traumatic)and
administrativedataandself-report.
Intervention=(“caremanag*”or“casemanage*”orcollaborat*or
Weincludedthefollowingoutcomesonlywhenavalidatedtool ”diseasemanag*“or“enhancedcare”or“managedcare”ormul-
wasused. ticomponentormulti-componentormultidisciplinaryormulti-
• Socialfunctioning,e.g.SocialAdaptationSelf-evaluation disciplinaryorstepped)
Scale(SASS)(Bosc1997). 2.CCDANCTR-References
Collaborativecarefordepressionandanxietyproblems(Review) 5
Copyright©2012TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
TheCCDANCTR-ReferencesRegisterwassearchedusingamore Selectionofstudies
sensitivesetoftermstoidentifyadditionaluntagged/uncodedref-
Tworeviewauthors(JAandPB)independentlyscannedtheiden-
erences:
tifiedstudiesandexcludedstudiesaccordingtothecriteriaabove,
1. (depress* or dysthymi* or anxiety or anxious or *phobi* or
onthebasisoftitlesandabstracts.Weretrievedfullcopiesofthe
PTSDorpost-trauma*or“posttrauma*”orpostrauma*orpanic
studiesdeemedeligiblebyoneoftheteam(JA)forcloserexamina-
orOCDorobsessi*orcompulsi*orGAD)[ti,ab,kw]
tion.Iftherewasuncertaintyordisagreement,wereachedconsen-
2.((collaborat*orcoordinat*orco-ordinat*orsharedorintegrat*
susbydiscussionandconsultationwithanotherreviewauthor(PB,
orsteppedorsystematic)AND(careorhealthcareor“healthcare”
DRorSG).Alogofallstudieswhichinitiallyappearedtomeet
orworkingorintervention*orserviceormodeloreffort*orman-
theinclusioncriteriabutwhichwelaterexcludedonretrievalof
age*))[free-text]
thefull-textaredetailedintheCharacteristicsofexcludedstudies
3.((augment*orenhance*)AND(care*orhealthcareor“health
tables.Wekeptarecordofthereasonsforexclusion.
care”orcommunicat*))[free-text]
4.(“caremanage*”or”casemanage*“or“chroniccare*”or“com-
plexintervention*”or“cooperativebehav*”or“co-operative be- Dataextractionandmanagement
hav*” or “joint working” or pathway or interprofessional or in-
ContentdatawereextractedbyJA,DR,KLandLGanddouble-
ter-professionalorinterdisciplinaryorinter-disciplinaryormulti-
extractedbyresearchassistants/associates.Outcomedatawereex-
disciplin*ormulti-disciplin*ormultiprofession*ormulti-profes-
tractedbyPBandresearchassistants.Astandardiseddataextrac-
sion*ortransdisciplin*ortrans-disciplin*ormultifacet*ormulti-
tionformwasusedforthefollowingcharacteristics.
facet*or“complexintervention*” or“multipleintervention*”or
1. Thepatientpopulation(demographicandclinical
multi-intervention*or“organisationalintervention*”or“organi-
characteristics).
zationalintervention*”or“interpersonalrelation*”or“inter-per-
2. Thenatureoftheintervention(e.g.typesofinterventions
sonalrelation*”or“interinstitutionalrelation*”or“inter-institu-
used,contactbetweenpatientandprofessional,andamountof
tionalrelation*”or“consultationliaison”oralgorithm*or“treat-
collaborationbetweenprofessionals).
mentguideline*”or“treatmentprotocol*”or“treatmentdelivery”
3. Internalvalidity(assessmentofriskofbias).
or“treatmentmodel”oradherenceorcomplianceorconcordance
4. Externalvalidity(contextofrecruitmentandmethodsof
or“patientcareteam”or“patientcaremanagement”or“patient
recruitment).
careplanning”or“casemanagement”or“managedcareprogram*”
Wepresentedanalysesusingthefollowingstructure.Intheanal-
or“deliveryofhealthcare”or“continuityofpatientcare”or“pro-
ysisof primary outcomes wedistinguished allcollaborative care
fessional-patient relations”or “interprofessional relations”)[free-
interventions,separatingstudiesbydiagnosis(depressionandanx-
text]
iety)andage(adolescentsandadults).Thereforeanalyses1.1,1.2
5.(1and(2or3or4))
and1.3reportoutcomesfordepressioninadults,analyses1.4,1.5
3.CINAHL(1982to11thNovember2010)
and1.6reportoutcomesforanxietyinadultsandanalyses2.1,2.2
We conducted an additional search on CINAHL (Cumulative
and2.3reportoutcomesfordepressioninadolescents.Nostudies
IndextoNursingandAlliedHealth)(searchstrategyinAppendix
reportedanxietyoutcomesinadolescents.
1).
We separately analysed primary outcomes reported as dichoto-
4.InternationalTrialRegisters
mousoutcomesandascontinuous outcomes. Eachtypeofout-
WealsocarriedoutsearchesontheWHOtrialsportal(ICTRP)
comewasreportedatfourtimeperiods:0to6months,7to12
andClinicalTrials.govtoidentifyongoingorunpublishedstudies
months,13to24months,and25+months.
usingtheterms:
Forthesecondaryoutcomeofmedicationuse,weappliedthesame
(”steppedcare“or”collaborativecare“orinterprofessionalorin-
analyticalmethods.Themajorityofstudiesreportedmedication
terdisciplinaryormultidisciplinary).Weimportedandfilteredre-
use using dichotomous outcomes; weexcludedtheminority re-
sultsintoExcelusingtermsfordepressionandanxiety.
portingcontinuousoutcomes.
Forthesecondaryoutcomeofqualityoflife,wecombinedanal-
ysesacross collaborative care interventions for patients with de-
Searchingotherresources
pressionandanxiety.Themajorityofstudiesreportedqualityof
Wecheckedthereferencelistsofreportsofallincludedstudiesand
lifeusingcontinuousoutcomes;weexcludedtheminorityreport-
othersystematicreviewsforadditionalpublished,unpublishedor
ingdichotomousoutcomes.Wesplitqualityoflifeoutcomesinto
ongoingresearch.
mentalhealthqualityoflife(e.g.SF-36emotionalrole,SF-mental
componentscore),andphysicalhealthqualityoflife(e.g.SF-36
physicalfunctioning,SF-physicalcomponentscore).Weexcluded
measuresthatdidnotreportseparatementalhealthandphysical
Datacollectionandanalysis
healthdimensions(e.g.EQ5Doverallutility).
Collaborativecarefordepressionandanxietyproblems(Review) 6
Copyright©2012TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.
Forsatisfactionoutcomes,wecombinedanalysesacrosscollabora- For continuous outcomes, asarange ofdifferentmeasureswere
tivecareinterventionforpatientswithdepressionandanxiety.We used, we calculated standardised mean differences (SMDs) and
analysedsatisfactionoutcomesreportedasdichotomousoutcomes 95%CIs.
and continuous outcomes separately. We only reported a single
satisfactionoutcomepointforeachstudy,choosingtheoutcome
Unitofanalysisissues
closesttosixmonthsasthelikelybestindicatorofpatientexperi-
enceoftheintervention,unaffectedbymemoryorotherbias.
Aspartoftheprotocol,weintendedtoreportonsocialfunction
Cluster-randomisedcontrolledtrials
outcomes.However,averywidevarietyofsocialfunctionoutcome
measureswerereported,andtherewasalackofclarityovertheir Ascollaborativecareisanorganisationalintervention,clustertri-
definition,scope,andcomparability.Itwasthereforenotpossible alsarecommonlyusedasawayofavoidingbiasassociatedwith
toproducearigoroussynthesisinthetimeframeofthereview. contamination.Weidentifiedstudiesusingclusterrandomisation
Wehave extractedsocial function outcomes andmay reporton andweadjustedtheprecisionofanalysesbasedonthesestudiesin
theseinalaterupdateofthereviewwhenasuitabletypologyhas themeta-analysisusingthe‘effectivesamplesize’methodoutlined
beendevelopedtoensureconsistencyinanalysis. intheCochraneHandbookforSystematicReviewsofInterventions
(section16.3.4)(Higgins2011a).Wecalculatedtheeffectivesam-
plesizeofgroupsineachclustertrialonthebasisoftheoriginal
Assessmentofriskofbiasinincludedstudies samplesize divided by the‘designeffect’.Thedesign effectwas
Foreachincludedstudy,onereviewauthor(JA,PC,CDorDR) calculatedby1+(M-1)ICC, whereMrepresentstheaverage
and one research assistant/associate independently applied The clustersizeandICCistheintraclustercorrelationcoefficient.We
CochraneCollaboration’s’Riskofbias’tool(Higgins2011b).This assumedacommondesigneffectacrossgroups.Forthebaseanal-
toolencouragesconsiderationof: ysisweassumedanintra-classcorrelationof0.02(Adams2004).
1. selectionbiasduetoinadequategenerationofarandomised Weexaminedtheeffectofadjustmentforclusteringinasensitivity
sequence; analysis using intra-class correlations of0.00 and 0.05 (Donner
2. selectionbiasduetoinadequateconcealmentofallocations 2002).
priortoassignment;
3. performancebiasduetoknowledgeoftheallocated
Studieswithmultipletreatmentgroups
interventionsbyparticipantsandpersonnelduringthestudy
Wherestudiesreportedmultiplecollaborativecareinterventions
(blinding);
againstasinglecontrolweextractedeachcollaborativecareinter-
4. detectionbiasduetoknowledgeoftheallocated
ventionasaseparatecomparisonandenteredthemwhererelevant
interventionsbyoutcomeassessors(blinding);
inthemeta-analysis,dividingthecontrolgroupsamplesizeappro-
5. attritionbiasduetoamount,natureorhandlingof
priatelytoavoiddouble-countingintheanalysis.Whereastudy
incompleteoutcomedata;
reportedasinglecollaborativecareinterventionagainsttwodiffer-
6. reportingbiasduetoselectiveoutcomereporting;
enttypesofcontrols(individualandclustercontrols)wetreated
7. biasduetointegrityoftheintervention;and
thisastwoseparatecomparisons,dividingtheinterventiongroup
8. biasduetootherproblems,suchas:
• anypotentialsourceofbiasrelatedtothespecificstudy samplesizetoavoiddouble-countingintheanalysis.
designused;or
• claimstohavebeenfraudulent;or
Dealingwithmissingdata
• someotherproblem.
Wedistinguishedbetweentwotypesof‘loss’ofdata:patientswho
Weusedourcommentstoshowhowweassessedtheriskofbias, didnotcompletetheirassignedcollaborativecaretreatment(‘treat-
with judgements of either low risk of bias, unclear risk of bias, mentcompletion’)andpatientswhodidnotcompletefollow-up
orhighriskofbias.Iftherewasuncertaintyordisagreement,we forassessmentofoutcome(‘losstofollow-up’).
reached consensus by discussion and consultation with another For‘treatmentcompletion’,weassessedwhetherthestudyusedan
reviewauthor(PC). appropriate’intention-to-treat’analysis(includingallpatientsin
theanalysis irrespectiveof treatmentcompletion) or ‘perproto-
col’analysis(excludingpatientswhodidnotcompletetreatment
Measuresoftreatmenteffect
accordingtosomedefinedcriterion).Wedescribetheapproaches
Studiesinthereviewreportedbothdichotomous(e.g.recovered/ usedbyindividualstudiesinCharacteristicsofincludedstudies.
notrecovered)andcontinuous outcomes(suchaspatientscores Toassess’losstofollow-up’inincludedstudies,wealsocalculated
onself-reportedoutcomescales).Fordichotomousoutcomes,we theproportionofrandomised patients whowerelosttofollow-
calculatedriskratios(RRs)and95%confidence intervals(CIs). upatthe0to6month follow-upacrossarms,andwithineach
Collaborativecarefordepressionandanxietyproblems(Review) 7
Copyright©2012TheCochraneCollaboration.PublishedbyJohnWiley&Sons,Ltd.