Background
Methods
Search methods
Study selection
Data extraction
Quality assessment
Data analysis
Results
RQ I—What structured communication tools are used in primary care for mental health consultations and what are common features or components in terms of intervention content and delivery?
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1. predictD Intervention. The intervention is the extension of the predictD tool that was developed to accurately predict the occurrence of major depression at twelve months, using data entered by patients regarding twelve risk factors (e.g. sex, age, childhood physical abuse, health-related quality of life) [25].As part of the intervention, primary care physicians attended training workshops on depression and how the predictD intervention applies to clinical case examples. Physicians offered three sessions to patients who scored at moderate to high risk on the predictD tool during which they provided a tailored bio-psycho-social intervention. Physicians are given a seven-item list of recommendations to activate and empower patients during those consultations. Additionally, patients are offered a booklet about preventing depression.
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2. Feedback/Feedback + counselling. Before attending their consultation, patients would fill in the General Health Questionnaire (GHQ) and a questionnaire about their current life stress, how well they had been coping with it and how much they felt the physician could help and what specific types of things they could do to help. The primary care physicians in the “feedback” intervention group were provided with patients’ GHQ score and an explanation of the probability of them having a mental health disorder.Physicians in the “counselling protocol” group were, additionally to the feedback, provided with a protocol which first listed questions to evaluate the stressful situation further and elucidate strategies patients use to cope in the past and present. Second, the protocol listed counselling interventions for the physician to choose, e.g. problem solving, restructuring patient attitudes, and effective coping strategies.
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3. Self-Efficacy Enhancing Interviewing Techniques (SEE IT). The intervention aims at teaching residents and primary care physicians interviewing techniques that would enhance patients’ self-efficacy in achieving health behaviour changes. SEE-IT consists of nine discreet components that are presented to the physicians as a process flow chart, i.e. the conversations start at “1. Solicit all of the patient’s concerns up front” and ends in “9. Negotiate when and how patient will follow-up with you on behaviour change progress”. Components 4, 5, and 7 have answer options which either skip components or move the conversation back to previous components. For example, “5. Assess confidence to take this step [towards the behaviour change goal]” can either be answered as “high” skipping ahead to component “8. Check for understanding of behaviour change plan” or “low” moving back to component “2. Negotiate behaviour change goal to focus on”.
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4. Problem-Solving Treatment in Primary Care (PST-PC). This is a brief, three session intervention targeting elderly patients with undiagnosed psychological problems. They are asked to complete the Hospital Anxiety and Depression Scale (HADS) prior to the consultation.Family medicine trainees have a proforma to complete HADS scores and symptoms, circle what they thought is the main psychological diagnosis, and record somatic symptoms and problems in living. Then the form would prompt them to “Ask the patient to identify their main problem” and rate it on a ten-point scale from very mild to extremely severe. Following this there was a six-step “solution plan” starting with “ask patient to think of possible solutions” and ending with “patient is to work on first step of their preferred solution and report progress to you”. The forms for the two follow-up sessions started by asking patients to rate the severity of their main problem again and answer two additional questions on what they have done to solve their problems since the last session and whether it was effective, before returning to the previous six-step plan. The authors reported that the sessions had three core tasks to achieve: “establishment of a positive therapeutic relationship, developing a shared understanding of the problem, and promoting change in behaviour, thoughts, and emotions” (p.971 [26]).
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5. Ultra-Brief Intervention (UBI). The authors describe this intervention as “guided, cognitive behavioural therapy-based self-management, with a focus on problem solving and behaviour change” (p.232 [27]). Patients were identified as having sub-threshold psychological distress by completing the Kessler-10 questionnaire. They were offered three sessions which were structured by a series of questions asked by the clinician in order to a) clarify the problem b) identify coping strategies c) create written plan of action d) and build motivation to carry out actions. Patients were given actions plans printed out as prescriptions and after the in-person sessions there would be one follow-up phone call or email.
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6. Shared Decision Making. This intervention introduced shared decision making into medication therapy management consultations between pharmacists and patients prescribed at least three medications. A conversation template with nine distinct steps was integrated into the electronic patient record. The template prompts started with eliciting patient concerns, preferences, values and goals, then move on to pharmacist assessment, patient and pharmacist identified solutions, a decision, communication of the plan, and lastly a follow-up. The initial step of patient reported concerns had pre-set options in a drop-down menu such as “medication cost” or “side effect”, as did the eighth step of “communication of plan”, e.g. “patient will take recommendation to provider” or “no action”.
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7. Reattribution. This was a structured cognitive approach for patients with diagnosed mental health disorders who presented with somatic symptoms in primary care during routine appointments. The two studies included in the review used a three- step model of reattribution which also contains several suggested sub-components. First step “feeling understood”: GPs would gain an understanding of patient’s complaint by taking a comprehensive history, responding to mood cues, exploring health beliefs and carrying out a physical examination. Second step “broaden the agenda”: GP would reframe physical complaint by summarising physical findings, acknowledge reality of complaint (e.g. pain), and reminding patient of other symptoms and life events. Lastly “Making the link”: GP would make the link between patient distress and physical complaint by explaining anxiety and depression, demonstrating the link practically, in terms of life events, or making explicit what is happening in the here and now or projecting onto a family member. A decade later, further refinement of the intervention led to the addition of a fourth step called “negotiating treatment” into the model [28].
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8. Peer Coaching. Veteran peer coaches would have up to four phone calls with veterans who screened positive for at least one mental health disorder but were not currently in treatment. Coaches would follow a motivational interviewing structure, after initial sharing of results of the mental health questionnaires. The target behaviour change was initiation of mental health treatment or, if that was achieved, treatment retention. Additional coaching language phrases around personal values and goals were also included.
Author(s), year of publication/country
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Design/ methods
|
Main objective
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Patient mental health criteria (n intervention vs control)
|
Staff profession (n)
|
Outcomes
|
Main findings
|
Quality (EPHPP/ CASP)
|
---|---|---|---|---|---|---|---|
RCT/ Quantitative | Can intervention delivered in primary care settings prevent depression | Moderate/high risk of depression (1663 vs 1663) | Primary care physicians (140) | Incidence of major depression; incidence of anxiety; cost-effectiveness | No difference in incidence of depression; lower incidence of anxiety in intervention group; very likely cost-effective | Strong | |
Brody et al. 1990 [29]/ USA | RCT/ Quantitative | Evaluate the impact of two types of interventions on the primary care physician's management of patients with mental health problems | Mental health problems, ≥ 3 on GHQ (29 vs 24 vs 50)a
| Internal medicine resident (60) | Patients: discussion of stress; compare pre-visit to post-visit attitudes about their stress; satisfaction with care; residents: care provided | More valuable stress counselling and more satisfied with their physician compared with control group; greater perceived reductions in the amount of stress and greater increases in their sense of control over stress; no difference in care provided by residents | Weak |
Collings et al. 2012 [30]/ New Zealand | Cohort/ Quantitative | Acceptability of ultra brief intervention | Mental health problems, > 35 on Kessler-10 (19) | GPs & nurses (6) | Patient & clinician satisfaction; psychological distress | High levels of acceptability; improvement in distress | Moderate |
Gask et al. 1989 [31]/ UK | Cohort/ Quantitative | Effectiveness of training in reattribution skills | Standardised patients (3) | GP trainees (22) | Increase in use of three steps of reattribution | Improvement in one step (“Making the Link”) | Moderate |
Jerant et al. 2009 [32]/ USA | RCT/ Quantitative | Effectiveness of intervention for training residents in SEE IT | Standardised patients (4) | Family medicine, internal medicine (64) | Use of SEE IT by residents; socio-demographic; training acceptability | Greater use of SEE ITs, training acceptable | Weak |
Jerant et al. 2016a [33]/ USA | RCT/ Quantitative | Effectiveness of intervention for training physicians in SEE IT | Standardised patients (6) | Family physicians, general internists (28 intervention vs 24 control) | Use of SEE IT; response to training | Greater use of SEE ITs; higher training value; similar low hassle | Weak |
Jerant et al. 2016b [34]/ USA | Case control/ Quantitative | Does exposure to SEE IT enhance patient self-efficacy and health behaviour change mediators | Mental health problems, ≥ 10 on PHQ-9 (131) | As above | Self-care self-efficacy; readiness for self-care of health conditions; health locus of control; socio-demographic; health indicator variables, depression symptoms | More favourable post-visit scores on a composite measure of five psychological HBCMs—driven by increased stage of readiness for self-care and reduced Chance health locus of control | Moderate |
Lam et al. 2010/ Hongkong [26] | RCT/ Quantitative | Effectiveness in improving quality of life and reducing consultation rates | Mental health problems, positive screen on HADS (149 vs 183 vs 150)a
| Family medicine trainees | HRQoL; mental health; consultation rate; trainees’ competences | Same improvement in HRQoL; same decrease in mental health severity; trainees used core techniques 90% of sessions | Moderate |
Mathieson et al. 2013 [35]/ New Zealand | Collaborative/ Qualitative | Develop brief intervention | Sub-threshold depression or anxiety (14) | Doctors & nurses (15) | n/a | CBT-based guided self-management approach; three sessions over 5 weeks | 7/9 criteria met |
Mathieson et al. 2012 [27]/ New Zealand | Cohort/ Mixed | Acceptability of ultra brief intervention for Maori population | Mental health problems, > 35 on Kessler-10 (22) | GPs & nurses (23) | Adaptations made; Patient & clinician satisfaction; psychological distress | Addition of Maori language and concepts to intervention; 56% completed intervention; positive feedback; improvement in distress | Weak |
Mathieson et al. 2019 [23]/ New Zealand | RCT/ Quantitative | Effectiveness of ultra brief Intervention In improving mental health and functioning | Mental health problems, > 35 on Kessler-10 (85 vs 75) | GPs (62 vs 50) | Psychological distress; anxiety/depression: work, social and relationship functioning | No difference in psychological distress & secondary outcomes; unable to achieve full recruitment to sample size | Moderate |
Montag Schafer et al. 2016 [24]/ USA | Cohort/ Mixed | Effectiveness, feasibility, acceptability of intervention | Diagnosed mental health disorder (20) | Pharmacists (8) | Patient & pharmacist satisfaction; number of drug therapy problems | Positive feedback from patients, mixed from pharmacists; average 2 DTP identified | Weak |
Morriss et al. 1998 [36]/ UK | Static group comparison/ Quantitative | Cost-effectiveness of training GPs in reattribution | Somatised mental health disorder & GHQ-12 > 3 (112 vs 103) | GPs (8) | Self-rated psychiatric symptoms; direct health costs | No difference in psychiatric cases; total costs reduced by 15% | Moderate |
Seal et al. 2021 [37]/ USA | RCT/ Mixed | Effectiveness in improving mental health treatment engagement among veterans | Screened positive for ≥ 1 mental health problem & not engaged in treatment (137 vs 135) | Veteran peer coaches (2) | Initiation of mental health treatment and retention; other care; mental health symptoms & QoL; patient experiences; fidelity | No difference in treatment initiation & retention; more intervention participants engaged in other activities; fewer MH symptoms, better QoL; fidelity was 3/5 | Moderate |
Training, supervision & fidelity
Bellon et al
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Brody et al
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Jerant et al
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Lam et al
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Mathieson et al
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Morriss et al
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Montag Schafer et al
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Seal et al
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Intervention |
predictD
Intervention
|
Feedback/ + Counselling
|
SEE-IT
|
PST-PC
|
UBI
|
Reattribution
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Shared Decision Making
|
Peer Coaching
|
Integrated into EPR |
?
|
x
|
x
|
x
| ✓ |
x
| ✓ |
x
|
Other materials | Patient booklet |
x
|
x
|
x
| Printed out action plans; three booklets |
x
|
?
|
x
|
GPs | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ |
x
|
x
|
Other profession |
x
|
x
|
x
|
x
|
x
|
x
| Pharmacists | Veteran peers |
Target population | Moderate to high risk for depression | Mental health problems | Not specified | Elderly with unrecognised psychological problems | Psychological distress | Somatised mental disorder | ≥ 1 mental health disorder; ≥ 3 medications | Veterans with ≥ 1 mental health conditions |
Orientation | Bio-psycho-family-social | Feedback/ Problem-solving, restructuring, coping strategies | Self-efficacy, MI, behavioural theories | Problem solving | Problem solving, MI, CBT | Bio-psycho-social | Shared decision making | MI, Coaching |
In-person/remote | In-person | In-person | In-person | In-person | In-person | In-person | In-person | Remote |
Consultation time | 10 min | ≤ 5 min | 20 min | 20-45 min | 30 min, 2 × 15 min | - | 30-60 min | 20-30 min |
Follow-up by clinician |
x
|
x
|
x
|
x
| Phone call/email |
x
| ✓ |
x
|
Self-report assessment | ✓ | ✓ |
x
| ✓ | ✓ |
x
| ✓ | ✓ |
Timing of self-assessment | Prior to consultation | Prior to consultation |
x
| Part of consultation | Prior to consultation |
x
| Part of consultation | Prior to consultation |
Conversation template | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ | ✓ |
Repeated sessions | ✓ |
x
|
x
| ✓ | ✓ |
x
|
x
| ✓ |
Actions/Goals/Plan |
?
|
?
| ✓ | ✓ | ✓ |
x
| ✓ | ✓ |
Training | 10-15 h | Brief one-to-one | 20 min × 3 | 9 h | 2 h | 8 h | Yes – no time given | Yes – no time given |
Training approach | Role-play; video comments; discussion | Overview of protocol; reading material | Standardised Patient visits; 7 min consultation; 13 min scripted teaching; visual aid | Three workshops; reading materials | Presentation; video demonstration; role-play practice; discussion; manual | Instructional video; detailed teaching; role play; video feedback in small group; written information | Overview of SDM theory & template | Not described |
Trainer |
?
| MD & clinical psychologist | Physician assistant | Clinical psychologist | Psychologist & PCP |
?
| Pharmacists & nurse practitioner | Psychologist |
Supervision/ Booster Training |
x
|
x
|
x
|
x
|
x
|
x
|
x
| ✓ |
RQ II. What is the evidence of effectiveness for mental health and quality of life outcomes?
Intervention
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Outcome (Measure)
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Time points of outcome measurement
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Intervention
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n
|
Control
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n
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Difference
(adjusted when available)
|
Stat. Sign
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---|---|---|---|---|---|---|---|---|
predictD Intervention
| New cases of depression (%; 95%CI) | 18m | 7.39 (5.85 to 8.95) | 1663 | 9.40 (7.89 to 10.92) | 1663 | -2.01 (-4.18 to 0.16) | 0.070 |
New cases of anxiety (%; 95%CI) | 10.4 (8.7 to 12.1) | 1484 | 13.1 (11.4 to 14.8) | 1514 | –2.7 (–5.1 to 0.3) | 0.029 | ||
Feedback/ + Counselling
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Changes in patient attitude about stress (mean, SE)
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Amount of stress | Post consultation | 3.8 (0.1)a / 3.6 (0.2)b
| 29a /24b
| 3.2 (0.1) | 50 | 0.003 | ||
Control over stress | 3.7(0.1)a/ 3.6 (0.2)b
| 3.1 (0.1) | 0.01 | |||||
Seriousness of stress | 3.5 (0.1)a / 3.4 (0.2)b
| 3.2 (0.1) | ns | |||||
Problem-solving – Primary Care
| Change in anxiety (95%CI) | 12m (6wks; 3m; 6m) | -1.17 (-1.84 to -0.51) | 149 | -1.58 (-2.09 to -1.07) | 150 | 0.41 (-0.14 to 0.96) | 0.146 |
Change in depression (95%CI) | 1.13 (0.39 to 1.88) | 1.4 (0.67 to 2.13) | 0.01 (-0.71 to 0.74) | 0.972 | ||||
Change in quality of life (95%CI)
| ||||||||
Physical functioning | 12m | -2.32 (-4.84,0.21) | -1.9 (-4.31,0.52) | -1.52 (-4.08, 1.03) | 0.243 | |||
Role Physical | 2.35 (-4.56,9.26) | 6.17 (-1.15,13.48) | -1.36 (-7.90, 5.19) | 0.685 | ||||
Bodily Pain | -1.11 (-5.7,3.47) | 7.37 (2.9,11.83) | -5.21 (-9.43, 0.99) | 0.016 | ||||
General Health | 2.46 (-1.46,6.38) | 2.35 (-1.47,6.18) | -1.90 (-5.87, 2.07) | 0.348 | ||||
Vitality | -2.18 (-6.05,1.69) | -0.9 (-4.45,2.65) | -2.00 (-5.72, 1.71) | 0.291 | ||||
Social Functioning | -1.76 (-6.62,3.09) | 2.67 (-1.76,7.09) | -4.21 (-8.26, -0.51) | 0.043 | ||||
Role Emotional | 3.13 (-4.88,11.14) | 10.89 (3.97,17.81) | -9.95 (-17.5, -2.39) | 0.010 | ||||
Mental Health | 0.86 (-2.31,4.03) | -0.4 (-3.31,2.51) | -0.60 (-3.68, 2.47) | 0.701 | ||||
Physical Component | -0.54 (2.18,1.09) | 0.8 (-0.96,2.56) | -1.48 (-3.25, 0.30) | 0.103 | ||||
Mental Component | 0.74 (-1.26 to 2.74) | 1.07 (-0.7 to 2.84) | -0.51 (-2.36 to 1.35) | 0.592 | ||||
Ultra-Brief Intervention
| Improvement in psychological distress (mean, 95%CI) | 6m (8wks; 3m) | 5.9 (4.0 to 7.8) | 70 | 7.6 (5.5 to 9.6) | 69 | 1.68 (− 1.18 to 4.55) | 0.255 |
Improvement anxiety& depression (mean, 95%CI) | 5.2 (3.5 to 6.9) | 7.0 (5.3 to 8.7) | 1.85 (− 0.62 to 4.31) | 0.149 | ||||
Veteran Peer Coaches
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Mental health symptoms (mean, SD)
| |||||||
PTSD | 16wks | 25.1 (18.4) | 137c
| 29.7 (16.7) | 135c
| 0.03 | ||
Depression | 9.4 (6.2) | 11.1 (6.5) | 0.01 | |||||
Anxiety | 1.2 (0.9) | 1.3 (0.8) | 0.19 | |||||
Panic disorder | 0.6(0.9) | 0.7 (0.9) | 0.21 | |||||
Alcohol and illicit substance use (mean, SD)
| ||||||||
Tobacco | 16wks | 8.8 (9.5) | 9.2 (10.0) | 0.73 | ||||
Alcohol | 7.1 (7.7) | 7.7 (8.6) | 0.46 | |||||
Cannabis […] | 3.1 (4.8) | 4.6 (6.7) | 0.01 | |||||
Quality of life (mean, SD)
| ||||||||
Physical health | 16wks | 12.6 (3.7) | 12.0 (3.1) | 0.06 | ||||
Psychological health | 13.4 (2.8) | 12.7 (2.5) | 0.004 | |||||
Social relationships | 13.3 (3.9) | 12.1 (3.8) | 0.003 | |||||
Environment | 14.4 (2.5) | 13.6 (2.6) | 0.004 |