On-site mental health workers delivering psychological therapy and psychosocial interventions to patients in primary care: effects on the professional practice of primary care providers

 

Abstract

Background

Mental health problems are common in primary care and mental health workers (MHWs) are increasingly working in this setting delivering psychological therapy and psychosocial interventions to patients. In addition to treating patients directly, the introduction of on-site MHWs represents an organisational change that may lead to changes in the clinical behaviour of primary care providers (PCPs).

Objectives

To assess the effects of on-site MHWs delivering psychological therapy and psychosocial interventions in primary care on the clinical behaviour of primary care providers (PCPs).

Search methods

The following sources were searched in 1998: the Cochrane Effective Practice and Organisation of Care Group Specialised Register, the Cochrane Controlled Trials Register, MEDLINE, EMBASE, PsycINFO, CounselLit, NPCRDC skill-mix in primary care bibliography, and reference lists of articles. Additional searches were conducted in February 2007 using the following sources: MEDLINE, EMBASE, PsycINFO, CINAHL, and Cochrane Central Register of Clinical Trials (CENTRAL) (The Cochrane Library).

Selection criteria

Randomised trials, controlled before and after studies, and interrupted time series analyses of MHWs working alongside PCPs in primary care settings. The outcomes included objective measures of PCP behaviours such as consultation rates, prescribing, and referral.

Data collection and analysis

Two review authors independently extracted data and assessed study quality.

Main results

Forty-two studies were included in the review. There was evidence that MHWs caused significant reductions in PCP consultations (standardised mean difference -0.17, 95% CI -0.30 to -0.05), psychotropic prescribing (relative risk 0.67, 95% CI 0.56 to 0.79), prescribing costs (standardised mean difference -0.22, 95% CI -0.38 to -0.07), and rates of mental health referral (relative risk 0.13, 95% CI 0.09 to 0.20) for the patients they were seeing. In controlled before and after studies, the addition of MHWs to a practice did not affect prescribing behaviour towards the wider practice population and there was no consistent pattern to the impact on referrals in the wider patient population.

Authors' conclusions

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.

 

Plain language summary

On-site mental health workers delivering psychological therapy and psychosocial interventions to patients in primary care: effects on the professional practice of primary care providers

Most people with mental health problems are treated by their family physician or general practitioner. Physicians will treat these problems, often without referral to mental health specialists, and at times the care is not consistent and could be improved.

This review investigated whether having mental health workers on-site to work with physicians at their offices would change the care that physicians provide. Forty-two studies were reviewed in which on-site mental health workers, such as counsellors or psychiatrists, worked alongside physicians to provide therapy to patients. The review found that when there were mental health workers on-site, patients may reduce the number of visits to their doctors; doctors may reduce how often they refer patients to off-site mental health specialists; doctors may reduce the number of drugs they prescribe to the patients who see the mental health workers; and the costs related to those drugs may be lower. However, these reductions were small and not found consistently in all the studies.

The review also found that there may be little or no difference in how the doctors prescribe drugs or refer patients who have mental health problems but are not seeing the on-site mental health workers. It is also not known what the effect of on-site mental health workers had on how well physicians recognised and diagnosed mental health problems.

 

摘要

背景

初級照護時現場的心理健康工作者提供病患心理治療及心理社會介入措施：對於初級照護提供者其專家實務的影響

心理健康問題在初級照護單位是常見的，而越來越多的心理健康工作者(MHWs)在此領域中工作以對病人提供心理治療和心理社會介入措施。除了直接治療病人以外，採用現場心理健康工作者可能造成初級照護提供者(primary care providers (PCPs))改變其臨床行為。

目標

評估現場心理健康工作者在初級照護單位提供心理治療及心理社會介入措施對初級照護提供者(primary care providers(PCPs))其臨床行為的影響。

搜尋策略

在1998年對下列來源進行全面檢索：Cochrane Effective Practice，Organisation of Care Group Specialised Register，the Cochrane Controlled Trials Register，MEDLINE，EMBASE，PsycINFO，CounselLit，NPCRDC skillmix in primary care bibliography，及文章的參考文獻。在2007年2月使用下列來源進行了更多的搜索：MEDLINE，EMBASE，PsycINFO，CINAHL，及Cochrane Central Register of Clinical Trials (CENTRAL) (The Cochrane Library)。

選擇標準

心理健康工作者(MHWs)與初級照護提供者(PCPs)在初級照護領域一起工作的隨機試驗，前後對照研究和間斷時間序列分析。結果包括客觀測量初級照護提供者的行為，如諮詢率，處方和轉診。

資料收集與分析

二名回顧作者分別摘錄資料並評估研究品質。

主要結論

42篇研究被納入這篇回顧。有證據指出，心理健康工作者會顯著減少病患對初級照護提供者的諮詢(standardised mean difference −0.17, 95% CI −0.30 to −0.05)，精神藥物處方(relative risk 0.67, 95% CI 0.56 to 0.79)，處方成本(standardised mean difference −0.22, 95% CI −0.38 to −0.07)，以及心理健康轉診率(relative risk 0.13, 95% CI 0.09 to 0.20)。前後對照研究指出，在初級照護單位，心理健康工作者的加入並不會影響其對更大範圍照護單位群的處方行為，且對更大範圍病患群的轉診行為的影響也未趨於一致。

作者結論

這篇回顧提供了一些證據顯示在初級照護單位工作的心理健康工作者，其提供心理治療和心理社會介入的措施可以顯著減少初級照護提供者的行為，如諮詢，處方，以及轉介到專科照護單位。然而，變化幅度不大，不一致，且無法外推到更大範圍的病患群，而且他們的臨床或經濟重要性尚不清楚。

翻譯人

本摘要由高雄榮民總醫院金沁琳翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

大多數人的心理健康問題是由他們的家庭醫生或一般科醫生處理。醫生治療這些問題時經常沒有轉介給心理健康專家，有時照顧並不一致而且尚有改進之處。本篇回顧研究，在醫生工作場所，有現場的心理健康工作者與醫生一起工作，是否將改變醫生提供的照護。本篇回顧了42篇有關現場心理健康工作者，如輔導員或精神科醫生，與醫生一起工作對患者提供治療的研究。回顧發現，當有心理健康工作者在現場，可以減少病人求診於醫生的次數，醫生也會減少轉介病人到非現場心理健康專家的頻率，醫生可能會減少有諮詢心理健康工作者之病人其處方藥物的數量，而且那些藥物的相關成本可能會比較低。然而，這些減少幅度是小的，且所有的研究中並未有一致性的發現。回顧還發現，對於那些有心理健康問題但是沒有諮詢現場心理健康工作者的病人而言，醫生的開處方藥物或轉介行為可能僅有很些微差異或根本沒有差異。目前也不知道現場心理健康工作者對醫師辨識和診斷心理健康問題的良窳的影響為何。