What works?

In primary care, collaborative care described in the NICE guideline35 has been successful in the United States.36

It involves37:

  • Multi-professional approach to patient care provided by a case manager working with the family doctor under weekly supervision from specialist mental health medical and psychological therapies clinicians
  • A structured management plan of medication support and brief psychological therapy
  • Scheduled patient follow-ups
  • Enhanced inter-professional communication patient-specific written feedback to family doctors via electronic records and personal contact.

In diabetes:

  • Collaborative care reduces glycosylated haemoglobin as well as co-morbid depressed mood and systolic blood pressure38, and a recent meta-analysis has confirmed the positive effect on diabetes outcomes.38
  • Addressing psychological needs has been shown to improve glycosylated haemoglobin (HbA1c) by 0.5 to 1 per cent in adults with Type 2 diabetes.38-39
  • Improvements with psychological intervention include reduced psychological distress and anxiety; improved mood and quality of life; improved relationships with health professionals and significant others; and improved eating-related behaviours such as binge eating, purging and body image symptoms.40

With coronary heart disease:

  • Psycho educational interventions significantly reduce angina frequency and medication use and psychological wellbeing in patients with stable angina.41
  • NICE-approved psychological therapies have been shown to:
    • Improve the psychological, symptomatic and functional status of patients newly diagnosed with angina.42
    • Reduce hospital admissions in refractory angina patients.44
  • A very recent review44 found 16 trials of psychological and pharmacological interventions for depression co-morbid with CHD. There was a small but clinically meaningful effect of psychological interventions and SSRI antidepressants on depression outcomes in CHD patients but there were no effects on mortality rates or cardiac events.
  • In the year following the brief cognitive behavioural intervention for patients with chronic refractory angina43, patients exhibited 5-10 fewer inpatient bed days associated with cardiac admissions on average, and 0.75 fewer inpatient bed days associated with myocardial infarction.

Psychological needs of patients and carers exist with other long-term conditions including, for example:

  • Post-stroke, neurodegeneration, epilepsy, sickle cell disease, cancer, renal disorders HIV/AIDS, gastro-intestinal conditions
  • Evaluation of the promising efficacy of psychological therapies and economic arguments of actual or potential savings associated with provision of psychological care in these areas is being developed.47

In secondary care, liaison services have been shown to bring the following benefits48:

  • Improved patient self-management of their care
  • Assessment, engagement, formulation and treatment with reduced healthcare costs, of patients who may be reluctant to attend other mental health services and including those with physiologically explainable symptoms PES (‘MUS’)
  • Improved physical and mental health outcomes, e.g. improvement of clinical outcomes of depression49-50 which is an independent predictor of readmission at six months in the elderly51
  • Support with patients admitted to medical wards with severe anorexia nervosa who are at high risk from combined physical, psychological and behavioural problems
  • Improved return to independent living for the elderly52
  • Reduced stigma associated with mental health care
  • Advocacy directly for the physical care of those with mental health problems in acute services
  • Reduction in readmissions and length of stay53
  • Advice on, and where appropriate, management of complex issues to do with the Mental Health Act and Mental Capacity Act
  • Reduction in subsequent healthcare utilisation, including emergency care and clinic visits51
  • Improved mental health skills and wellbeing of staff in acute hospital settings
  • Assistance in  relieving the stress that staff often feel when dealing with patients with complex needs and this reducing levels of sickness absence

Liaison services aim to increase the detection, recognition and early treatment of impaired mental wellbeing and mental disorder to:

  • Reduce excess morbidity and mortality associated with co-morbid mental and physical disorder
  • Reduce excess lengths of stay in acute settings associated with co-morbid mental and physical disorder
  • Reduce risk of harm to the individual and others in the acute hospital by adequate risk assessment and management
  • Reduce overall costs of care by reducing time spent in A&E departments and general hospital beds, and minimising medical investigations and use of medical and surgical outpatient facilities
  • Ensure that care is delivered in the least restrictive and disruptive manner possible.

Priorities for development in all general hospitals are services for:

  • Acute mental health presentations to the Emergency Department including self-harm
  • Acute mental health issues on wards especially delaying discharge (mainly depression but also organic psychosis, personality disorders impacting on treatment, advice on capacity, complex diagnoses, and advice on the use of psychopharmacology)