NIHR Highlight Options in the care of people with depression
Published March 2017
Depression may affect more than one in ten of the UK population at any one time, and cost the NHS in excess of £500m per year, with high additional costs in informal care and lost working time. Depression is typically a recurring condition, and more than half of people who experience depression once will go on to have at least one more episode.
Up to 90% of patients with depression are treated in primary care, but care can be complex, involving a number of different specialists and requiring access to different forms of treatment. In practice care can become fragmented and reactive rather than proactive.There is also high demand for treatments for depression. Provision of psychological therapies has increased under the NHS ‘Improving Access to Psychological Therapies’ programme, but waiting lists remain in some areas.
The NIHR has funded important new research which provides evidence for a different way of managing care of people with depression – collaborative care – by co-ordinating this through a designated care manager. A key element of collaborative care is the provision of behavioural activation, a simple psychological therapy. Behavioural activation can be delivered as a standalone therapy too and this Highlight also considers the evidence for how effective it might be.
Published: March 2017
Collaborative care could have potential for managing the care of people with depression in the UK.
Up to 15%
of UK population may be affected by depression and anxiety at any one time
cost of depression and anxiety to the NHS per year
Up to 90%
of patients with depression are treated in primary care
A number of recent NIHR studies have provided useful new evidence on collaborative care and behavioural activation for depression. This Highlight considers some of the key points arising from the studies, but it is not a complete review of all the evidence in this area (see ‘About the research’ for more information).
What is collaborative care?
Collaborative care is a means of managing care for people with mental health conditions, involving co-ordination of medications, therapies and appointments by a dedicated case manager.
What is behavioural activation?
Behavioural activation is a therapy that encourages patients with depression to approach activities they may have been avoiding, through the development of goals and activity schedules. The rationale is that depression is linked to avoiding certain situations or activities, which in turn limits opportunities for positive experiences.
At a glance
- In a number of trials, collaborative care was associated with a greater improvement in symptoms of depression than usual care. The difference was often quite small, but similar to improvements seen with other types of treatment.
- The largest and most recent trial of collaborative care in the UK echoes this finding, with patients experiencing a small but significant improvement in depression over usual care, and a greater chance of responding to treatment or recovering.
- Patients in this trial were more satisfied with collaborative care than usual care.
- Collaborative care is not expensive and appears cost-effective, based on the thresholds used by NICE.
- Collaborative care is linked to small improvements in depression for a range of patient groups, including people with depression with or without an accompanying physical health condition, and older people with mild depression.
- An ongoing study is exploring whether collaborative care is also effective for older people with more severe depression.
- Behavioural activation is a simple psychological therapy that can be delivered by more junior staff than other commonly used talking therapies.
- The largest trial to date of behavioural activation found it was no less effective than cognitive behavioural therapy (the most commonly used alternative) in treating depression.
- Because less highly trained staff are able to deliver behavioural activation, it is cheaper than cognitive behavioural therapy and appears to be more cost-effective.
Questions for healthcare professionals
- In your area, has collaborative care been used before? Has it proved worthwhile?
- If it isn’t yet available, could collaborative care be appropriate and feasible for patients with depression in your area?
- Are there particular patient groups who could benefit – such as older people, or those with comorbidities?
- Is behavioural activation available in your area? Could it be offered to patients who might currently be receiving other therapies?
- How could your service realise and use the cost savings that research suggests could be achieved through the wider use of behavioural activation?
Questions for patients
- Which types of therapy are available in your area?
- Do you know what behavioural activation is, and whether it might suit you?
- Have you discussed the options for different treatments with your GP?
Collaborative care is a way of managing care and treatment for patients with chronic conditions. Each patient is allocated a case manager (typically a mental health worker or nurse), usually based at their GP surgery, who liaises between different professionals, ensures patients adhere to treatment plans, monitors progress and delivers brief psychological therapies. Other types of support, including depression education and medicines management, may also be offered.
To date, collaborative care has been most widely adopted in the US, where it has been shown to be effective in managing mental health care. In the UK, NICE recommends collaborative care for mild to moderate depression, but only where the patient also has a chronic physical health condition and difficulty undertaking daily tasks as a result.
A review of all recent research found that patients with depression and anxiety who received collaborative care demonstrated a significantly greater improvement in their symptoms than those receiving usual care, both in the short and longer term, although the difference disappeared after two years. Patients were also more satisfied with collaborative care than usual care. This suggests collaborative care could have potential as an option for managing the care of people with depression in the UK.
These findings were echoed by a randomised controlled trial which compared collaborative care to usual care for people with depression. Some patients were offered a collaborative care package which consisted of regular phone contact with a care manager to negotiate a treatment programme, assist with medications, provide advice and support, and offer behavioural activation (a simple psychosocial therapy). This lasted around three months and consisted of up to 12 contacts. Others received usual care from their GP. After four months, the patients receiving collaborative care had a slightly lower depression score and expressed higher satisfaction with their treatment than those receiving usual care. The benefits lasted for 12 months.
Patients in both groups experienced a reduction in levels of depression, but those receiving collaborative care were more likely to respond to treatment or recover. However, the difference in depression symptoms between the two groups was quite small: 1.3 points on a 27 point scale, where the difference between moderate and moderately severe depression is considered to be five points. Whilst not a large difference, this is a similar effect to other treatments for depression, and patients were positive about the experience of receiving collaborative care.
This study also considered whether collaborative care would be cost-effective if it were adopted in UK primary care – an analysis which hadn’t been done before. From this analysis it appears likely that the gain in healthy life years would come at a reasonable cost compared to other interventions – the measure normally used by NICE. In addition, when the costs of informal care by friends or family were taken into account, collaborative care appeared likely to be cost-saving compared to usual care.
“What we learned from our research is that if you look after patients in a structured way, keep in contact with them and give them some basic mental health advice, you can achieve good results.”
Professor David Richards, University of Exeter.
At the moment, NICE recommend collaborative care only for people who have both depression and a chronic physical condition. But evidence suggests that collaborative care could be effective for people with depression alone.
A study looked at 31 randomised controlled trials that had compared the effectiveness of collaborative care with usual care in depression, then analysed whether the presence of a physical condition changed the effect of collaborative care. There didn’t appear to be any significant effect, suggesting that this approach could be useful for people with depression regardless of whether they also have a chronic physical condition.
Collaborative care could also be of benefit to older people, who are disproportionately affected by depression. In this age group, it is more likely to occur alongside physical health conditions, and is strongly associated with a poorer quality of life. Evidence suggests that providing collaborative care to older people who have mild depression – below the normal criteria for treatment – may help prevent the depression from progressing. In a recent trial, 700 people with an average age of 77 years were randomised to receive either collaborative care or usual GP care. Participants were all experiencing mild symptoms of depression. As with the other trials described here, the collaborative care comprised contact from a case manager including telephone support, symptom monitoring and behavioural activation.
At four months, there was a modest difference in depression score in favour of those participants receiving collaborative care. This was similar to the difference observed in the trials (described above) with adults with diagnosed depression, and in line with other treatments for depression. After a year, those receiving collaborative care were less likely to have developed depression severe enough to warrant treatment. Delivery of collaborative care cost an additional £500 over usual care and was found to be cost-effective in terms of the overall health gains.
A new NIHR study is now extending the research to see if a similar collaborative care package could benefit older people with more severe depression. This is likely to report in 2017.
Together, this evidence about collaborative care suggests that it can lead to small improvements in depression for people of different ages, with different levels of depression and with or without accompanying physical health issues. It also appears to be cost-effective, within the limits generally used by NICE.
One of the elements of collaborative care in the studies described in this Highlight was a simple form of psychosocial therapy called behavioural activation.
In fact, when researchers in one study analysed which elements of collaborative care seemed to have most effect on patients’ depression symptoms, they found that it was behavioural activation that had the biggest impact, even though in this trial it was delivered in a simple, low-intensity form.
Behavioural activation (BA) is a therapy that encourages patients with depression to approach activities they may have been avoiding. With a therapist, patients define goals and ‘activity schedules’. The rationale is that depression is a consequence of avoiding particular activities or situations. It is similar to cognitive behavioural therapy (CBT), but does not focus on analysing thought patterns, but rather on encouraging an increase in activity. At the moment, NICE recommends behavioural activation for mild to moderate depression, with the caveat that the evidence base is less strong than for CBT.
BA is of interest because it can be delivered by more junior mental health workers than CBT. If it is as effective as CBT, then it could be a cost-effective way of increasing access to therapies for people with depression – but up until now, there has not been sufficient evidence to show this.
The NIHR has supported new research which may help fill some of this evidence gap. This large trial found that behavioural activation was no less effective than the more commonly used CBT in treating depression. The study recruited over 400 adults, all of whom were suffering from depression, and randomly allocated them to receive either CBT or BA. In both cases, participants received up to 20 sessions over a period of 16 weeks. The CBT was delivered by qualified psychotherapists with additional qualifications in CBT. The BA was delivered by junior mental health workers, who had received previous training in delivering self-help interventions together with five additional days of specific BA training. They had no professional mental health qualifications. However, BA in this study was a more intensive therapy than that delivered in the collaborative care trials discussed elsewhere in this Highlight.
After 12 months, both groups of patients reported that their depression symptoms had reduced, by a similar amount. Patients who had received BA also showed no difference in recovery from symptoms of anxiety compared to those who had received CBT. Around two thirds of patients in both groups demonstrated recovery from depression or response to treatment.
This is the largest trial of BA to date, was well-designed and implemented, and offers promising results. There may be some limitations – for example, many patients in both groups were also using anti-depressants, which could affect their response to the therapies. The study also excluded patients who had primary alcohol or drug problems, so we don’t know if BA would work for these groups.
Behavioural activation can be delivered by more junior mental health workers, who have been trained in the therapy but don’t necessarily have formal mental health qualifications. The study found that BA is likely to be cost-effective compared to CBT, according to the standard measures used by decision-makers such as NICE. This underlines the potential of BA for increasing access to therapy in a cost-effective way.
“Patient choice and collaboration are highly associated with recovery so you can help people better if you can provide them with a choice of treatments that are evidence based.”
Jamie Short, Psychological Wellbeing Practitioner.
What is the research that this Highlight is based on?
This Highlight is based on findings from the following NIHR-funded studies:
- Collaborative care for depression and anxiety problems in primary care (Cochrane Common Mental Disorders Group, NIHR SRP project number 11/4002/12)
- Clinical effectiveness and cost-effectiveness of collaborative care for depression in UK primary care (CADET): a cluster randomised controlled trial (MRC/HTA, project number 09/800/19)
- COBRA (Cost and Outcome of BehaviouRal Activation): a Randomised Controlled Trial of Behavioural Activation versus Cognitive Behaviour Therapy for Depression (HTA, project number 10/50/14)
- Collaborative Care in Screen-Positive Elders, The CASPER Trial (HTA, project number 08/19/04)
- Association Between Chronic Physical Conditions and the Effectiveness of Collaborative Care for Depression: An Individual Participant Data Meta-analysis (School for Primary Care Research, grant 212)
We selected these studies because they are recent, high quality and directly relevant to the topic of this Highlight. There is another study underway which is also highly relevant to the issues discussed here, and which will publish in 2017:
- The CASPER-PLUS Trial: Collaborative care for screen-positive elders with Major Depressive Disorder (HTA, project number 10/57/43)
The following NIHR study is also of relevance to the topic:
Integrated primary care for patients with mental and physical multimorbidity: cluster randomised controlled trial of collaborative care for patients with depression comorbid with diabetes or cardiovascular disease (Greater Manchester CLAHRC)
There are other NIHR studies that may have some relevance to the topic – you can find out more at nihr.ac.uk or netscc.nihr.ac.uk.
The Cochrane Common Mental Disorders Review Group carries out a range of systematic reviews on depression and other conditions, see http://cmd.cochrane.org/
- Collaborative mental health care in the NHS has small but meaningful benefits for people with depression
- Collaborative care can be moderately effective at treating depression regardless of physical health status
- Simpler, cheaper therapy (behavioural activation) can be as good as CBT for treating depression
How strong is the research evidence in this area?
This Highlight does not aim to bring together all the evidence in this area, but discusses a small number of key studies which have published recently. Overall, the evidence presented here is of good quality. It includes two systematic reviews, which bring together all the research in a particular area and analyse the findings together. Both of these reviews looked at randomised controlled trials, which are the most reliable form of evidence. In addition to these reviews, the Highlight includes findings from three randomised controlled trials. These were all large, well-designed studies which followed up participants over two years. One is the first large trial to look at the effectiveness of collaborative care in the UK; another is the largest trial to date of behavioural activation. Together this research represents the most recent, best evidence for these interventions in the UK context.
How does this fit with current guidance?
NICE currently recommends that collaborative care can be offered to patients with both mild or moderate depression and a physical health condition, but it isn’t recommended as standard management for patients with depression alone. The evidence presented here indicates that collaborative care seems to be effective for patients with depression, regardless of the presence of a physical comorbidity. However, the improvement in depression symptoms was only slightly greater than that for usual care. Although collaborative care costs more than usual care, evidence suggests that it is cost-effective in that these extra costs will yield a greater improvement in people’s health. NICE and commissioning bodies will be responsible for deciding whether this is worthwhile.
NICE currently recommends behavioural activation as an option for the treatment of depression, but notes that the evidence base is less strong than for cognitive behavioural therapy. The evidence presented here goes some way to filling that gap, and also demonstrates that the therapy is cost-effective. NICE is currently reviewing the guidance on depression.
Collaborative care started life in the US and, until the CADET study, it hadn’t been comprehensively tested in the UK health system.
NICE (National Institute for Health and Care Excellence) were keen to see the evidence on this method of coordinating the therapeutic care of patients with depression, so they could decide what guidance to offer for its use.
We set out to test the value of collaborative care as an organisational strategy. The point of CADET was to examine what happens when you have a worker who glues the various disparate elements of a patient’s care together, while giving them some low-intensity therapeutic input. What we learned from CADET is that if you look after patients in a structured way, keep in contact with them and give them some basic mental health advice, you can achieve good results.
When we set up the CADET trial we delivered the collaborative care intervention using graduate mental health workers, as the role of the psychological wellbeing practitioner – the mainstay of the IAPT service – had not yet been developed. The staff were trained as case managers, with responsibility for maintaining phone contact with the patient, guiding the patient in self-help, managing their medication, and providing consultation liaison with primary care.
Crucially, these case managers were supervised by mental health professionals such as psychiatrists, psychologists, nurses and other mental health experts. Case managers acted as the conduit for that professional expertise, ensuring they gave high-quality mental health care advice.
The low-intensity self-help component of the CADET trial was in the form of behavioural activation: agreeing on action goals and monitoring how the patient got on. The results for the collaborative care intervention were good and behavioural activation was a key part of this approach to patient care.
When, later, we set up the COBRA trial, we were testing a much more intensive form of one-to-one behavioural activation, substantially different from the guided self-help used in CADET. COBRA tested the hypothesis that benefits comparable to CBT could be achieved by using therapists with less training.
The BA approach is based on the premise that you don’t need to change the way you are thinking or feeling directly, what’s important is changing what you are doing. It says ‘go and do, despite what you are feeling, and you will notice a link between what you do and your mood'. Using this ‘outside-in’ approach, a personalised programme of activities will, in turn, have a positive effect on mood.
We were delighted that we got such positive results from the COBRA trial. It gives us a definite indication that BA was not inferior to CBT and I am optimistic that NICE will now consider BA in their revised guidelines for people with depression.
Author: Dave Richards. Professor of Mental Health Services Research, University of Exeter
I am a Cognitive Behavioural Therapist employed in a local mental health service. I deliver CBT and other psychological interventions to clients who refer themselves or are referred to us.
We see the whole range of anxiety disorders: social, health, phobia, OCD or any generalised anxiety disorder. Some people experience depression alongside this, or they may present with a standalone depression. We also see people who have experienced trauma earlier in their life and need help with the impact now.
My service was one centre in the COBRA trial. Patients were randomised to receive either CBT or behavioural activation. I provided CBT and a colleague saw the patients who were received behavioural activation.
The practicalities of establishing a new patient in the study were dealt with by the research team. My responsibility wasn’t very different from usual practice because I deliver CBT for depression as part of my job anyway. We recorded every session, with the patient's consent of course, but the face-to-face therapy was similar to our usual practice.
We usually provide patients with sixteen 50-minute sessions. For the COBRA trial, twenty such sessions were available, plus the option of four ‘booster’ sessions, which patients were keen to take up.
The COBRA trial was the first piece of research I had been involved in. It was well-organised and I really appreciated being part of it. There was always support on hand and we therapists were never left floundering with any dilemmas.
Both the CBT and the behavioural activation inputs were high-intensity treatments. The results were incredibly pleasing, supporting the hypothesis that BA was not inferior to CBT.
Now the trial is over and the evidence is being considered by NICE, I am keen to see how this will be taken forward. If NICE recommends behavioural activation in their revised guidelines, there may be a surge of demand for us to implement it – and I hope we do.
Author: Sarah Goff. Cognitive Behavioural Therapist
What can a patient bring to the management of a randomised controlled trial? Nigel Reed had experienced several bouts of depression and his GP identified him as eligible to participate in the PREVENT trial, which examined the value of mindfulness-based cognitive therapy for people whose depression kept coming back.
“I enjoyed being part of PREVENT” Nigel explained, “and later joined a ‘lived experience’ group of patients who support the clinical, teaching and research activities of psychology at the University of Exeter”.
The COBRA study explored whether a simple therapy for depression, behavioural activation, was any less effective than the more commonly used cognitive behavioural therapy. The research team was looking for a public contributor to join the trial management group, so approached the Exeter lived experience team. The trial management group has a formal responsibility to oversee the conduct of the trial, ensuring the protocol is followed and any problems or adverse issues are dealt with properly.
“It was happenstance that I was picked to join the trial management group,” says Nigel, “but it was a great experience. I joined the group at a stage when there were some problems with recruitment to the trial, so the group were keen to learn from my experience of being a participant in the earlier study.
"I was able to point out that during the (sometimes long) gap between recruiting a patient and actually starting the allocated therapy, it was important to keep in touch with the patients so that they felt part of the process and knew what was happening.”
The trial management group brought research experts together. “Meetings had up to a dozen specialist academics around the table but I was always carefully listened to as we picked our way through recruitment milestones, retention rates, adverse incident reports and all the other responsibilities to the trial. I felt part of the team, always given the chance to contribute ideas and ask what must have seemed like very basic questions! I was closely involved with the drafting of the Lancet article about our trial results, working to ensure that the message was clear for the reader.
“It was great to be part of a team that made a success of the study.”
Author: Nigel Reed. Patient
As a graduate mental health worker, I was directly involved in the CADET trial. Our primary care mental health team in Bolton was one of the study sites and I was allocated to provide the collaborative care arm of the study.
After an initial one-hour assessment, we would support patients by means of a 20-minute phone call once a week for twelve weeks. The essence of the intervention was guided self-help for the patient. We recognised that every patient was different but used a standard package of materials as the basis of helping them to understand the nature of depression and what they could do. Patients benefitted from help, tailored to their needs, with managing their medication and their symptoms.
Behavioural activation was a particular element of the way in which we supported patients. This approach helps people to be more motivated to get momentum going in their life. We would help them to record what they did during the day and then plan, thinking about the nature of their activities and how easy they found it to do the routine, pleasurable or necessary things in their life. Gradually, people could be supported to see that getting things done – even before they felt like doing them – helped them to feel better.
I saw real improvements in the patients that were allocated to me. I don’t say a collaborative care intervention would be right for everyone but it was great for people who wanted to access treatment largely at home and by phone, especially if they found it hard to take time off work and/or didn’t want others around them to know they were receiving treatment.
Acting as a case manager, I learned – more than I had in previous practice – to combine flexibility of approach with a strong commitment to ‘being present in the moment’ with patients. In future, I would like to see collaborative care offered as an option to patients who come to our service.
Author: Champa Mistry. Graduate Mental Health Worker
I have been a psychological wellbeing practitioner in an IAPT service for five years now, working my way along the career pathway. First, gaining a postgraduate certificate in evidence-based psychological therapy, then another enabling me to supervise other therapists and lead a team.
I really like the work. We see a wide range of people with mild to moderate depression and different types of anxiety. Using a standardised package of Cognitive Behavioural Therapy (CBT), we help people to think differently about the way they see the world and what’s happening in their lives.
I’m based in a centre that was selected for the COBRA trial and I was interested to be allocated to deliver the Behavioural Activation arm. This meant I was delivering a different therapy. Longer sessions, over a longer period than our usual CBT, to people who had been screened by local GPs as suitable for the study. In over two and a half years, I saw a total of 27 patients in this way.
It was a 20-session package, starting with a structured assessment and then formulating a plan to address the patient’s difficulties and issues. We asked patients to monitor what they did each week, exploring what improved their mood and what changed it.
Together we would build up a package of activity the patient found helpful. This might include specific activities that made them feel better, and would usually include work on how they solve problems as they encounter them, how they think about their health state, how they communicate with people around them, and so on. We used the new techniques and learning to apply this to different issues each week. This helped them generalise use of their coping strategies.
COBRA is described as a high-intensity intervention and it is quite demanding for the patient. They are asked to record what they have been doing and how they felt more frequently than with ‘conventional’ CBT – sometimes once an hour. This gives the therapist and patient lots of fruitful material to work on when they meet.
As a therapist, working in this way and having more time to devote to the work with the patient made the therapeutic relationship grow strongly. It was different from the usual CBT but I felt it was more likely patients would be able to sustain the changes in their life afterwards.
I was pleased the COBRA trial found Behavioural Activation wasn’t inferior to standard CBT. I could see my patients in the trial benefitting from the Behavioural Activation approach and I would like to see BA routinely offered as an alternative therapy so patients could get the therapy that is best for them. Since the trial finished I have used some of the BA tools and techniques in my routine practice and I am introducing newly qualified practitioners to them as well. Taking part in COBRA has been an enriching experience.
Author: Jamie Short. Psychological Wellbeing Practitioner