Interventions to reduce sickness absence with common mental disorders in Primary Health Care Centers

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1 Interventions to reduce sickness absence with common mental disorders in Primary Health Care Centers Cecilia Björkelund, University of Gothenburg, Sweden Preconference 10 TH EUROPEAN PUBLIC HEALTH CONFERENCE

2 Two aims To study effects on return-to-work and sick-leave duration of single and complex interventions in primary care To study effects of Care-as-Usual on depression and Quality-of-life as well as sick-leave outcomes

3 Primary Care is complex: In Sweden with >9 million inhabitants, 40 million visits are made in primary care (almost ½ to GPs ), more than 70% of all visits in health care. In UK, with 64 million inhabitants, 340 million visits to GPs, >90% of all visits! More than 700 different diagnoses are set. In Sweden - around 8 % of the visitors to GPs get Depression diagnose, and another 4% Anxiety/Adjustment disorder (= total 12 % CMD) The majority of sick certification is effected in primary care and 40% is caused by mental problems

4 Primary care is the major platform of Common Mental Disorders in health care: Around 70% of all patients with depression are treated in PC BUT

5 The problem: Most clinical trials claiming to test effectiveness of depression treatments are not performed in primary care and do not have Treatment/Care-As-Usual (TAU/CAU) as control arm. Many studies use advertisement recruitment, no treatment after diagnose, or even waiting list proceedings for individuals in the control arm. When sufficient scientific context conditions are fulfilled, care as usual is often shown to be as effective as or nearly as effective as the intervention. and most interventions have no effect on return-to-work and sickleave duration

6 Results from depression treatment RCTs in primary care in Sweden PRIM-NET Internet-CBT in primary care PRI-SMA use of self-assessment instruments PRIM-CARE Care Manager function at the PCC Pragmatic primary care trials for depression

7 Evidence is important from the primary care context baseline 3 month follow-up 6 month follow-up 12 month follow-up BDI TAU BDI ICBT ICBT RCT Control group : Waiting-list ICBT RCT Control group: TAU primary care Per Carlbring, Malin H agglund b Anne Luthstr om, Mats Dahlin, Asa Kadowaki, Kristofer Vernmark, GerhardAndersson. Internet-based behavioral activation and acceptance-based treatment for depression:- A randomized controlled trial Kivi M, Eriksson MC, Hange D, Petersson EL, Vernmark K, Johansson B, Björkelund C. Internet-Based Therapy for Mild to Moderate Depression in Swedish Primary Care: Short Term Results from the PRIM-NET Randomized Controlled Trial. Cognitive Behaviour Therapy. 2014;43(4):289-98

8 Single interventions

9 Internet Cognitive Behavior Therapy in mild to moderate depression in primary care - effects on depression symptoms, sick listing and quality of life PRIM-NET study RCT - 3, 6 and 12 months follow up

10 Background ICBT has shown good effects as treatment of depression in RCTs with participants recruited from psychiatric and psychological departments as well as (web- based) advertisements. However, few RCTs with patients from ordinary primary care have been performed.

11 Purpose To evaluate if treatment of depression (mild-moderate) in the primary care context can be improved by the use of internet based cognitive behavior therapy (ICBT) compared to Treatment as Usual with emphasis on long time outcomes concerning depressive symptoms (BDI-II) Quality of life (EQ-5D) sick listing (days)

12 Randomised controlled study PRIM-NET Randomised on patient level Patients with mild/moderate depression episode in primary care diagnosed by MINI + positive to ICBT Intervention 3 months with I-CBT by PCC therapist Treatment as Usual 3 months 3, 6 and 12 months follow up 3, 6 and 12 months follow up Education and continuous support from research therapists and research personell

13 Results 16 participating PCCs 12 therapists 90 patients 66% women Mean age 37 years 75% participation rate 3 and 12 months At Baseline: No significant differences between intervention and TAU concerning; age, gender, ethnicity, socio-economy, education baseline BDI-II, EQ-5D antidepressant medication sick-listing days the year before entering study

14 BDI (Depressive symptoms) baseline, 3, 6 and 12 month follow-up BDI TAU BDI ICBT 5 0 baseline 3 month follow-up 6 month follow-up 12 month follow-up

15 EQ-5D (Quality of life) 3, 6 and 12 month follow-up 0,9 0,8 0,7 0,6 0,5 0,4 0,3 0,2 0,1 0 baseline 3 month follow-up 6 month follow-up 12 month follow-up TAU ICBT

16 Conclusions Psychologist supported ICBT treatment in primary care patients shows as good effect on depressive symptoms as TAU the same level of increase of Quality of Life compared to TAU. about the same level of need of sickness certification with some advantage for ICBT. Eriksson MCM, Kivi M, Hange D, Petersson EL, Ariai N, Haggblad P, Björkelund C. Long-term effects of Internet-delivered cognitive behavioral therapy for depression in primary care - the PRIM-NET controlled trial. Scandinavian Journal of Primary Health Care. 2017;35(2): Holst A, Nejati S, Björkelund C, Eriksson MC, Hange D, Kivi M, Wikberg C, Petersson E-L. Patients experiences of a computerised self-help program for treating depression - a qualitative study of internet mediated cognitive behavioural therapy in primary care. Scand J Prim Health Care 2017:35(1):46-53.

17 Treatment as usual in (Swedish) primary care Psykolog/pterapeut läkare sköterska antidepressiva Fysioterapeut Psychotherapy GP Nurse Antidepressives

18 PRI-SMA use of self-assessment instrument for depression in regular GP consultations does it really make a difference? Aim: To study if use of a self-assessment instrument in regular GP consultations effects course and depression outcomes and return to work in a long time perspective compared to Treatment as Usual

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20 Randomisation on GP level 23 PCCs 91 GPs 45 GPs randomised to intervention 46 GPs randomised to TAU 258 patients 125 intervention group 133 TAU-grupp. 3-months follow up: 72% 6-months follow up: 72% 12 months follow up: 67%

21 BDI-II Blue --- Control group patients Green Intervention group

22 EQ-5D Blue --- Control group patients Green Intervention group

23 The continuous use of self-rating scales in the treatment of primary care patients with depression does not seem to increase treatment effects compared to the usual treatment provided in primary care in terms of outcomes of depression symptoms quality of life consumption of care but increases adherence to antidepressant medication during full 6 months in a significantly higher frequency than Treatment as Usual (96% vs 81%) or sick leave Wikberg C, Westman J, Petersson EL, Larsson ME, André M, Eggertsen R, Thorn J, Ågren H, Björkelund C. Use of a self-rating scale to monitor depression severity in recurrent GP consultations in primary care - does it really make a difference? A randomised controlled study. BMC Fam Pract 2017:18(1):6. Wikberg C, Pettersson A, Westman J, Björkelund C, Petersson EL. Patients' perspectives on the use of the Montgomery-Asberg depression rating scale self-assessment version in primary care. Scand J Prim Health Care 2016:1-9..

24 Complex interventions in depression treatment: Collaborative care with Care manager for patients with depression at PCC PRIM-CARE

25 Care Manager tasks complex interventions Patient contact Makes a structured management plan together with the patient Contact every every second week (telephone) Follows with selfassessment instrument Keeps close cooperation with the patient s GP and inter-professional communication Organisation Supports development of an organization for collaborative care cooperation (physician, psychologist, psychotherapist, counselor, rehabilitation personnel etc.) Facilitates cooperation with psychiatry, secondary care, community services, etc. Facilitates continuity and accessibility

26 Randomised controlled study PRIM-CARE Randomised on PCC-level 11 PCCs Intervention 3 months with Care Manager at the PCC 6 months follow up 12 months follow up 23 PCCs 12 Control-PCCs Care as Usual 3 months 6 months follow up 12 months follow up Education and continuous support from research personell and Health Care Management

27 Results PRIM-CARE Care Manager study 376 patients with newly diagnosed mild/moderate depression disorder were included Control PCCs 184 patients Intervention PCCs 192 patients Followed 12 months concerning depressive symptoms, sick-leave

28 Conclusions Care manager function increases depression outcomes compared to Treatment as Usual- and increases RTW and reduces net-sickleave duration But Treatment as Usual is very effective

29 Treatment-as-usual and Care-as-usual = effective person-centred care AND a collaborative care organisation enhances effectiveness of care and rehabilitation in several ways

30 Research groups Jeanette Westman Eva-Lisa Petersson Irene Svenningsson Dominique Hange Cecilia Björkelund Carl Wikberg Shabnam Nejati Margareta Jerlock Lars Wallin Malin André Camilla Udo Maria Eriksson Robert Eggertsen Marie Kivi Maria Larsson Christina Möller Maria Magnil Åsa Porathe Christina Ramnfors Care Managers PCCs Jörgen Thorn