Engaging patients, GPs and Specialists: different levels, different communications
Depression, anxiety, phobias and panic are common mental diseases usually treated within a primary care setting and they are a priority for Mental Health Systems.
There is substantial evidence to support the use of stepped care treatments for depression using evidence based: Medication and Psychological Interventions. Medication is usually the first treatment offered, but is often associated with side-effects.
International guidelines are unanimous in recommending cognitive-behavioral psychosocial interventions and psychotherapy as first choice in the less severe forms of depression (medium-mild) and in particular, low intensity cognitive-behavioral interventions, as help-books and computerized services, which can be put into practice by users on their own or with limited support from a psychologist or a psychiatrist. In 1996 Gavin Andrews emphasizes how some cognitive-behavioral psychosocial interventions “if they had been registered as drugs would be effective and safe and would make an essential part of the pharmacopoeia of every doctor”.
Computerised cognitive behaviour therapy (cCBT) is a self-help option that offers appropriately screened patients the potential benefits of CBT with less therapist involvement. There are lot of structured cCBT used all round the world (MyndGym, Ifightdepression, livinglifetofull beatingtheblues) and in 2006 Kalthentaler & coll. published a review about CCBT in the world, but no study was performed in Italy. There are even the international guidelines (NICE) on the use of cCBT for anxiety and depression and so…
LET’S START cCBT in Italy through Mastermind!
There are no works about cCBT in Italy on database like Pubmed or Psychinfo. Mastermind program has pushed the first case of structured cCBT application in Italy: the use of cCBT tool “I fight depression” in Treviso and Torino.
Like in every innovative and changing process, we need to address the trend to retain habits and the “not changing” state of mind, at different levels, with the aim to engage people and clinicians to Mastermind services.
Mastermind tele-medicine services (cCBT and cVC) are a powerful collaboration tools between general practitioners (GPs) and Psychiatrists to create a common language about Mental Health and collaborative care.
Engaging MaterMind in ULSS 9, TREVISO, ITALY
At the beginning GPs’ and Specialists’ collaboration was not simple and this has slowed down the promotion of Mastermind program.
Due to these initial difficulties we have put in place three different levels of actions in order to involve better clinicians and also citizens: engaging Community, GPs and Medical Center staff.
The first target is citizens. Different versions of poster and flyers have designed to invite people to consider Bio-Psychological Health and depression symptoms.
In the poster and in the flyers, the people are invited to contact their GP or the MH Department to have help and a new pathway to be assisted in the care of their pathology. In some GPs office we are offering to recruited patients the possibility to have the meeting with the Mastermind psychologists directly at the GPs office, once a month.
Also some pubblic meetings were organized in collaboration with the local Municipality using movies and public talking.
2. Involving GPS
At the first step of MAstermind the involvement of GPs has been difficult, maybe because they are very busy in their clinical practice and have no time for innovative programs.
We are visiting all the GPs enrolled at their office to promote PHQ9 screening and CVC and offering support for collaborative care. We have also asked to the GPs to make a useful exercise, consulting their electronic health record and trying to identify the potential eligible patients. We offered 2 ECM training course for GPs and Specialists to promote Mastermind tele-services.
3. Involving SPECIALISTS AT THE MENTAL HEALTH DEPARTMENT
At the Mental Health Center some specialists , psychiatrics and psychologists, consider cCBT tool difficult to use and not confident for patients. Dr Sanzovo , Psychiatric at MHC in Mogliano Veneto says “ that was my opinion at the beginning, too, but using cCBT, II understood it can be very useful and it can save your time. Our fear was that the patient were alone only with the computer. Our goal is that the patient is ever with the tool.”
We are promoting Mastermind services (cCBT and cVC) at different levels of Mental Health Centers: some training and meetings have been organizing to involve psychiatrics, psychologists and nurses.
We also are engaging nurses: some are supporting patients during the use of the cCBT tool (iFightDepression) because some technical features are creating problems: we have decided to support all patients in the approaching of the IFD software and in using cCBT mainly in the first accesses.
How PATIENT can be reached and empowered from cCBT
We are spreading the culture of Mental Health and Well-Being, focusing on GP’s practice to reach patients with low and moderate symptoms of depression. At the moment Mastermind team in ULSS 9 – Treviso, had reached 80 patients offering screening with Patient Health Questionaire (PHQ9), collaborative care between GPs and specialists and offering cCBT .
This is a case-story of a very interested user, who looked at the new MASTERMIND poster at her GP’s office, and she asked to her GP more informations about the program.
This was the occasion for GP to talk about common psychological diseases and to introduce the screening with PHQ9 and so invite the lady to be recluted in Mastermind study.
After a week, she was contacted for a clinical interview at the Mental Health Center with the Mastermind Psychologist. She was very enthusiastic to start the cCBT to improve her Mental Health, in the evening hours after her work using her computer, without loosing evidence-based therapy. She prefers to print the modules and worksheets.
She is going on with the program, and she is very happy of thinking and acting differently.
cCBT has distinct possible advantages:
- It allows the dissemination of standardised and personalised treatments.
- The programs can be customised for each patient while still maintaining protocols in the correct sequence.
- Finally, the costs associated with computer-based treatments are potentially less than those associated with clinician-based treatments.
- many patients can be reached because cCBT can be used at home , 24 hours a day, 7 days a week, depending on access, without affecting efficiency. There are different setting options for computer-based therapies: GPs offices, psychiatric clinics and libraries.CCBT can be particularly useful for people who are currently unable to access care services.
- Privacy and consistency of care and ease of data collection are other advantages.
- CCBT can offer a better access to Mental Health System: there are currently problems with due to staff shortages, patchy services, poor coordination between services and long waiting lists.
Mastermind is Treviso is using different communication for different target: focisung on the evidence-based treatments for common mental health for the communications to patients; promotion of Mental Health and collaborative care for GPs and specialists.
We trust that GPs are the link to reach patients with low and moderate depression and we are empowering their important role and this communication.
What are the best way to engaging GPs used in the other pilots?
Waiting for your suggestions, and… let’s go on with Mastermind services!
Kaltenthaler E, Brazier J, De Nigris E, Tumur I, Ferriter M, Beverley C, et al.Computerised cognitive behaviour therapy for depression and anxiety update: a systematic review and economic evaluation. Health Technol Assess 2006;10(33)
Gavin Andrews. Talks that work: the raise of cognitive-behaviour therapy. British Medical Journal, 1996,313,1501-1502
National Institute for Clinical Excellence. Guidance on the use of computerised cognitive behavioural therapy for anxiety and depression. London: NICE; 2006.