Introduction: shared or Collaborative Care in the treatment of Depression is an evidence based intervention which has been shown to be more effective than ordinary general Practitioner care in the treatment of Depression, however, it is not yet Government policy in the United Kingdom. We aimed to bring together in one place all the studies which have been carried out, up till mid 2009, in order to demonstrate the evidence that shared collaborative care has important advantages in terms both of depression outcomes and cost benefits, in order to argue for the adoption of this approach in the United Kingdom and n Europe.
Methods: we carried out a literature search using PUBMED in order to identify and describe all trials, systematic reviews and Metanalyses which have been carried out on shared care until mid 2009. We also described a shared care service for depression which some of us had been involved in developing and working in in Luton in the late 1990's. We have excluded papers which describe trials which have not yet been carried out, and instead focussed on the trials which have reported.
Results: it has been demonstrated in numerous recent studies that shared care in the treatment of depression, which includes the training of General Practitoners in the treatment of depression, and the provision in Primary Care of a Nurse specialist or another professional who will impart psycho-education, ensure concordance with medication, and may provide psychotherapy, leads to both improved treatment outcomes and increased doctor and patient satisfaction, as well providing some cost-benefits, despite somewhat increased immediate costs. This is the case in both adult and adolescent patients, while in the case of diabetic patients depression is improved, despite the lack of improvement in glycaemic control. The shared care intervention continues to be useful in the case of patients with resistant depressive symptoms, though a longer input will be necessary in such cases. Patients with subthreshold depression will not benefit as much, and patients expressed more satisfaction when psychological interventions were offered. It is also the case that collaborative or shared care is effective in treating depression in the elderly. This is shown by studies which include older patients who also suffer from multiple health conditions, arthritis, diabetes, anxiety and PTSD, the poorer, those with suicidal ideation, and also in Ethnic Minorities.
Discussion: The results described above are mostly based on studies carried out in the USA, but similar studies have been reported from the United Kingdom, and are consistent with the experience of the service in Luton which we describe. From these results it would seem important that shared, collaborative care, with primary and secondary care doctors (General Practitioners and Psychiatrists) working as part of a single team, with the help of mental health practitioners attached to primary care, but with easy access to secondary care is a productive way of optimising the treatment of depression. In the UK, however, it has not yet been possible to develop such a service for the whole population. This is becausein the UK, General Practice is managed by Primary Care Trusts, while Secondary Care, including Psychiatry, is managed by Mental Health Trusts. This has led the National Institute of Health and Clinical Excellence, and indeed local commissioners of care to focus on a Stepped Model for the treatment of depression, with one key issue being access (or referral) to secondary care, and discharge back to primary care, with a group of Mental Health workers focussing on the facilitation (or gate-keeping) of these processes, rather than focussing on actually optimising outcomes of care.
Conclusion: the evidence argues for the development of collaborative care between primary and secondary care for the treatment of Depression. This will require common medication guidelines across both Primary and Secondary Care, easy access so that General Practitioners can receive advice from Psychiatrists about patients, and the use of Mental Health Professionals to provide patients with psycho-education, support of concordance with treatment, and psychotherapy. It may be that, in order for this to be achieved, services may need to be re-structured, to allow easy communication between professionals.