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1.0 Background
The importance of depression as a major health problem, and of primary care based support for the majority of people with depression is now well recognised. However, it is also acknowledged that a large proportion of people with depression remain with their condition unrecognised and untreated.
The capacity for services to deliver the full range of services required to meet the needs of those experiencing depression has been limited. It is recognised that systems need to build capacity through multi-partner and multidisciplinary networks of care. In order to use existing resources more effectively and efficiently ( e.g. tailoring the existing range of skills and expertise to the appropriate level of need) there needs to be appropriate responses at all service tiers and effective communication across all levels of service. Hence the strategy required is not merely about the input of more resources but how these are utilised and managed, and how service components communicate and share information.
1.1 The evidence base
Research and evidence-based guidelines, such as NICE Guidelines for Depression ( NICE, 2004) support the use of time-limited psychological interventions to address mild to moderate mental health problems presented in primary care. In addition there is increasing attention to opportunities to link patients with mental health problems to non-medical sources of support (Department of Health, 2001). There is also emerging evidence in support of social referral schemes to help people address and better cope with factors which impact on their mental health and well-being. Such approaches extend the range of social and therapeutic options available and benefit people by reducing low mood and by facilitating the development of skills (including confidence), resilience and social resources (Mentality, 2003; Scottish Development Centre for Mental Health, forthcoming). Self help (self care or self management) approaches are also being promoted within health care policy to improve both prevention and care across a wide range of health problems (Scottish Executive, 2005). There are many different conceptualisations of self help, and across both professional and public perceptions the boundaries between self help, guided self help and psychological therapies often merge or differ, depending on the context in which they are delivered. Nonetheless, there is a growing body of evidence (particularly in the field of CBT based approaches) in support of self help approaches for common mental health problems (National Institute for Mental Health, 2003). With respect to the use of medication, the current evidence base gives preference to limited prescription of pharmacological treatments for people suffering from mild to moderate depression ( NICE, 2004).
Evidence from organisational models of care have demonstrated that stepped care and collaborative care models are effective in delivering integrated care in ways which best meet the needs of individuals. These approaches are also superior in terms of utilisation of expensive and scarce resources. There are many different models within stepped care and collaborative approaches and these are discussed in more detail elsewhere (Scottish Executive, 2005).
Essentially, collaborative care models involve a multidisciplinary team assisting the primary care provider in delivering evidence-based treatment. Based on a chronic illness model, it includes patient, provider and system level components.
Stepped care models are often linked to activities based within 'tiers' or sectors of care (see Figure 1 below). People may need access to services from more than one tier at the same time but in general the principles of stepped care are:
- The least restrictive available treatment should be recommended
- Stepped care model should be adapting to patients' changing needs
The expected impact of a stepped care approach is that more individuals will have access to treatment, and will be able to access these more quickly, and that there will be more appropriate use of specialist, expensive and scarce resources.
Taken together, the current evidence base and new directions for the management of health problems provide potential solutions as to how to address the large volume of mental health need within primary care. These sources advocate approaches which make best use of available resources and promote access to a wider range of options, including non-medical sources of support.
Figure 1 Description of Mental Health Service Tiers
| Tier 4 | This service includes day units, and highly specialised in-patient and out-patient care. |
| Tier 3 | A multi-disciplinary team or service, working in a community mental health team or psychiatry out-patient department. This is a specialised service for people with more severe, persistent and complex disorders. The team might include psychiatrists, community psychiatric nurses, clinical psychologists, occupational therapists and social workers, among others. |
| Tier 2 | At this level support and assessments would come from more specialist professionals such as counsellors, primary care mental health workers, and psychologists. Services may be based within primary care. Primary care mental health workers are a relatively new support service within this tier. |
| Tier 1 | Help at this level would be provided by GPs, other primary care professionals, social workers, and voluntary sector agencies. General advice and treatment for less severe problems would be offered at this tier and referrals can be made to more specialist services as required. Self help workers would operate within this tier. |
| Tier 0 | At this level people would be accessing resources within the community that would enable them to cope better and avoid the need for professional or other interventions at Tier 1. |
1.2 The Doing Well initiative
To progress the potential of these approaches and to improve the recognition and management of depression in Scotland, the Scottish Executive initiated the Doing Well by People with Depression (also known as Doing Well programme. This three-year initiative, managed by the Centre for Change and Innovation, aimed to:
- Build capacity for self help to meet the needs of those with mild to moderate depressive disorders and provide support through the pathway of care
- Build capacity for psychological interventions in primary care to reduce pressures on secondary services
- Improve assessment of symptoms and associated problems to ensure an agreed understanding of user need and the most effective sequences of treatments and/or support
- Improve access to a range of community based services and support
In the first phase of Doing Well, local projects in seven NHS Board areas (Ayrshire and Arran, Argyll and Clyde, Borders, Dumfries and Galloway, Grampian, Lanarkshire and Greater Glasgow) were funded to develop their services and share learning across Scotland and were the subject of the national evaluation. A consortium including the University of Edinburgh, Scottish Development Centre for Mental Health, the University of Dundee and the University of Glasgow was commissioned to conduct a two year evaluation of the Doing Well initiative. This report presents the findings of the evaluation in relation to:
- how whole systems working regarding organisation of services and care provision contributes to producing solutions that meet the needs of those with depression
- factors bearing on effectiveness of different approaches to service delivery for people with depression, with attention to issues of context, process and outcome
- the key learning points for local and national services and service systems in developing enhanced responses for people with depression.
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