Structured communication methods for mental health consultations in primary care: a scoping review

Abstract Background Majority of people with mental health problems attend primary care for support. Interventions that structure consultations have been found effective for physical health conditions and secondary mental health care. The aim of the review is to identify what tools or interventions exist to structure communication in primary care for appointments related to mental health problems and examine existing evidence for effectiveness for mental health and quality of life outcomes. Methods Quantitative and qualitative studies were eligible for inclusion if staff was based in a primary care setting and the intervention involved bi-directional communication with adult patients. Six databases were searched (MEDLINE, Web of Knowledge, EMBASE, PsycINFO, The Cochrane Library, CINAHL) with no time restriction. Search terms combined four concepts with key words such as “structured” and “interaction” and “mental illness” and “primary care”. Reference lists of eligible studies were searched. Results After removing duplicates, 3578 records were found and underwent further screening. A total of 16 records were included, representing eight different interventions from five countries. The majority were delivered by primary care doctors and focused on patients experiencing psychological distress. Similarities across interventions’ service delivery were that most were created for a broad patient population, used self-report assessments at the start and actions or plans as the end point, and employed group settings and didactic methods for training staff in the intervention. Booster and follow-up trainings were not offered in any of the interventions, and supervision was only part of the process for one. The evidence for effectiveness for mental health and quality of life outcomes was mixed with three out of five RCTs finding a positive effect. Conclusions Although the idea of structuring communication for mental health consultations has been around since the 1980s, relatively few interventions have attempted to structure the conversations within the consultation, rather than modifying pre-visit events. As the evidence-base showed feasibility and acceptability for a number of interventions, there is scope for those interventions to be developed further and tested more rigorously

The cost-effectiveness of financial incentives to achieve heroin abstinence in individuals with heroin use disorder starting new treatment episodes: A cluster randomised controlled trial-based economic evaluation

OBJECTIVES: Cost-effectiveness analysis of two 12-week contingency management (CM) schedules targeting heroin-abstinence or attendance at weekly keyworker appointments for opioid agonist treatment (OAT), compared to treatment as usual (TAU). METHODS: Cost-effectiveness analysis was conducted alongside a cluster randomised trial of 552 patients from 34 clusters (drug treatment clinics) randomly allocated 1:1:1 to OAT plus weekly keyworker appointments with either: i) CM targeted at heroin-abstinence (CM Abstinence); ii) CM targeted at on-time attendance at weekly appointments (CM Attendance); or, iii) no CM (TAU). The primary cost-effectiveness analysis at 24 weeks post-randomisation took a societal cost perspective with effects measured in heroin-negative urine samples. RESULTS: At 24-weeks, mean differences in weekly heroin-negative urine results compared with TAU were 0.252 (95%CI -0.397 to 0.901) for CM Abstinence and 0.089 (95%CI -0.223 to 0.402) for CM Attendance. Mean differences in costs were £2562 (95%CI £32 to £5092) for CM Abstinence and £317 (95%CI -£882 to £1518) for CM Attendance. Incremental cost-effectiveness ratios were £10,167 per additional heroin-free urine for CM Abstinence and £3,562 for CM Attendance with low probabilities of cost-effectiveness of 3.5% and 36%, respectively. Results were sensitive to timing of follow-up for CM Attendance, which dominated TAU (better outcomes, lower costs) at 12-weeks, with an 88.4% probability of being cost-effective. Probability of cost-effectiveness remained low for CM Abstinence (8.6%). CONCLUSIONS: Financial incentives targeted toward heroin-abstinence and treatment-attendance were not cost-effective over the 24-week follow-up. However, CM Attendance was cost-effective over the treatment period (12-weeks), when participants were receiving keyworker appointments and incentives