A trial of problem-solving by community mental health nurses for anxiety, depression and life difficulties among general practice patients. The CPN-GP study

T Kendrick,^1* L Simons,² L Mynors-Wallis,³ A Gray,⁴ J Lathlean,² R Pickering,⁵ S Harris,⁵ O Rivero-Arias,⁴ K Gerard⁵ and C Thompson⁶

¹ Primary Medical Care, University of Southampton, Aldermoor Health Centre, Southampton, UK
² School of Nursing and Midwifery, University of Southampton, UK
³ Alderney Hospital, Parkstone, UK
⁴ Institute of Health Sciences, University of Oxford, UK
⁵ Health Care Research Unit, Southampton General Hospital, UK
⁶ Priory Healthcare Group, Southampton, UK

* Corresponding author

Background

Community mental health nurses (CMHNs) care for people living in the community with severe and chronic mental illnesses. They also provide counselling and support for patients with less severe illnesses, who are referred by their GPs. Techniques such as problem-solving treatment may be used to help such patients.

Objectives

The aims of the study were (1) to compare the effectiveness of CMHN problem-solving and generic CMHN care, against usual GP care in reducing symptoms, alleviating problems, and improving social functioning and quality of life; and (2) to undertake a cost–utility, cost-effectiveness or cost-minimisation comparison of each CMHN treatment compared with usual GP care, evaluating not only the direct costs of treatment but also patient costs, including time off work.

Methods

The study was designed as a pragmatic, randomised controlled trial with three arms: CMHN problem-solving, generic CMHN care and usual GP care. General practices in Hampshire and Dorset were included in the study. CMHNs were employed by local NHS trusts providing community mental health services.

Participants were general practice patients aged 18–65 years with a new episode of anxiety, depression or reaction to life difficulties. For inclusion, patients had to score at least 3 points on the General Health Questionnaire-12 screening tool. Symptoms had to be present for a minimum of 4 weeks but no longer than 6 months.

Interventions

Patients were randomised to one of three groups: (1) CMHN problem-solving treatment: a brief structured treatment designed to be given in primary care to help to resolve problems, (2) generic CMHN treatment: nurses were asked to help patients become well as quickly as possible using whatever treatments they were experienced in giving, or (3) usual GP care: GPs were asked to treat the patients as they would normally. All three groups of patients remained free to consult their GPs throughout the course of the study, and could be prescribed psychotropic drug treatments.

Main outcome measures

Patients were assessed at baseline, and 8 weeks and 26 weeks after randomisation. The primary outcome measure was psychological symptoms measured on the Clinical Interview Schedule – Revised. Other measures included social functioning, health-related quality of life, problem severity and satisfaction. The economic outcomes were evaluated with a cost–utility analysis.

Results

Twenty-four CMHNs were trained to provide problem-solving under supervision, and another 29 were referred patients for generic support. In total, 247 patients were randomised to the three arms of the study, referred by 98 GPs in 62 practices. All three groups of patients were greatly improved by the 8-week follow-up. No significant differences were found between the groups at 8 weeks or 26 weeks in symptoms, social functioning or quality of life. Greater satisfaction with treatment was found in the CMHN groups. CMHN care represented a significant additional health service cost and there were no savings in sickness absence.

Conclusions

Specialist mental health nurse support is no better than support from GPs for patients with anxiety, depression and reactions to life difficulties.

Implications for healthcare

The results suggest that primary care trusts could consider adopting policies of restricting referrals of unselected patients with common mental disorders to specialist CMHNs. There may be other roles in primary care that CMHNs could play effectively, for instance consultation and liaison to support members of the primary healthcare team, or the provision of treatment for patients not responding to self-help or primary care team interventions, in managed stepped care systems, for which there is emerging evidence from the USA. However, this will compete with the need for CMHTs within community mental health teams to deliver the emerging psychosocial therapies for patients with severe and enduring mental illness, such as compliance therapy and cognitive behavioural therapy for moderate to severe depression and psychotic illnesses.

Recommendations for research

The following areas should be considered for future research:

Research needs to address the predictors of chronicity in common mental disorders, to be able to identify which patients are less likely to recover within a few months with treatment from their GPs alone, and so target extra treatment to those for whom it is needed.
More research is needed into the effectiveness and cost-effectiveness of problem-solving treatment for other disorders including major depression, deliberate self-harm and personality disorders, and for the prevention of mental disorders.
More research is needed into the effectiveness and cost-effectiveness of facilitated self-help treatments for common mental disorders.
More research is needed into the effectiveness and cost-effectiveness of CMHN care for people with severe and enduring mental illnesses.

Publication

Kendrick T, Simons L, Mynors-Wallis L, Gray A, Lathlean J, Pickering R, et al. A trial of problem-solving by community mental health nurses for anxiety, depression and life difficulties among general practice patients. The CPN-GP study. Health Technol Assess 2005;9(37).

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